Amid the devastation of armed conflict, hospitals stand as fragile sanctuaries, overwhelmed by demand and depleted of essential supplies. Struggling to function under relentless strain, they remain uniquely vulnerable – yet, rather than being protected, they are too often caught in the crosshairs of tactical attacks and political allegations.

In this first installment of the Emerging Voices series, Khang Phan and Thao Nguyen, recent graduates of Ritsumeikan Asia Pacific University, trace patterns in attacks on hospitals in contemporary conflicts. They examine the legal protections in place and the practical challenges that undermine compliance and enforcement. In doing so, they underscore the need for more effective warning systems and stronger communication among stakeholders to ensure hospitals receive the fullest possible protection.

Between early 2023 and the end of 2024, approximately 1,800 attacks impacted medical facilities, severely disrupting their functioning. The damage and destruction, particularly to hospitals, deprive people of critical access to medical care, endangering thousands of lives in conflict zones. Under international humanitarian law (IHL), hospitals enjoy four elements of special protection (see here and here). First, they may never be attacked under any circumstances.  Secondly, they shall at all times be respected and, thirdly, protected – unless they are used, beyond their humanitarian function, to commit acts harmful to the enemy. Fourth, if a hospital loses its specific protection status, a clear and effective warning must be issued before any military operation is taken in response. Moreover, for such a loss of specific protection to justify an attack, the commission of an act harmful to the enemy must lead the hospital to fulfill the cumulative criteria for qualifying as a ‘military objective’ (see also para. 1847).

In reality, hospitals’ operations are all too often disrupted by intense military operations. Damage to their surrounding essential infrastructures and checkpoint blockages obstruct ambulance services and cut off essential supplies such as electricity, water, and medical equipment. Mass evacuation orders drive civilians – including injured people, children, women, older persons, and people with disabilities – to seek refuge in overcrowded hospitals, straining already scarce resources. As conditions deteriorate, medical personnel have to flee, and civilians must abandon hospitals that can no longer sustain even the most basic care (see also here and here).

Moreover, hospitals are increasingly subjected to unfounded allegations that cast doubt on their humanitarian function, leading to attacks on and/or near them that disrupt critical healthcare services. Patterns of such attacks often lack clear procedures, particularly regarding the issuance of due warnings. Strengthening the protection of hospitals requires a strict interpretation of the warning obligation in cases where their special protection is contested, as well as the development of better practices to improve communications among parties to conflicts.

Legal framework for protecting hospitals

Hospitals are granted special protection as medical units under IHL, a safeguard rooted in their life-saving function of providing care to the wounded and sick. These protections are enshrined in the First and Fourth Geneva Conventions (GCI, GCIV), and, where applicable, Additional Protocols I and II (API and APII), as well as customary international humanitarian law. During armed conflicts, hospitals must be “respected and protected in all circumstances.”

The obligation to “respect” hospitals is a negative duty, meaning they may never be made the object of attack. The obligation to “protect” them is a positive duty, requiring parties to take all feasible precautions to spare hospitals from the effects of military operations (see the ICRC’s 2016 Commentary on the First Geneva Convention, para. 1797 & ICRC’s 1958 Commentary on the Fourth Geneva Convention, p. 147). For instance, if an attack occurs near a hospital, parties must take all necessary measures to avoid or at least minimize its impact. A direct strike would likely constitute a violation of the rule.

Furthermore, parties must ensure that hospital operations are neither obstructed nor impeded, even if the facility falls into the hands of the adverse party (see para. 1799). This includes taking all feasible measures to allow for the safe operation of ambulances, resupply of medical equipment, and access to electricity, water, and fuel to fulfill medical functions (see paras. 1804-1808).

Hospitals must never be used as human shields against attack and should be located away from areas at risk of hostilities. When relocation is not possible, military objectives must not be installed nearby – or, if already present, must be removed (see ICRC’s 1958 Commentary on the Fourth Geneva Convention, p. 152). It may be prohibited to use hospitals as military units, for weapons storage, or other functions outside their humanitarian purpose, which may risk forfeiting their specific protection (see para. 1800).

The law stipulates that hospitals may lose their special protection if they are used to commit acts harmful to the enemy beyond their humanitarian function (see here and here). However, admitting wounded and sick combatants or civilians does not compromise a hospital’s protected status (see here and here). If conditions for the loss of specific protection arise, parties to the conflict are required to issue a “due warning.” The issuing of such warnings differs from those found in the fundamental precautionary obligations, as they are a general requirement that is not subject to the caveat “unless circumstances do not permit” (see para. 1848).

The law does not specify what a due warning is, and in practice, it can take various forms, such as direct orders, emails, phone calls, leaflets, or public announcements on TV, the internet, and other media (see para. 1850 and here). However, so-called “roof-knocking” strikes or shells fired near hospitals may be deemed inappropriate, as they can harm civilians and incite panic.

In the absence of an immediate threat to the lives of advancing combatants, any warning must be accompanied by a reasonable time limit. This allows the hospital to respond to allegations – either by providing contrary evidence to dispel suspicion or by ceasing any harmful acts (see ICRC’s 2016 Commentary on the First Geneva Convention, para. 1852 and ICRC’s 1958 Commentary on the Fourth Geneva Convention, p. 155).

If a warning is ignored or harmful acts continue, sufficient time must be given to ensure the safe evacuation of wounded and sick persons, medical personnel, and any civilians inside who are not responsible for the alleged conduct and should not share its consequences. The decision to launch an attack without prior warning or without allowing time for evacuation must be an absolute exception, taken only with extreme caution and full consideration of the risks to the wounded and sick and medical personnel inside the hospital (see para. 1849).

If the conditions that led to the loss of specific protection no longer exist, the hospital must immediately regain its full protected status (see paras. 1853, 1856, 1857). Parties to the conflict are then obligated to respect its functioning, refraining from arbitrary searches, detentions or other forms of interference (see paras. 1801-1804), without hindering access to essential supplies.

In other words, the warning duty serves as an additional safeguard to protect hospitals from the effects of hostilities and preserve their full life-saving functions. It must never be misused as a pretext to justify attacks on hospitals or to force the evacuation of medical personnel and patients. Even when an attack against a hospital that has lost its specific protection status can be justified, attacking parties remain bound to uphold the protection of the wounded and sick, medical personnel and medical objects inside.

Any such attack must adhere strictly to the fundamental principles of distinction, proportionality, and precautions, ensuring that harm to hospital facilities, medical staff, patients and civilians is avoided – or at the very least, minimized as much as possible (see here).

Practical challenges to the legal framework for hospital protection

Despite the established legal framework, significant challenges remain in ensuring the full protection of hospitals in practice. One major gap is the absence of a standardized procedure for issuing warnings to hospitals before launching attacks. Without clear guidelines, warnings risk being misused – turning into threats rather than protective measures, thereby undermining the very safeguards they are meant to uphold.

A communication that fails to meet the minimum requirements outlined in the previous section cannot be considered as a “due warning”. Instead, it amounts to little more than a threatening allegation, which not only jeopardizes the hospital’s security but also weakens the overall effectiveness of legal protections in armed conflict.

The ICRC’s 2024 Challenges Report emphasizes the need for further research into good practices for issuing warnings, ensuring they are accessible and include clear guidance on timing, duration, and the window granted for ceasing acts deemed harmful to an adversary (see pp. 36-37). However, establishing a fully standardized, step-by-step procedure remains highly complex. In practice, parties to conflict may disregard or bypass certain steps depending on circumstances, making the consistent application of warning protocols particularly challenging. Real-time information is crucial for fostering mutual efforts to protect hospitals, particularly in cases of dispute. However, communication channels between parties to conflict remain inadequate. Greater cooperation is needed between armed actors and neutral entities to exchange and update information, especially regarding the status and operational capacity of hospitals under allegation, as well as viable evacuation alternatives.

For warnings to be effective, they must reach the appropriate recipients. While hospital authorities should be informed, they may not always be aware of military activity occurring within the facility or have the ability to stop it. Therefore, warnings should also be directed at other relevant parties, including those who may be responsible for or involved in the alleged harmful act. Ultimately, a warning must be issued to those actually committing an “act harmful to the enemy” to fulfil its legal and protective purpose (see para. 1850).

Similarly, parties to conflict are strongly encouraged to mutually establish clear terms regarding warnings and organization of evacuation in cases where an attack on a hospital becomes unavoidable. This can be achieved through special agreements under common Article 6 of the First, Second and Third Geneva Conventions (GCI, II, III), and Article 7 of the Fourth Geneva Convention (GCIV). These provisions grant parties the flexibility to determine the content and format of such agreements, provided they do not negatively impact the situation of the wounded and sick or other protected persons.

Ultimately, despite the practical challenges, the failure to respect and protect hospitals often stems from a concerning disregard for IHL. It is essential to recall that unduly and intentional attacks against medical units may lead to a serious breach of IHL and constitute war crimes (see the Rome Statute, Article 8(2)(b)(ix)). To strengthen accountability and prevent recurring violations, parties to conflict should adopt better practices for investigating the causes of allegations and attacks on hospitals, as monitoring and verification of violations remains extremely challenging (see para. 2). Neutral entities can also play a critical role in shedding light on these incidents and contributing to the investigative process, ensuring greater transparency and compliance with legal protections.

Beyond legal obligations, protecting hospitals is essential to alleviating the suffering caused by war and to upholding humanity in armed conflict. An attack on a hospital is an attack on human life and the fundamental right to health. Parties to conflict are therefore urged not only to respect the law, but also adopt good practices that strengthen the protection of hospitals, ensuring uninterrupted access to life-saving medical care for people affected by armed conflict and violence.

See also:

• Marnie Lloydd, Peter Herby, Caroline Baudot, Tobias Ehret, Protecting essential service personnel is a vital part of humanitarian action, October 10, 2024
• Michel Anglade, Mark Chapple, Elizabeth Rushing, Protecting education from attack during armed conflict, September 13, 2023
• Kubo Mačák, Tilman Rodenhäuser, Cyber attacks against hospitals and the COVID-19 pandemic: How strong are international law protections?, April 2, 2020