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Security Council Distr.: General 29 March 2019

Original: English

Letter dated 14 March 2019 from the Permanent Representative of Sweden to the United Nations addressed to the President of the Security Council

On 21 December 2018, Sweden and partnered with Belgium, Côte d’Ivoire, Germany and Peru to host an Arria formula meeting on the protection of health care in armed conflict (see the concept note for the meeting, annex I). The purpose of the meeting was to take the important debate on the protection of health care in armed conflict – and the implementation of Security Council resolution 2286 (2016) – from policy to practice, to the country contexts where its implementation matters the most. Another objective was to identify key actions and support measures needed to strengthen the protection of medical care. Please find attached to the present letter – as a contribution to the further work in New York and beyond – a report that summarizes the discussions and main findings of the meeting (see annex II). I would be grateful if, in your capacity as President of the Security Council for the month of March 2019, you could have the present report and its annexes circulated as a document of the Security Council.

(Signed) Olof Skoog On behalf of the six co-hosts Ambassador Extraordinary and Plenipotentiary Permanent Representative

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Annex I to the letter dated 14 March 2019 from the Permanent Representative of Sweden to the United Nations addressed to the President of the Security Council

Concept note for the Arria formula meeting on “Protecting medical care in armed conflict – from policy to practice”, hosted by the Permanent Mission of Sweden to the United Nations, in partnership with the Permanent Missions of Belgium, Côte d’Ivoire, France, Germany and Peru on 21 December 2018 in New York

Objective

1. Reiterate the need to protect medical care in armed conflict and implement Security Council resolution 2286 (2016). 2. Take discussion from policy to practice by looking at country-level challenges and implications with field-level practitioners. 3. Identify key actions and support measures needed to strengthen the protection of medical care in the field.

Background

International humanitarian law is clear – parties to conflict must search for, collect, evacuate and provide medical treatment to the wounded and sick, regardless of whether they are combatants or not, regardless of which side they belong to. This is the very foundation of contemporary international humanitarian law. Attacks against medical care in situations of armed conflict are prohibited. Medical personnel, transport and facilities exclusively assigned to medical duties must be respected and protected in all circumstances. Punishing a person for performing medical duties compatible with medical ethics or compelling a person engaged in medical activities to perform acts contrary to medical ethics is prohibited. Attacks directed against medical personnel and objects displaying the distinctive emblems of the Geneva Conventions in conformity with international law are war crimes. The landmark Security Council resolution 2286 (2016), adopted in May 2016, reiterates the legal framework that protects the wounded and sick and those endeavouring to assist them in situations of armed conflict. Resolution 2286 (2016) reaffirms applicable law by clearly stating that States have an obligation to ensure the protection of all the wounded and sick, medical personnel and humanitarian personnel exclusively engaged in medical duties, their means of transport and equipment, as well as hospitals and other medical facilities, in situations of armed conflict. The Council has confirmed these obligations in a number of resolutions. Only in 2018 the Council has condemned attacks on health care and called for respect for obligations under international law, inter alia, in resolutions 2401 (2018) on Syria, 2405 (2018) on Afghanistan, 2406 (2018) on South Sudan, 2409 (2018) on the Democratic Republic of the Congo, as well as in thematic resolutions 2417 (2018) on conflict and hunger, 2427 (2018) on children and armed conflict and 2439 (2018) on Ebola. However, there is a steady and often daily flow of horrendous reports from conflict situations around the world of attacks against medical facilities, transport and personnel: and this is just the tip of the iceberg. Access to medical care is often impeded by parties to conflict in more insidious, less visible ways: doctors and nurses are threatened or attacked for performing their duties; medical equipment is looted; and ambulances are prevented from reaching those in need.

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The World Health Organization has reported 583 attacks on health care to date in 2018, resulting in 132 deaths and 742 injuries, each of them equally unacceptable. In recent years, the United Nations and Member States have strengthened their response, notably following the adoption in May 2016 of resolution 2286 (2016) and – later the same year – the presentation of a set of concrete recommendations by the Secretary-General to enhance the protection of medical care in armed conflict. Additional efforts have been made to maintain and reinforce multilateral momentum for the protection of medical care in armed conflict, including through the organization of successive high-level side events and seminars in New York and the signing of a political declaration on the protection of humanitarian and health workers on 31 October 2017. Progress has been made in a number of areas, including monitoring within the United Nations system; however, the situation as regards the protection – or lack thereof – of medical care in armed conflict remains unacceptable and the current trends worrisome. Most importantly, there is still often a clear gap between the principles and priorities set out in Security Council and General Assembly documents and the real-life behaviour of parties to armed conflict – a gap between norms and practice that unfortunately is not uncommon under the protection of civilians agenda. In view of this, the purpose of the Arria meeting – open to the whole United Nations membership, as well as stakeholders in civil society – will be to take the debate on the protection of health care in armed conflict and the implementation of United Nations Security Council resolution 2286 (2016) from policy to practice, to the field level and to the country contexts where its implementation really matters the most. The meeting will focus on two country situations, Afghanistan and South Sudan, hear from practitioners dealing with health-care issues in those two countries and with the aim of identifying a set of key measures that could be taken by national Governments, international partners and/or the United Nations system to improve the situation and reverse current trends.

Programme

Introductory remarks

Olof Skoog, Permanent Representative, Sweden

Legal framework and the main challenges for protecting medical care in conflicts

Alice Debarre, Policy Analyst, Humanitarian Affairs, International Peace Institute

Experiences from medical practitioners in the field

Farhad Javid, Country Director, Marie Stopes International, Afghanistan Dr. Evan Atar Adaha, Medical Director, Maban Hospital, South Sudan

Statements by co-hosts, other Council Members and – time permitting – other participants

Concluding remarks

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Annex II to the letter dated 14 March 2019 from the Permanent Representative of Sweden to the United Nations addressed to the President of the Security Council

Summary report of the Arria formula meeting on “Protecting medical care in armed conflict – from policy to practice”, held in New York on 21 December 2018

On 21 December 2018, Sweden – in partnership with Belgium, Côte d’Ivoire, France, Germany and Peru – hosted an Arria formula meeting on the protection of health care in armed conflict. The purpose of the meeting was to take the important debate on the protection of health care in armed conflict – and the implementation of Security Council resolution 2286 (May 2016) – from policy to practice, to the field level and to the country contexts where its implementation matters the most, as well as to identify key actions and relevant support measures needed to strengthen the protection of medical care. The present report summarizes the discussions and main findings of the meeting. The meeting was opened by Olof Skoog, Permanent Representative of Sweden to the United Nations, who recalled that, despite some progress on the policy side (notably the adoption of Security Council resolution 2286 (2016) in May 2016), there was still a steady and almost daily flow of horrendous reports from conflict situations around the world of attacks against medical facilities, transports and personnel – “there is a wide and unacceptable gulf between what is said and what is done”. Following that introduction, Alice Debarre of the International Peace Institute then set out the legal framework for the subject matter and pointed to the robust and longstanding rules and principles of international humanitarian law in relation to medical care in armed conflict. Ms. Debarre underlined the importance of resolution 2286 (2016), which reaffirms international humanitarian law and calls for respect for and implementation of those rules. Ms. Debarre then pointed to three main challenges to its implementation: first, lack of accountability; second, inadequate or burdensome national legislation and administrative procedures; and third, politicization of medical care. The meeting then turned to two specific country situations – Afghanistan and South Sudan. Participants heard from two medical practitioners, who shared their experiences and gave their recommendations on how to strengthen the protection of health care. Dr. Evan Atar Adaha, Medical Director at Maban Hospital in northern South Sudan and a 2018 winner of the Office of the United Nations High Commissioner for Refugees Nansen Award, underlined education and accountability as central elements in improving the protection of medical care. He also pointed to the fact that many attacks against health care in South Sudan were carried out by unorganized groups, often with limited or weak central command structures. In addition, Dr. Atar mentioned the importance of education for children and youth as a longer-term strategy for avoiding such attacks in the future. Speaking next, Farhad Javid from Marie Stopes International Afghanistan said that mothers and children were particularly affected by the lack of access to medical care in armed conflict. Mr. Javid also said that, through dialogue with a wide spectrum of actors, Marie Stopes International had been granted access to many conflict areas. Mr. Javid underlined in particular the importance of providing care strictly in accordance with the humanitarian principles and of not making any distinction between patients on other than medical grounds.

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From policy to practice

Following those remarks from the panel, a number of statements from participating Member States – first, from the co-hosts of the meeting (Belgium, Côte d’Ivoire, France, Germany and Peru), then from other Council members, from (at that stage) incoming Council members and from other Member States. New Zealand made a statement on behalf of the four original co-penholders of resolution 2286 (2016) (Egypt, Japan, New Zealand and Uruguay). The European Union delegation in New York also made a statement, on behalf of the 28 member States of the European Union. There were important recurring themes in many of the statements made, including, not least, support and respect for the work of medical and humanitarian workers in conflict and crisis situations. In addition, many of the participants also made concrete, forward-looking proposals about how the work on the protection of medical care in armed conflict could be strengthened, in the Security Council, elsewhere in New York and on the ground in conflict settings. The (non-exhaustive) summary below lists a few of the concrete proposals made during the debate, which is put forward as an input to the further work and discussions in New York and beyond:

Armed forces and armed groups

• Training in international humanitarian law should be a central component of training for national armed forces. States should ensure training in international humanitarian law as a component of training mission partnerships. • Military taskings should, where appropriate, be reviewed to ensure that they adequately address issues relating to the protection of and access to health care. • Education aimed directly at armed groups is important, to ensure that such groups understand the rules that apply to them and the consequences of attacking medical care and of hindering access. • Sharing of information on the role and work of humanitarian organizations, as well as on the emblems, is crucial to prevent future attacks – focus on youth through education. • Leveraging new technologies to ensure that medical facilities are better protected.

National legislation and other possible action

• Ensuring prompt collection of information and evidence to prevent further attacks and ensure accountability and, in that regard, make better use of peacekeeping intelligence. • Ensuring that national law allows for the prosecution and conviction of those responsible for these crimes. • Ensuring that national legislation protects the emblems, to counter abuse. • Ensuring that national legislation respects and protects international humanitarian law and medical ethics and does not punish medical workers for providing impartial care, including in contexts of counter-terrorism activities. • Revisit – on a national basis – the Secretary General’s recommendations on the implementation of Security Council resolution 2286 (2016). • Consider signing up to the political declaration on the protection of medical care in armed conflict of October 2017.

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• Ensuring a more consistent exchange on challenges and best practices with respect to the protection of medical care.

Security Council

• The Council needs to maintain the issue of medical care on its agenda and consistently and strongly underline the seriousness of attacks on medical care and denial of access. • The Council should further investigate the links between health and conflict, the lack of basic health care as a root cause of conflict and the impact of armed conflict on health-care systems. • The Council should make greater use of its existing mechanisms, such as meetings with troop-contributing countries and its informal working group on the protection of civilians, to strengthen respect for the protection of civilians. • The Council should explore ways that the existing children and armed conflict system can be used to enhance the protection of medical care in armed conflict, investigate attacks and ensure accountability. • The Council should invite actors such as the World Health Organization, the International Committee of the Red Cross and Médecins Sans Frontières to brief not only during thematic debates, but also in debates on country situations. • The Council should to a greater degree consider including issues relating to the protection of medical care in country resolutions and mission mandates. • The Council should consider attacks against medical care and restricting access to medical care to be a separate sanctions criterion.

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