One of the fundamental rules for the protection of health-care personnel in any circumstance, including contexts of armed conflicts, provides for a prohibition on punishing medical professionals who merely act in accordance with medical ethics. However, although the reasons for this prohibition may seem obvious, in contexts of non-international armed conflicts the provision of medical care to wounded and sick members of non-state armed groups can expose medical personnel to accusations of participation in criminal activities. Based on the Colombian domestic legislation and jurisprudence on the matter, this article aims to propose elements of analysis on the apparent contradiction that exists between, on the one hand, the prohibition against punishing medical personnel for merely providing health care to the wounded and sick who need it, and on the other, the prerogative of the state authorities to restore order and security within their territory through the imposition of criminal sanctions on members of non-state armed groups or their aiders and abettors.

To open this issue on ‘Violence against Health Care’, the Review sought the perspective of a health-care professional who has worked in the context of an armed conflict.

Dr Walter T. Gwenigale is the Minister of Health and Social Welfare of the Republic of Liberia. A practising surgeon for more than 30 years, including during the civil war, he has served as Bong County health officer, director of Phebe Hospital and president of the Christian Health Association of Liberia. He has also served on the World Health Organization's executive board and as a board member of the Roll Back Malaria campaign.

In this interview, Minister Gwenigale explains how the armed conflict in Liberia impacted on the work of remotely-located Phebe hospital, on the needs of its patients and on the ability of the hospital staff to provide them with adequate medical care. He describes the main security challenges and the way in which the hospital staff attempted to address them. He also recalls instances in which the hospital staff and facilities were the direct target of this violence, sometimes leading to tragic consequences. In addition to the short-term impact of the armed conflict he witnessed as a doctor, Minister Gwenigale also reflects on the long-term effect of this conflict on the health system in Liberia today.

The spectrum of peacekeeping operations has grown increasingly broad and has come to include various – and sometimes simultaneous – dimensions, such as conflict prevention, peacekeeping, peacemaking, peace enforcement and peacebuilding. With the ascendancy of more robust peacekeeping mandates, such as the one assigned by United Nations (UN) Security Council Resolution 2098 to the UN Organisation Stabilisation Mission in the Democratic Republic of the Congo (MONUSCO), there is a need to analyse thoroughly the complexity of the contexts in which peacekeepers are deployed today, the rules applicable to their engagement, and the modalities they can introduce to adapt to new realities. In this interview, the Review sought the opinion of a distinguished military commander and strategist on the future evolution of peacekeeping missions.

Lieutenant General Babacar Gaye has been the serving UN Military Adviser for Peacekeeping Operations and Head of the Office of Military Affairs for the past three years. He has exercised command responsibilities at all levels of the military hierarchy and has been among the privileged officers to lead the Senegalese military. Besides his participation in Operation Fode Kaba II in Gambia and the conduct of several campaigns in Casamance, Senegal, General Gaye has taken part in UN operations in Sinai, Lebanon, and Kuwait, where he commanded the Senegalese battalion during Operation Desert Storm. His experience also includes a tour of duty of more than five years in the Democratic Republic of the Congo as MONUC/MONUSCO Force Commander. Prior to that, he served as Ambassador of the Republic of Senegal to Germany, Austria, and the organs of the UN in Vienna. General Officer of the Armoured Cavalry branch, General Gaye is a graduate of the prestigious Saint-Cyr military academy and the Ecole Supérieure de Guerre of France.

Among the increasingly frequent acts of non-compliance with, and grievous violations of, international humanitarian law around the world, especially in non-international armed conflicts, attacks on objects and persons enjoying special protection, and their abuse, as well as the misuse of the distinctive emblems of the Red Cross and Red Crescent, come as no surprise. Although a repressive approach to the problem – through the prosecution and punishment of perpetrators – cannot completely prevent such occurrences, an effective and appropriate judicial stigmatisation can significantly contribute to making them as rare as possible. In this regard, the court proceedings held before the War Crimes Chamber in Belgrade and the International Criminal Tribunal for the former Yugoslavia in The Hague in connection with the events in and around the Vukovar Hospital and Ovčara farm have provided an appropriate judicial response. This is notwithstanding the fact that, at least for now, not all perpetrators have been prosecuted for their acts (or failure to act) at the time of the commission of these grave crimes.

Multifunctional peace operations have become an integral part of international society to the extent that they are now one of the major regulating institutions of international relations. The United Nations (UN) is the main player in setting up such operations. The UN has seen a major but gradual evolution of its role in maintaining and establishing peace. Having developed peacekeeping as a form of impartial interposition between belligerents during the Suez Crisis in 1956, the UN has continually broadened its sphere of action. These cumbersome and complex operations are demanding and present the UN with a number of challenges.

This article explores the methodology and main findings of field studies conducted for the ICRC's Health Care in Danger project in Afghanistan, Somalia, and the Democratic Republic of the Congo between 2010 and 2013. It discusses some of the actions that the ICRC takes in its health programmes to facilitate access to health care, and its approach to promoting better respect for the laws protecting it. It then suggests what more needs to be done to curb the violence.

Many aid agencies and commentators suggest that humanitarian principles are of little value to the humanitarian crises of today. However, through profiling the experience of the Lebanese Red Cross, this article highlights the enduring value and impact of the application of the International Red Cross and Red Crescent Fundamental Principles as effective operational tools for acceptance, access and safety. Having suffered a series of security incidents during the civil war and subsequent disturbances and tensions, this National Society deliberately sought to increase its acceptance amongst different groups. One of the approaches used was the systematic operational application of the Fundamental Principles. Today, the Lebanese Red Cross is the only public service and Lebanese humanitarian actor with access throughout the country. This article seeks to address the relative absence of attention to how humanitarian organisations apply humanitarian principles in practice – and their responsibility and accountability to do so – by describing the systematic approach of the Lebanese Red Cross.

This research examines the impact on health-care provision of advanced state failure and of the violence frequently associated with it, drawing from six country case studies. In all contexts, the coverage and scope of health services change when the state fails. Human resources expand due to unplanned increased production. Injury, threat, death, displacement, migration, insufficient salaries, and degraded skills all impact on performance. Dwindling public domestic funding for health causes increasing household out-of-pocket expenditure. The supply, quality control, distribution, and utilisation of medicines are severely affected. Health information becomes incomplete and unreliable. Leadership and planning are compromised as international agencies pursue their own agendas, frequently disconnected from local dynamics. Yet beyond the state these arenas are crowded with autonomous health actors, who respond to state withdrawal and structural violence in assorted ways, from the harmful to the beneficial. Integrating these existing resources into a cohesive health system calls for a deeper understanding of this pluralism, initiative, adaptation and innovation, and a long-term reorientation of development assistance in order to engage them effectively.

The aim of this article is to carry out a preliminary analysis of issues relating to the types of violence that are directed against humanitarian medical missions. Starting from the observation that violence can cause some degree of disruption for a medical organisation such as Médecins Sans Frontières, despite its wide experience which has brought it much wisdom and generated numerous and sporadic responses to such events, the article offers a more subtle analysis of terms and of situations of violence so as to contribute to the establishment of a research project and, in a second phase, to an awareness-raising campaign focusing on these complex phenomena.

The ‘protection of civilians’ mandate in United Nations (UN) peacekeeping operations fulfils a critical role in realising broader protection objectives, which have in recent years become an important focus of international relations and international law. The concepts of the ‘protection of civilians’ constructed by the humanitarian, human rights and peacekeeping communities have evolved somewhat separately, resulting in disparate understandings of the associated normative bases, substance and responsibilities. If UN peacekeepers are to effectively provide physical protection to civilians under threat of violence, it is necessary to untangle this conceptual and normative confusion. The practical expectations of the use of force to protect civilians must be clear, and an overarching framework is needed to facilitate the spectrum of actors working in a complementary way towards the common objectives of the broader protection agenda.

Attacks on health workers, clinics, hospitals, ambulances and patients during periods of armed conflict or civil disturbance pose enormous challenges to humanitarian response and constitute affronts to the imperatives of human rights and civilian protection. Violence inflicted on humanitarian aid workers is gaining the global attention it warrants. While the number of attacks on aid workers has decreased in recent years, in a handful of places, notably Sudan, Afghanistan, and Somalia, they have become more spectacular and frightening, with aid agencies targeted for kidnapping and subjected to use of explosives because of their perceived affiliation with Western governments. The assaults have galvanised the humanitarian aid community to track attacks and to engage in intensive and sophisticated discussion of means to increase operational security. After worldwide consultation, in 2011 the United Nations (UN) Office for the Coordination of Humanitarian Affairs (OCHA) issued a report that summarised the fruits of experience and stimulated consideration of security strategies for aid providers. By contrast, however, until very recently the far larger number of incidents of violence inflicted on and interference with indigenous health services and on international and local development agencies by state and armed groups has received comparatively little attention.

Health-related data provide the basis of policy in many domains. By using a methodology specifically designed to gather data about any form of violence and its impact, violence affecting health-care personnel, health-care facilities, and the wounded and sick in these facilities can be quantified on an objective basis. The impact of this form of violence and its accompanying insecurity goes beyond those directly affected to the many who are ultimately denied health care. Reliable data about both the violence affecting health-care personnel and facilities and the ‘knock-on’ effects of this violence on the health of many others have a critical role to play in influencing the policies of all stakeholders, including governments, in favour of greater security of effective and impartial health care in armed conflict and other emergencies. The International Committee of the Red Cross has undertaken a study that attempts to understand on a global basis the nature and impact of the many different kinds of violence affecting health care.

Mandates of United Nations (UN) peacekeeping missions increasingly include stabilisation and peace enforcement components, which imply a proactive use of force often carried out by national, regional or multinational non-UN partners, operating either in support of or with the support of the UN, acting as ‘proxies’. This article analyses the legal, policy and perception/security implications of different types of ‘peace operations by proxy’ and the additional challenges that such operations create for humanitarian action. It suggests some mitigating measures, including opportunities offered by the UN Human Rights Due Diligence Policy, for a more coherent approach to the protection of civilians, but also acknowledges some of the limitations to an independent UN-led humanitarian action.

In 2011, the International Red Cross and Red Crescent Movement launched the Health Care in Danger project, a global initiative with an ambitious objective: to improve the security of health-care delivery in armed conflicts and other emergencies. Two years later, Pierre Gentile, the ICRC's Head of Project, speaks about the achievements, the challenges and the way forward to make this intention a reality.

The Colombian National Permanent Roundtable for the Respect of the Medical Mission (hereinafter ‘the Roundtable’) is a platform launched in 2008 on the initiative of the Ministry of Health and Social Protection and the Emergency Control Centre of the Ministry of Health of Cundinamarca with the support of the International Committee of the Red Cross (ICRC) and the Colombian Red Cross. It provides a space for discussion on topics related to the protection and safeguarding of health services, in the context of the non-international armed conflict taking place in Colombia. The permanent members of the Roundtable include a representative of the Ministry of Health and Social Protection, a representative of the Presidential Programme for Human Rights and International Humanitarian Law, the Colombian Red Cross and the ICRC. In this interview, the members of the Roundtable give their perspectives on the motives that inspire its work and the main challenges that it faces for the protection of the medical mission in Colombia.1

The multifaceted nature of peace operations today and the increasingly violent environments in which their personnel operate increase the likelihood of their being called upon to use force. It thus becomes all the more important to understand when and how international humanitarian law (IHL) applies to their action. This article attempts to clarify the conditions for IHL applicability to multinational forces, the extent to which this body of law applies to peace operations, the determination of the parties to a conflict involving a multinational peace operation and the classification of such conflict. Finally, it tackles the important question of the personal, temporal and geographical scope of IHL in peace operations.

In view of the challenges frequently encountered in providing assistance to civilians in opposition-held territories, consideration is sometimes given to cross-border relief operations. Such operations raise numerous legal questions, including whose consent is required; what constitutes arbitrary withholding of consent; what the consequences of withholding of consent are, both for those wishing to provide assistance and for the parties withholding consent; and what alternatives exist for providing assistance in such circumstances.

This article examines the status of military and civilian personnel of sending states and international organisations involved in UN peace operations. It undertakes an assessment of relevant customary law, examines various forms of treaty regulation and considers topics and procedures for effective settlement of open issues prior to the mission. The author stresses the need for cooperation between the host state, the sending states and the international organisation in this context. He draws some conclusions with a view to enhancing the legal protection of personnel involved in current and future UN peace operations.