BACKGROUND: Colombia has experienced decades of conflict between the government and non-state actors. Attacks on healthcare have been a grave but regular facet of that violence. In response, the Misión Médica (MM) program was developed to support, protect, and defend healthcare. Sporadic violence continues, with many recent attacks perpetrated not by armed actors but by residents. Given the history of conflict and ongoing violence, we sought to capture the perspectives of both healthcare workers (HCWs) and community members (CMs) regarding the characteristics and impacts of attacks on health in Colombia to gain insight into how to better prevent violence and mitigate its impacts. METHODS: A cross-sectional survey was conducted from January to March 2021 in seven departments in Colombia in regions that witnessed attacks on healthcare. Questionnaires were administered to HCWs and CMs via purposive sampling, probing their experiences with attacks on health with both closed and open-ended questions. The categorical responses were stratified by health worker vs. non-health worker and descriptively analyzed. Narrative responses were analyzed via a hybrid deductive/inductive thematic approach. RESULTS: Seventy-three individuals participated in the study (36 HCWs and 37 cm). Approximately 77% of HCWs believed that attacks on healthcare impacted health outcomes while 68% of CMs did not see a direct connection between violence against healthcare and poor health outcomes. Awareness of the MM program was significantly different between HCWs (83.3%) and CMs (37.8%). The survey responses explored the characteristics of attacks on health, compounded impacts of violence on the health system, personal impacts, and perspectives on mitigation efforts. CONCLUSIONS: The study demonstrates that: (1) attacks on healthcare are context-dependent and require a local lens for mitigation and management; (2) both HCWs and CMs have critical perspectives that must be considered, (3) the impacts of violence against healthcare are complex and compounded and (4) that awareness of the legal protections of the Geneva Conventions must be combined with education on the health impacts for robust protection strategies. Critically, Both CMs and HCWs experience fear and psychosocial ramifications of these attacks, suggesting the need for stronger protections and resources to support the health workforce and the local community.

Background

Attacks on health care in armed conflict, including those on health workers, facilities, patients and transports, represent serious violations of human rights and international humanitarian law. Information about these incidents and their characteristics are available in myriad forms: as published research or commentary, investigative reports, and within online data collection initiatives. We review the research on attacks on health to understand what data they rely on, what subjects they cover and what gaps exist in order to develop a research agenda going forward.

Methods and findings

This study utilizes a systematic review of peer-reviewed to identify and understand relevant data about attacks on health in situations of conflict. We identified 1479 papers published before January 1, 2020 using systematic and hand-searching and chose 45 articles for review that matched our inclusion criteria. We extracted data on geographical and conflict foci, methodology, objectives and major themes. Among the included articles, 26 focused on assessment of evidence of attacks, 15 on analyzing their impacts, three on the legal and human rights principles and one on the methods of documentation. We analyzed article data to answer questions about where and when attacks occur and are investigated, what types of attacks occur, who is perpetrating them, and how and why they are studied. We synthesized cross-cutting themes on the impacts of these attacks, mitigation efforts, and gaps in existing data.

Conclusion

Recognizing limitations in the review, we find there have been comparatively few studies over the past four decades but the literature is growing. To deepen the discussions of the scope of attacks and to enable cross-context comparisons, documentation of attacks on health must be enhanced to make the data more consistent, more thorough, more accessible, include diverse perspectives, and clarify taxonomy. As the research on attacks on health expands, practical questions on how the data is utilized for advocacy, protection and accountability must be prioritized.