Reconciling Counterterrorism and Health Care in Conflict Zones

The German Technical Cooperation Agency, which has been a major underwriter of health service delivery in the northwestern Syria governorate of Idlib for more than five years, suspended its funding to Idlib Health Directorate last month, three days after an Al-Qaeda affiliated group took full control of the governorate, the last-remaining opposition-controlled area in Syria.

Idlib Health Directorate has been the de-facto health authority in the opposition-controlled governorate since 2013. It was established by a group of local Syrian doctors to sustain medical standards and health governance in the absence of the central health ministry and has repeatedly pronounced it is neutral in the conflict. Besides healthcare delivery and governance, it runs essential projects such as ambulance services, blood banks, medical waste management and laboratories.

UN and European counterterrorism measures criminalize the direct or indirect provision of financial or other support to entities designated as terrorist. Al-Qaeda fits into this category. The German government issued no statement on the reasons for the suspension, but if it was an attempt to comply with these measures, that exposes a misalignment between counterterrorism measures and international humanitarian law, which foresees the delivery of healthcare in situations of armed conflict.

For the most part counterterrorism measures do not address the question of their interplay with humanitarian action and how not to undermine the continuity of humanitarian services in areas under the control of a designated group. This vagueness has created a chilling effect among donors, several of whom have suspended funding for humanitarian services in Idlib.

This is not the first time when access to health care has been compromised because of counterterrorism measures. Concerns that assistance provided in the course of humanitarian action may violate the prohibition have contributed to suspension of funding in other areas, such as areas under the control of al Shabab in Somalia and those under the Taliban rule in Afghanistan.

The implications for the health sector in Idlib

The Syrian conflict has had catastrophic consequences for the health sector. According to the World Health Organization, the vulnerability of the population in opposition-controlled areas is worsened by health risks such as limited access to health care and shortage of medical supplies. Targeted attacks against health care remain a pervasive problem, with Physicians for Human Rights documenting 550 attacks against healthcare facilities and workers since 2011.

The suspension of funding will cause further deterioration of health determinants as services run short of supplies and health workers are forced to leave and find jobs elsewhere.

The vacuum in health governance that will result from disempowering Idlib Health Directorate will lead to further politicization of the health sector. It will create an opportunity for armed groups to leverage health services for political gain, especially if they fill the funding gaps, as is the case with services controlled and run by the Taliban in Afghanistan.

Potential solutions

There is an urgent need to find long-term solutions to this issue. UN Security Council Resolution 1373, which criminalizes the financing of terrorism, and related measures at EU and national level should include new provisions that guarantee the continuity of health services even when at least one party in the context is classified as terrorist. These provisions should protect health providers from prosecution and propose new mechanisms for transparent financial reporting around the delivery of health services.

They could be in the form of exemptions for health providers alongside pre-conditions for increased transparency and accountability. An example would be to focus on sending medical equipment and medicines instead of money, to address the risk of misappropriation. They could also suggest alternative ways to provide health services that minimize the risk of the resources being seized by terrorist groups or individuals.

To be operationalized, the new provisions should be reflected in the relevant national and regional laws. This requires political commitment and a high level of collaboration between national and international legislators. Moreover, they should be adequately communicated in political and humanitarian circles to avoid the chilling effect and its consequences.

Health is a universal right for everyone regardless of ideological affiliation. This right is enshrined in international humanitarian law. This protection is compromised by the current breadth of counterterrorism measures and the resulting chilling effect. Therefore, the international community should push for a revision of counterterrorism regulations to explicitly align them with the provisions of international humanitarian law that protect health care in conflict settings.