No health without peace: Health justice in armed conflict settings – a blog post

10 July 2024

Armed conflicts severely affect health systems, exacerbating existing inequalities and creating new obstacles to health justice. Achieving health justice in conflict settings is urgent and complex due to the destruction of healthcare infrastructure, displacement and the need for humanitarian interventions. A webinar held by the Thematic Working Group on Health Systems in Fragile and Conflict-Affected Settings [opens new tab] in collaboration with ReBUILD for Resilience, discussed the unique challenges to health justice and strategies used to ensure equitable healthcare access amid ongoing violence in three conflict zones: Yemen, Sudan, and Myanmar. The webinar underscored the necessity of systemic reforms to provide equitable healthcare, address inequities exacerbated by conflict and support vulnerable populations in these contexts.

Dr Wesam Mansour of ReBUILD for Resilience gave the keynote presentation, defining health justice as a framework which requires policies and laws that frame healthcare as a human right, ensure dignity and fairness, address social determinants of health, and promote equitable and quality care.

Experiences from different conflict zones

Yemen: a humanitarian crisis

Professor Najla Al-Sonboli, of Al-Sabeen Hospital for Maternity and Children in Sana’a, Yemen, discussed the impact of war and siege on Yemen’s health system.
Yemen’s prolonged conflict has resulted in one of the worst humanitarian crises in the world. War has led to the destruction of health infrastructure, lack of funding, fuel shortages, unavailability of medications and a shortage of qualified health workers. The internal displacement of people has increased demand for health services, leading to the spread of epidemics and further strain on an already collapsing health system. One example was the cholera outbreak that began in 2016 and which has affected more than a million people. The destruction of the water and sanitation systems helped spread the disease. Efforts to contain the outbreak, including ensuring functioning healthcare facilities, have been hampered by the ongoing violence. The situation in Yemen highlights the urgent need for health justice in conflict zones. Ensuring equitable access to healthcare, protecting healthcare infrastructure and the people that work within it, providing access to clean water and medical supplies, and addressing the needs of displaced populations are critical components of health justice.

Sudan: conflict and health disparities

Dr Mohammed Abdalgadir, Chief of Party at MOMENTUM Integrated Health Resilience in Sudan [opens new tab], presented the current situation of the health system in Sudan and the ongoing conflict.

The conflict between the Sudanese Armed Forces (SAF) and the Rapid Support Forces, which escalated in April 2023, has severely impacted the health system. The conflict compounded existing economic vulnerabilities and disrupted essential services, pushing the country towards potential collapse and creating significant health disparities. About 80% of health facilities in areas of active conflict are not functional, and millions of people lack access to health services. The displacement of nearly nine million people, including almost 1.6 million women and girls of reproductive age, has resulted in overcrowded camps with limited access to basic healthcare. Women in conflict zones face extreme challenges in accessing prenatal and postnatal care. Additionally, malnutrition among children is massive, exacerbated by food insecurity and inadequate healthcare. The conflict has increased the risk of gender-based violence, affecting an estimated four million women and girls.

Despite challenges, local associations continue to provide essential health services amidst the conflict, and mobile health units and temporary clinics are set up in refugee camps. MIHR (Momentum Integrated Health Resilience) supports health facilities and community-led initiatives, such as training midwives to enhance maternal, newborn and child health services and addresses gaps in WASH services to maintain safe drinking water sources. This has the added impact of preventing conflict triggered by a scarcity of water. Recognizing the trauma experienced by conflict-affected populations, efforts have also been made to integrate mental health services into broader health justice initiatives. This holistic approach aims to address both physical and psychological health needs. The Sudanese case illustrates the great impact of conflict on health systems and the need for a comprehensive approach integrating health justice with peacebuilding initiatives for achieving equitable healthcare access and improved health outcomes.

Myanmar: ethnic conflict and health inequities

Dr Khine Wai Wai Oo, a Deputy Chief of Party for Community Partners International [opens new tab], presented on Myanmar’s healthcare situation amid conflict.

Myanmar, with a population of around 50 million people, mostly rural, has faced a long history of political instability marked by ethnic conflicts and military rule from 1962 to 2011. There was some hope for political reform during the quasi-civilian (2011-13) and civilian-led governments (2014-20), however, a decade of relative stability came to an end in February 2021 with a military coup which has severely impacted on every part of life in Myanmar. The country’s healthcare system comprises a centralised public sector and a diverse private sector, including NGOs and community-based organisations, who are particularly active in hard-to-reach areas. In parts of the country with ethnic minorities, ethnic authorities are in de facto control and have shown remarkable resilience in providing healthcare in conflict zones, often delivering services in remote areas. During the democratic period (2014-20), efforts were made to bridge the public and ethnic health systems, fostering collaboration and improving healthcare delivery. This initiative, halted by the 2021 coup, included joint immunisation programmes and patient referral systems, illustrating healthcare’s potential as a bridge for peace. Since the coup, healthcare professionals have led anti-military protests and faced severe retaliation, forcing many to seek refuge in ethnic-controlled areas. Makeshift “jungle hospitals” have emerged, demonstrating resilience despite military airstrikes targeting these facilities. More than 1,100 incidents of violence against healthcare facilities have been recorded, with nearly 900 health workers detained. Ethnic leaders are now establishing a federal health system, strengthened by the influx of displaced healthcare workers to ethnic-controlled areas. They mobilise resources, connect with the international community, and expand healthcare services, including preventative care and epidemic control. Their adaptable and inclusive approach promotes equity and community trust, enhancing the resilience of Myanmar’s health system amid the ongoing conflict.

Across Yemen, Sudan, and Myanmar, several common patterns emerge. The conflicts have led to the widespread destruction of hospitals, clinics, and other health facilities making it difficult for civilians to access basic healthcare services. Internally displaced people and refugees face severe health challenges due to a lack of resources and damaged infrastructure. Mobile clinics and community health workers are crucial in providing care where formal health facilities are lacking or destroyed. However, there are key difference across the three countries such as the nature and duration of the conflicts, health challenges and health justice efforts. For instance, Yemen faces severe malnutrition and cholera outbreaks due to blockades and the breakdown of water and sanitation systems. Sudan struggles with high maternal mortality rates and child malnutrition in conflict zones, whereas Myanmar deals with restricted healthcare access for ethnic minorities, resulting in poor health outcomes.

The way forward: advocating for health justice

The webinar highlighted the theoretical and practical challenges of achieving health justice in fragile and conflict-affected settings. Empirical evidence is limited, emphasising the need for more research. Strategies to promote health justice include policy reform, advocacy, community engagement and intersectoral collaboration within armed-conflict settings.

This should be underpinned by

1. Protection of healthcare facilities and health workers: ensuring that health facilities are not targeted in conflicts and are protected under international humanitarian law.
2. Equitable access to healthcare: providing access to healthcare for all affected populations, including marginalised and displaced groups.
3. Infrastructure and capacity building: rebuilding healthcare infrastructure and training local healthcare workers to create sustainable, resilient health systems.
4. Addressing root causes: tackling the underlying political, economic, and social factors that contribute to health inequalities in conflict zones.

Further information

• Webinar recording: watch it here
• Webinar slides: read them here
• Related video: Professor Al-Sonboli spoke at LSTM in June 2024 on The Tragedy of War: partnerships and strategies to deliver essential health care to vulnerable Yemeni children and babies. Watch that presentation here.

Image: An ambulance at Shifaa Hospital, Gaza, November 2023. Gigi Ibrahim via Flickr [opens new tab]. CC BY 2.0 DEED