The impact of attacks on health care1 in Fragile, Conflict-affected and Vulnerable (FCV) settings2 goes well beyond endangering health providers. Reduced capacity, interrupted services and loss of health care resources deprive vulnerable populations of urgently needed care, undermine health systems and jeopardize long-term public health goals.
As the world struggles with the COVID-19 pandemic, protecting health care where health systems are the most vulnerable has become more important than ever. Ensuring the right to access health care for everyone, everywhere is not only at the core of WHO’s commitment to achieve better health but also a stepping stone to a reaching the Sustainable Development Goals or SDGs.
Here, the analysis of publicly available data collected via WHO’s Surveillance System for Attacks on Health Care (SSA) from 2018 to 2020 presents a global overview of attacks on health care, the resources that they affected and their immediate impact on health workers and patients.
The results demonstrate that attacks on health care are highly context-dependent. The occurrence, nature and dynamics of attacks are closely related to changes in the operational context of the local health response. Such changes may include the emergence of new crises, intensification of conflicts, ceasefires or the deterioration of community acceptance.
In addition, changes in the operational contexts of individual FCV countries or territories where attacks are more prevalent play an important role in driving global-level patterns of attacks on health care. For this reason, it should be noted that the results of this analysis are not representative of country-level trends and only provide a global overview of all verified incidents reported through the SSA. However, this analysis can be replicated at country-level using the SSA dashboard’s data export function.
Health personnel is the most frequently affected health resource;
Attacks on health care were associated with a higher proportion of deaths in 2020;
Changing contexts are an important driver for yearly differences in the data;
Reports of attacks on health care involving psychological violence, threats of violence or intimidations have decreased in 2020;
Changes in the number of reported attacks on the SSA preceded the onset of the COVID-19 pandemic;
Attacks affecting health facilities, transport and patients became more frequent after the onset of the COVID-19 pandemic.
Attacks on Health Care initiative In 2012, World Health Assembly Resolution 65.20 was adopted and called on WHO’s Director-General to provide global leadership in the development of methods for the systematic collection and dissemination of data on attacks on health facilities, health workers, health transport and patients in complex humanitarian emergencies. WHO subsequently created the Attacks on Health Care (AHC) initiative to collect evidence, advocate for the end of attacks, and promote best practices for protecting health care.
Collecting data of attacks on health care
WHO’s Surveillance System for Attacks on Health Care (SSA) collects standardized primary data about attacks against health care in FCV settings. WHO works closely with partners on the ground in 17 countries and territories to gather relevant information about incidents, which is then verified by the WHO Country office. A detailed methodology for the collection of data via the SSA is available here.
Incidents reported via the SSA include ‘any acts of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access and delivery of curative and/or preventive health services during emergencies’3. In this definition, both ‘higher-impact’ attacks on health care – such as bombings – and ‘lower-impact’ attacks – such as verbal threats – are included.
Magnitude of the problem
As of 21 April 20214, the SSA recorded 797 attacks on health care in 2018, 1029 in 2019 and 323 in 2020 across 17 countries and territories.
Further analyses into patterns of attacks before and after the onset of the COVID-19 pandemic highlighted that the number of reports on the SSA fell before the pandemic. The data collected during the COVID-19 crisis showed that in the majority of FCV countries and territories already confronted with high volumes of attacks on health care there was no marked change in the number of reported incidents during that period.
Rather, reports of attacks on health care became markedly less frequent starting mid-2019. Data collected via the SSA between 2018 and 2020 shows that the number of reported attacks dropped during the last quarter of 2019 and reached its lowest during the first quarter of 2020.
Changes in the operational contexts of a limited number of countries and territories with FCV settings were one of the main drivers for yearly differences in number of reports. For example, the Democratic Republic of the Congo (DRC) and the occupied Palestinian territories (oPt) accounted for two thirds of all reported attacks in 2019 with respectively 406 and 267 reports. It is notable that when both are removed from calculations, the number of attacks reported in 2020 is not as markedly lower than in previous years5.
Between 2018 and 2020, DRC faced the world’s second largest Ebola outbreak during which numerous incidents of attacks on health workers and Ebola treatment centres6 were reported. Many of these attacks were motivated by mistrust and misunderstanding of the disease in an already vulnerable setting. The number of reports fell after the scaling down of the response towards the end of 2019.
In oPt, an unprecedented number of attacks on health care was recorded in the context of the 2018-2019 demonstrations in the Gaza Strip7, known as Gaza’s “Great March of Return”8. After the demonstrations ended towards the end of 2019, reports of attacks on health care became markedly less prevalent.