When Law Fails to Protect: Operationalizing International Humanitarian Law Through Intersectoral Training in Post-Conflict Ethiopia

VIEWPOINT
 
Grace Lee
 
The World Health Organization defines attacks on health care as “any act of verbal or physical violence or obstruction or threat of violence that interferes with the availability, access, and delivery of curative and/or preventive health services during emergencies.”^[1] Despite explicit prohibitions under international humanitarian law (IHL), such attacks remain widespread: More than 3,600 incidents of violence against or obstruction of health care were reported globally in 2024, with profound consequences for population health and access to care.^[2]

These global patterns are clearly reflected in Ethiopia’s Tigray region, where the health system is now at risk of collapse following more than five years of conflict between the Ethiopian National Defense Force and the Tigray People’s Liberation Front. In March 2026, the Bureau of Health of the interim administration of Tigray issued an urgent appeal for international support, warning that conflict-related destruction and limited post-conflict recovery have left the region unable to meet even basic population needs.^[3]

This appeal follows a period of acute and sustained disruption. Within months of the conflict’s onset, the region’s health system was effectively dismantled. All primary health posts were rendered inoperative, and only a fraction of hospitals and health centers remained functional.^[4] Medical equipment and patient records were destroyed or looted, while facilities were repurposed for military use, severely restricting civilian access to care.^[5] Violence against health care workers—including intimidation, detentions, kidnappings, and extrajudicial killings—further eroded service delivery.^[6] Although precise figures remain difficult to verify due to communication constraints and underreporting, available evidence indicates that attacks on health care have persisted throughout the crisis.^[7]

These conditions expose the practical limits of existing protective frameworks. Despite clear protections under IHL and Ethiopia’s formal commitments under international human rights law (IHRL), health facilities have been targeted and destroyed with impunity.^[8] The capacity of Tigray’s regional government to rebuild remains severely constrained. In effect, Tigray—like many conflict-affected settings—represents the progressive realization of the right to health in reverse, with millions displaced and famine conditions widespread.^[9]Legal obligations alone have not translated into meaningful protection or accountability. The core challenge, therefore, is not the absence of normative standards but the persistent failure to operationalize them.

What can be done to reassert respect for international humanitarian law and international human rights law?

A key priority is the development of strategies that bridge the gap between legal rules and their practical enforcement. One promising approach is intersectoral training, which convenes actors across the health, legal, and security sectors to build a shared understanding of obligations and operationalize protections for health care. Evidence from other conflict-affected settings suggests that such training can align knowledge and professional norms across institutions, helping close the gap between law and practice. In the Philippines, for example, the International Committee of the Red Cross supported multisectoral training on IHL and domestic implementing legislation (Republic Act No. 9851), bringing together judges, prosecutors, law enforcement officials, and human rights actors.^[10] This effort strengthened practical understanding of legal protections and improved coordination across the justice system, while “training of trainers” models supported longer-term institutionalization and local ownership.^[11]

There is also evidence that training security forces on IHL and medical neutrality can shape operational conduct. Studies of military personnel suggest that exposure to such training is associated with greater restraint and improved protection of civilians and infrastructure.^[12] While training alone cannot eliminate violations, it can influence decision-making in high-pressure environments and reinforce norms that reduce harm.

Intersectoral training offers a politically feasible and operationally practical entry point for strengthening implementation without requiring immediate large-scale legal reform. In Ethiopia, such programs could be co-developed by the Ministries of Health and Justice in partnership with academic institutions and international actors, targeting three key groups: military and security forces, health care workers, and judicial and prosecutorial personnel.

For military and security forces—including the Ethiopian National Defense Force and regional forces—training should be grounded in realistic operational scenarios. Modules could address the prohibition on occupying health facilities, the obligation to facilitate passage of ambulances and medical supplies, and the protected status of patients and health care workers. Given documented patterns of looting and facility misuse, training should also emphasize command responsibility and the duty to prevent and respond to violations by subordinates.

For health care workers, training must reflect Ethiopia’s decentralized, community-based health system. Tigray relies heavily on the Health Extension Program, which deploys health extension workers (HEWs) to deliver primary care through rural health posts—a frontline system severely disrupted by the destruction of facilities and the displacement or targeting of HEWs.^[13] Training should therefore reach both facility-based clinicians and community-level HEWs, emphasizing practical safety protocols, incident response procedures, and secure documentation practices. Given pervasive underreporting, establishing simple and confidential reporting pathways adapted to low-connectivity settings is essential. Training should also reinforce principles of medical neutrality and impartial care, equipping health care workers to navigate coercion or pressure from armed actors.

For legal and judicial actors, capacity-building should address enforcement realities in Ethiopia. This includes strengthening the ability of prosecutors and investigators to handle cases involving attacks on health care, particularly where evidence is limited or politically sensitive. Training should integrate IHL and IHRL provisions with existing domestic frameworks, providing practical guidance on documenting violations and pursuing accountability within institutional constraints.

A key advantage of intersectoral training is its potential to reduce institutional fragmentation by fostering coordination across sectors. Joint sessions convening military, health, and legal actors can standardize procedures and build mutual understanding. This is particularly important in post-conflict Tigray, where trust in state institutions has been profoundly weakened.

Crucially, this approach strengthens implementation feasibility by aligning health care protection with domestic priorities in the recovery period, particularly the restoration of basic services and the strengthening of state functionality. Rather than requiring politically sensitive structural reforms, intersectoral training offers a comparatively low-friction entry point for improving governance through existing institutions. Beyond coordination, such training can yield tangible operational gains, including more predictable checkpoint procedures for ambulances, reduced interference with health facilities, clearer reporting pathways, and improved management of security risks in clinical settings. These measures support continuity of care and help reduce preventable morbidity and mortality associated with disrupted access to essential services. Framing health care protection in this way also reinforces Ethiopia’s obligations under the International Covenant on Economic, Social and Cultural Rights, underscoring that intersectoral training forms part of the state’s duty to respect, protect, and fulfill the right to health.^[14]

International humanitarian law’s protections for health care are unambiguous. In Tigray, they have been systematically ignored. While intersectoral training is not a panacea, it offers a concrete mechanism to operationalize protections that currently exist only on paper. For a health system in collapse, that is not a modest contribution.
 
Acknowledgments
I gratefully acknowledge Joseph J. Amon for his editorial support and guidance on the structure and content of this viewpoint.
 
Grace Lee, MSPH, is a graduate researcher at the Johns Hopkins Bloomberg School of Public Health, Baltimore, United States.
 
Please address correspondence to the author. Email: grace.yeolee@gmail.com.
 
Copyright © 2026 Lee. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
 

References
[1] World Health Organization, “Attacks on Health Care Initiative: Documenting the Problem” (July 22, 2020), https://www.who.int/news-room/questions-and-answers/item/attacks-on-healthcare-initiative-documenting-the-problem.
[2] Safeguarding Health in Conflict Coalition, Epidemic of Violence: Violence Against Health Care in Conflict 2024 (Insecurity Insight, 2025).
[3] “Tigray Health Bureau Issues Urgent Appeal Warning of Imminent Health System Collapse amid Fuel, Medicine Shortages,” Addis Standard (March 5, 2026), https://addisstandard.com/tigray-health-bureau-issues-urgent-appeal-warning-of-imminent-health-system-collapse-amid-fuel-medicine-shortages/.
[4] H. Gesesew, K. Berhane, E. S. Siraj, et al., “The Impact of War on the Health System of the Tigray Region in Ethiopia: An Assessment,” BMJ Global Health 6/11 (2021).
[5] “Tigray Health Bureau Issues Urgent Appeal Warning” (see note 3).
[6] Safeguarding Health in Conflict Coalition (see note 2); United Nations Office for the Coordination of Humanitarian Affairs, “HC a.i. Statement on the Killing of 23 Aid Workers in the Tigray Region Since the Start of the Crisis” (September 2, 2021), https://reliefweb.int/report/ethiopia/hc-ai-statement-killing-23-aid-workers-tigray-region-start-crisis.
[7] T. G. Weldemichel, “Tigray War: Modern Geographies of Mass Violence and the Invisibilization of Populations,” Political Geography 118 (2025).
[8] Committee on Economic, Social and Cultural Rights, General Comment No. 14, UN Doc. E/C.12/2000/4 (2000); Human Rights Watch, “If the Soldier Dies, It’s on You”: Attacks on Medical Care in Ethiopia’s Amhara Conflict (2024).
[9] Gesesew et al. (see note 4).
[10] International Committee of the Red Cross, “Philippines: Multisectoral Training on IHL Domestic Legislation” (August 2, 2019), https://www.icrc.org/en/document/multisectoral-training-ihl-domestic-legislation.
[11] International Committee of the Red Cross, “Philippines: Strengthening Domestic Knowledge and Enforcement of International Humanitarian Law” (August 13, 2020), https://www.icrc.org/en/document/strengthening-domestic-knowledge-and-enforcement-ihl.
[12] A. Bell, “Can IHL Training Influence Military Conduct in War?,” ICRC Humanitarian Law and Policy Blog (May 7, 2024), https://blogs.icrc.org/law-and-policy/2024/05/07/can-ihl-training-influence-military-conduct-in-war.
[13] Gesesew et al. (see note 4).
[14] Committee on Economic, Social and Cultural Rights (see note 8).