Could you please explain how your organization is currently or could in the future be involved in ensuring that hospitals remain protected in accordance with IHL?

Nicolas Gérard: Our Office is mandated by the United Nations [UN] Security Council to monitor the six grave violations against children, including attacks on schools and hospitals, in order to provide a comprehensive picture of how armed conflict affects children.Footnote ¹ As part of this mandate, we verify incidents of attacks on health facilities and cases where hospitals are used for military purposes, with the aim of prompting concrete remedial action. In 2025, most incidents of attacks on hospitals were verified in Israel and the Occupied Palestinian Territory, Ukraine, Sudan, Myanmar, the Democratic Republic of the Congo and Syria.

This work is part of a broader UN effort to protect medical facilities. It includes programmatic responses to mitigate attacks, as well as advocacy to ensure that hospitals are vacated after having been used by military actors. Engagement happens both in the field and at the political level, including in New York.

The Security Council has also requested the Secretary-General to identify persistent perpetrators of attacks against hospitals in the annexes to his annual reports.Footnote ² This listing mechanism is designed to incentivize parties to adopt and implement action plans, including measures to prevent attacks against hospitals and to vacate them when used by armed forces or groups. While our work contributes to broader normative efforts to strengthen the protection of medical facilities, we assess these violations through a child protection lens.

Finally, we work closely with the World Health Organization [WHO], particularly through its Surveillance System for Attacks on Health Care, to present to the international community a more comprehensive picture of attacks on health care.

Vaios Koutroulis: The legal basis of the International Humanitarian Fact-Finding Commission [IHFFC] is Article 90 of Additional Protocol I [AP I]. The Commission was established with a twofold mandate. First, under Article 90(2)(c)(i) and Article 90(2)(d), it is tasked with inquiring into grave breaches of the Geneva Conventions and AP I or other violations of international humanitarian law [IHL]. Second, under Article 90(2)(c)(ii), it is mandated to facilitate, through its good offices, the restoration of respect for the Conventions and the Protocol.

Within this framework, the IHFFC may be engaged in fact-finding missions concerning allegations of violations related to the protection of hospitals during armed conflict. This reflects the Commission’s more traditional role. In such cases, an alleged attack against a hospital – potentially amounting to a grave breach or serious violation of IHL – would be the subject of a request for inquiry.

Beyond this investigative function, the IHFFC’s good offices mandate allows it to support follow-up engagement, including encouraging the implementation of any recommendations arising from an inquiry. In addition, the Commission offers a further avenue for engagement: it may address allegations of the misuse of hospitals before an incident occurs, thereby facilitating the restoration of respect for the rules relating to the protection of hospitals and contributing to the prevention of further serious violations.

Claude Maon: Médecins Sans Frontières [MSF] is an independent, privately funded medical humanitarian organization established in the 1970s. With more than fifty years of experience, it is now one of the largest private medical humanitarian actors globally. MSF operates in over seventy countries, including many affected by armed conflict.

Given this operational context, MSF has long been engaged in efforts to protect its medical facilities in conflict settings. This engagement takes multiple forms. Guided by IHL, and as reflected in its strict operational framework for security and medical ethics, MSF consistently advocates for access to medical care for all wounded and sick persons, including wounded combatants from opposing parties, without discrimination. The organization also enforces a strict no-weapons policy within its medical facilities and limits the presence and involvement of military and law enforcement actors. When acting in partnership with national health authorities, MSF applies the same principles, while not assuming full responsibility for their implementation.

Many States, institutions and academics take the position that the rules under IHL are already clear and afford strong protections to medical facilities – in your view, why does implementation remain a challenge in practice? What approaches has your organization used to address this?

Claude Maon: Three main factors help explain this situation: legal, practical and political.

From a legal perspective, while IHL affords protection to hospitals, it also provides for exceptions where such facilities are used for military purposes outside their humanitarian function. In practice, however, these exceptions are often subject to unilateral and opportunistic interpretation by parties to a conflict. A further, frequently under-appreciated challenge arises from the interaction between IHL and domestic counterterrorism frameworks. In many States, legislation defines offences such as “material support to terrorism” in broad terms, with the result that providing medical care to wounded members of non-State armed groups – an explicit obligation under IHL – may be criminalized. This effectively weaponizes domestic law against compliance with IHL.Footnote ³ While some States, such as Switzerland, have introduced explicit humanitarian exemptions, others have not, despite being party to the relevant treaties. These exemptions are integral to ensuring the protection of hospitals, particularly in a context where counterterrorism narratives are increasingly invoked to justify attacks on facilities alleged to be supporting terrorists.

From a practical perspective, the unilateral interpretation and assessment of when medical facilities and personnel lose their protection contribute significantly to current shortcomings. Determinations of loss of protection require clear definitional guidance and transparent assessment mechanisms, which are almost always lacking.

From a political perspective, in certain contexts, depriving the enemy and associated populations of access to health care is not merely an incidental effect of hostilities but forms part of a deliberate strategy aimed at deterrence or punishment. Such intent is rarely acknowledged by the parties concerned, and is often masked by arguments that hospitals and medical personnel have lost their protected status.

In response, our organization has pursued several approaches. We have a long-standing practice of calling for independent investigations, including by the IHFFC, to assess both the factual circumstances and the legal assessment of attacks. In some cases, we also engage directly with national judicial or military investigation systems. In addition, we have conducted internal fact-finding exercises following major attacks on MSF-supported facilities. These analyses enable a detailed examination of the circumstances of each incident and provide a basis for engaging with the assessments put forward by military actors. Such case-based analysis has proven valuable in identifying areas of ambiguity within IHL that may contribute to errors, misuse or violations. It has also, in some instances, led to acknowledgment of responsibility and assurances of non-repetition, which we regard as an important step towards accountability.

Claire Bertouille: Three main factors may help to explain the persistent gap in the implementation of otherwise clear legal rules. First, contemporary armed conflicts are increasingly conducted in densely populated urban environments, where hospitals and other civilian infrastructure are situated in close proximity to potential military objectives. Essential services are also highly interconnected: damage to electricity, water or telecommunications infrastructure can have significant effects on the functioning of health-care facilities. This raises complex questions regarding how parties to a conflict apply the principles of proportionality and precaution, particularly in relation to reverberating effects in urban warfare. The use of explosive weapons in populated areas is of particular concern in this regard, given its disproportionate impact on children, and remains a key focus of advocacy.

Second, there are significant gaps in training and operational guidance. Many armed forces and non-State armed groups lack adequate training in IHL, and fragmented command structures can further complicate engagement as well as dissemination and enforcement of relevant norms. Military doctrine often provides limited guidance on the protection of health care, including with respect to both direct and indirect effects of military operations. In addition, deficiencies in targeting processes – such as incomplete or outdated no-strike lists – and in the practical implementation of advance warning requirements exacerbate the risks faced by health-care facilities. More broadly, there is a shortage of practical examples and operational guidance on how these obligations should be implemented, alongside a persistent accountability gap. We therefore welcome the outcome document of the Global Initiative to Galvanize Political Commitment to IHL [Global IHL Initiative], which offers concrete guidance on how these rules can be put into practice

Third, attacks on health care frequently go uninvestigated at the domestic level, reflecting weaknesses in national accountability systems. This lack of accountability undermines deterrence and contributes to the persistence of impunity.

In response to the three challenges identified above, the Office of the Special Representative of the Secretary-General for Children and Armed Conflict centres its work on the Monitoring and Reporting Mechanism [MRM],Footnote ⁴ which collects data on the six grave violations, including attacks against hospitals. This data underpins evidence-based advocacy, informs the Secretary-General’s annual reports on children and armed conflict, and supports engagement with parties to conflict to end and prevent such attacks. The Office applies a combination of advocacy, both public and private, including through the Security Council Working Group on Children and Armed Conflict.Footnote ⁵ It also supports capacity-building efforts with UN partners in the field, aimed at integrating the protection of health-care into standard operating procedures [SOPs] and rules of engagement, as well as codes of conduct, thereby fostering a culture of respect for IHL. Finally, it promotes accountability, including by encouraging the criminalization of attacks against hospitals at the national level and by using the listing mechanism to incentivize behavioural change.

Vaios Koutroulis: Despite the requirement to interpret exceptions under IHL in good faith, there is a concerning tendency in practice to invert the relationship between rule and exception. Overly broad or abusive interpretations risk transforming what is intended as a narrowly defined exception into the norm, thereby undermining the protective rule itself.

Ultimately, this points to the central issue of incentives. States must recognize that expansive or abusive interpretations of IHL, even when perceived as advantageous in the short term, carry longer-term risks. Once such interpretations are articulated, they may be invoked by others in future conflicts, including in ways that affect a State’s own population, including the wounded and sick. This short-term approach fails to account for the cumulative and reciprocal nature of legal interpretation in international law.

Although the IHFFC has not yet established specific practice with respect to the protection of hospitals in armed conflict, it systematically offers its services to parties to armed conflicts in relation to specific incidents, in accordance with Article 90 of AP I. In this context, the Commission regularly proposes both its good offices and fact-finding mandate to States confronted with situations involving alleged violations of IHL rules.

The IHFFC thus remains active in situations where there is a risk of grave breaches or other serious violations of IHL. A positive response to such offers from parties to the conflict would strengthen the implementation of IHL and allow the Commission to play the role it is designed to play in ensuring respect for IHL, including for the rules relating to the protection of hospitals.

Many international actors stress the urgent need to take action while pointing out that attacks on hospitals are ongoing, with serious humanitarian consequences. What actions should States prioritize within the next year?

Claude Maon: Hospitals in conflict zones are being attacked at levels not seen in the past; patients are dying from preventable causes, and these consequences are both widely known and highly visible. In this context, States should adopt policy frameworks – consistent with initiatives such as the International Committee of the Red Cross’s [ICRC] Global IHL Initiative – that endorse and consolidate existing good practices developed and implemented at the operational level. Such frameworks should enable the effective operationalization of IHL protections for medical missions, including in the interaction between armed forces and humanitarian and medical actors.

At a minimum, these policy frameworks should include several core elements. They should require high-level command authorization for any military action affecting a medical facility. They should establish mandatory advance warning procedures, ensuring that the medical organization concerned is notified with sufficient time to take protective measures. They should also require the provision of specific and transparent information regarding any alleged military misuse of medical facilities, which needs to be duly established and verified, rather than relying on generalized assertions of dual use. In addition, they should ensure the activation of independent fact-finding mechanisms, such as the IHFFC or other appropriate bodies, to verify allegations made before or after the attack: since an attack can be legitimized by allegations made before and after the attack, fact-finding mechanisms should be able to verify both types of allegations.

These measures are not theoretical – they are reflected in existing good practices that have been implemented in operational contexts, including through engagement with armed forces in settings such as Afghanistan and Yemen. What remains lacking is their formal endorsement and integration into binding political commitments and military doctrine at the State level. The burden should not rest on medical actors and humanitarian organizations to continually persuade parties to respect and protect medical missions.

The obligation to protect medical facilities is a legal one, binding on all parties to armed conflict, including both States and non-State armed groups. Reliance only on ex post facto criminal accountability or on the individual responsibility of commanders to apply proportionality assessments when attacking hospitals is both insufficient and, at times, disingenuous. It is first and foremost the responsibility of States to define, adopt and disseminate clear political and military doctrine, as well as operational guidance, that effectively constrains attacks on hospitals and guarantees access to health care for victims of armed conflict.

The forthcoming tenth anniversary of Security Council Resolution 2286, adopted in May 2016, provides a timely opportunity for States to translate existing commitments into practice. A decade after the resolution’s adoption, the situation has significantly deteriorated, underscoring the urgency of renewed and concrete action. The resolution already calls upon all parties to comply with IHL in relation to medical personnel and facilities; the challenge lies in implementation.

MSF does not call for new legal frameworks or mechanisms – rather, the priority is to promote and operationalize good practices that are fully compatible with existing IHL obligations. States should ensure that forthcoming recommendations – whether arising from the Global IHL Initiative or the anniversary of Resolution 2286 – are explicitly aligned with existing frameworks, including Resolution 2286 itself, the MRM, and the Secretary-General’s annual reports on children and armed conflict. Recommendations developed in isolation from these established reporting and accountability mechanisms are unlikely to produce meaningful change; by contrast, systematically integrating data on attacks against hospitals into these existing mechanisms represents a concrete and achievable step towards improving compliance.

Nicolas Gérard: Given our primary engagement with the Security Council, it is essential that Council members – and States more broadly – consistently push back against overly permissive interpretations of IHL. This includes using all available tools to reaffirm the special protection afforded to health-care facilities, and their civilian character. Public reaffirmation by States of existing norms is critical to their respect, while private diplomatic engagement – whether bilateral, multilateral or regional – can reinforce these efforts. Together, these approaches are essential to counter interpretations that risk legitimizing attacks on health-care facilities and personnel, which are incompatible with IHL.

Importantly, the pattern of harm extends beyond damage to infrastructure: attacks are also increasingly directed against health-care workers and related personnels. These violations should carry legal, political and reputational consequences. In this context, and within the scope of our mandate, third States play a key role in encouraging and pressuring parties to conflicts to engage with the UN, including our Office, particularly where such parties have been listed in the annexes of the Secretary-General’s annual reports. This engagement is essential to secure concrete commitments aimed at strengthening compliance with IHL and enhancing the protection of hospitals, including from a child protection perspective.

At the same time, accountability and remedial efforts must be reinforced. WHO is placing increasing emphasis on accountability for attacks on health care, and States should actively support its surveillance systems and related initiatives. WHO has identified a number of practical measures that require implementation, including the restoration of damaged health-care facilities, the maintenance of medical supply chains, and the provision of emergency care and support to health-care workers in order to sustain essential services. These efforts depend on sustained and predictable funding, which remains a critical component of the overall response.

Attacks against health care raise a more fundamental concern: they call into question whether the core humanitarian rationale underpinning IHL is being respected. In many respects, the current situation echoes the conditions that prompted the creation of the first Geneva Convention in 1864. The foundational impulse – to prevent the abandonment of wounded and sick individuals without care – remains as relevant today as it was at that time. The present moment therefore requires a renewed effort to place humanity at the centre of IHL and to reaffirm the principles that gave rise to the Geneva Conventions in the first place.

Professor Koutroulis, how can the services of the IHFFC be used to enable rapid verification of claims that medical facilities are being misused? How can the IHFFC’s mandate be more effectively applied to investigate violations of IHL protecting medical facilities? In these situations, what measures could help to ensure that there is meaningful follow-up – beyond the submission of confidential reports to the parties to the conflict – to effectively restore respect for IHL among the belligerents?

Vaios Koutroulis: This question brings us to the core of the IHFFC mandate and the conditions under which the Commission’s competence can be triggered. A defining feature of the Commission, as originally conceived, is that it can only operate and fulfil its investigative mandate with the consent of the States concerned. This distinguishes it from other fact-finding mechanisms, which are frequently criticized by parties alleged to have violated IHL, particularly on the grounds of limited access to information or methodological shortcomings. The IHFFC addresses precisely this concern. By securing the consent of the parties involved in the alleged violation or violations, it aims to ensure that the establishment of facts is entrusted to an independent and impartial body whose action is accepted by the relevant belligerent parties.

In situations involving allegations of misuse of hospitals, parties to a conflict could agree to refer the matter to an independent mechanism before undertaking further military action against the facility concerned. Such an approach would allow for the verification of allegations while preserving the protection of the wounded and sick receiving treatment. This reflects the logic of the relevant IHL rules, which prioritize the protection of health care over short-term military advantage. However, this scenario presupposes a willingness on the part of belligerents to indeed make the protection of health care a priority during armed conflict.

In this respect, it is important to distinguish inquiries from good offices missions. The latter may include appropriate determinations of law and fact and do not necessarily require the consent of all parties to an armed conflict; rather, they are intended to facilitate the restoration of an attitude of respect for IHL by identifying, for the State or the international organization requesting the good offices, elements conducive to that objective. It should be noted, however, that it is difficult to envisage how factual determinations regarding the alleged misuse of hospitals during ongoing hostilities could be credibly made without the consent of all parties to an armed conflict. Establishing whether a medical facility has lost its protection will normally require access to information from all sides of the conflict. In practice, post-incident assessments are often characterized by competing narratives: one party will probably allege that a medical facility was misused in order to commit acts harmful to the enemy and as a consequence became a lawful target, while the other will deny any such conduct and maintain that the hospital retained its protected status. Without access to the factual basis underpinning both accounts, any determination risks lacking credibility.

This underscores the rationale behind the IHFFC’s design. Its mandate reflects the assumption that belligerent parties would recognize the value of an independent mechanism capable of establishing facts in a manner that is both impartial and authoritative. The added value of such a mechanism becomes more apparent in view of the increasing perception that national inquiries on problematic incidents lack the credibility necessary to put to rest allegations of violations of IHL. The gravity of the alleged violations involving attacks on hospitals – one should not forget that the rules relating to the protection of the wounded and sick and the correlative protection awarded to medical facilities and personnel are among the oldest in IHL – increases the need for an efficient reaction on the part of the belligerent parties. In this sense, the system relies on a degree of trust – trust that States continue to value the importance of IHL rules protecting hospitals and will therefore consent to independent scrutiny in order to effectively dispel any allegations of misconduct on their part. To date, however, this expectation has remained largely unfulfilled, and neither the IHFFC nor any comparable mechanism has been systematically used to clarify such incidents.

Beyond its fact-finding function, as was mentioned above, the IHFFC’s mandate also includes good offices in order to facilitate the restoration of respect for IHL. Such good offices enable follow-up engagement, even though the Commission’s reports are confidential. In this respect, the functioning of the IHFFC’s approach bears some similarity to that of the ICRC, combining confidential assessment with dialogue aimed at improving compliance. If invited, the IHFFC may continue to engage with the parties to the conflict following the submission of its report, with a view to supporting implementation of, and strengthening respect for, IHL. This non-public, cooperative approach – eschewing naming and shaming – constitutes a distinctive and valuable aspect of the Commission’s contribution.

How can senior military leadership of State armed forces or non-State armed groups be compelled to take responsibility for enforcing the protections due to hospitals within the military rank and file? How can the political leadership be harnessed to achieve this?

Nicolas Gérard: Our Office maintains sustained engagement, both in New York and in the field, with military leadership, armed forces and armed groups, as well as with political authorities. This allows for a continuous stream of advocacy. Historically, the impact of this mandate has been reinforced by its visibility in Security Council documents and reports. In particular, the inclusion of perpetrators of grave violations in the annexes to the Secretary-General’s annual reports on children and armed conflict has proven to be an effective tool for exerting influence on both military and political leadership. Such listing has carried weight by signalling that violations are documented and visible, thereby introducing a degree of political accountability and encouraging behavioural change.

At present, however, this form of external political leverage appears more challenging than in the past. In response, we increasingly rely on the influence of third States that maintain bilateral or political relationships with parties to a conflict. By engaging these States, we encourage them to use their leverage to convey messages on compliance and to reinforce the importance of respecting IHL.

In the past, many parties to conflict – including non-State armed groups – sought to demonstrate their compliance with international norms as a means of affirming their status within the international community. Some even relied on IHL-based arguments to support claims of compliance, including with respect to the protection of children. While the mandate of our Office adopts a broader understanding of child protection, it has been notable that such actors engaged with the legal framework and invoked it in their own discourse. This suggests that the desire to be perceived as compliant actors can, and should, be leveraged.

Engagement with political leadership is particularly important in influencing the conduct of military actors. Even in contexts where military authorities hold significant power, there are often internal dynamics that can be shaped. Through sustained engagement, it is possible to engage with those actors who are receptive to humanitarian norms, thereby shifting the balance within political and military structures.

Action plans represent a key tool in this regard. While they are typically concluded with military actors, the involvement of political leadership has proven critical for their effective implementation. Political engagement can facilitate the development of internal norms within armed groups and support the adoption of relevant legislation by States, and this, in turn, strengthens accountability and promotes compliance.

Practical measures are also essential. These include the development of tools such as clearly marked maps of protected sites, operational reminders for personnel, and field-level supervision mechanisms. Such measures help ensure that military actors are aware of the location of protected facilities and understand the applicable rules. Political leadership plays a key role in framing these efforts, ensuring that public commitments, internal directives and official messaging consistently reinforce that attacks on health-care facilities are unacceptable.

Finally, accountability must be pursued through multiple avenues. Listing in the annexes of the Secretary-General’s annual reports constitutes one form of political accountability; beyond this, it is essential to establish internal mechanisms within armed forces and armed groups to investigate incidents, draw lessons and prevent recurrence.

Claude Maon: SOPs and good practices should require high-level command authorization prior to any military action affecting a medical facility. In situations where a loss of protection is alleged, and where, following an assessment of all relevant principles governing the conduct of hostilities, a military objective is considered to have been identified, such authorization should be elevated to the highest political level. Decisions of this nature should not rest solely within the military chain of command but require approval at the level of the head of State or government.

A second key measure is the adoption of a zero-tolerance approach to attacks on hospitals within the military hierarchy. Such incidents are often framed as failures in the chain of command rather than as the result of deliberate policy. However, if commanders face clear and meaningful consequences for violations – including the prospect of career-ending sanctions – this may strengthen incentives to comply with IHL.

Third, the protection of hospitals should be integrated into the definition of mission success. Ensuring the continued availability of medical care for the civilian population, as well as for the wounded and sick, should be treated as a core operational objective rather than as a secondary consideration.

Finally, there is a need for sustained investment in IHL education and training at all levels of the military. This should extend beyond legal specialists to include all personnel involved in operations. Future commanders, in particular, must develop a thorough understanding that the protection of medical infrastructure is not only a legal obligation but also an operational imperative, and cannot be relegated to merely being a “good practice”.

Many argue that relying solely on criminal justice is insufficient. What are the alternative accountability approaches that could complement criminal justice mechanisms while still ensuring – particularly from the perspective of affected populations – that justice is both done and seen to be done?

Claude Maon: Accountability mechanisms can, at times, risk becoming a substitute for meaningful outcomes. States may establish investigative processes that ultimately fail to produce concrete results, thereby allowing procedure to stand in for accountability. While MSF fully supports the establishment of mechanisms to investigate allegations, it emphasizes that systems based on military self-investigation cannot be considered genuinely independent. Any credible accountability framework must incorporate elements of independence, whether through national judicial oversight, independent commissions or international mechanisms.

In this context, restorative and non-judicial approaches – such as truth commissions, public hearings and community-based reparation schemes – can play an important complementary role. These mechanisms can provide visible acknowledgment of harm without requiring the high evidentiary threshold associated with criminal convictions, which is often difficult to meet in practice. Access to relevant facts is frequently constrained by military secrecy, making the establishment of criminal responsibility particularly challenging.

By contrast, civil litigation before national or international courts has, in some instances, proven effective. The prospect of such proceedings can incentivize States to disclose operational information and acknowledge institutional responsibility.

Finally, the IHFFC, particularly through its good offices function, could – if activated – serve as a neutral intermediary. In situations where criminal accountability is politically blocked, it may facilitate dialogue between parties and support the adoption of corrective measures.

Vaios Koutroulis: There is a persistent risk that discussions on accountability may serve to deflect rather than address responsibility. In some cases, the existence of investigative processes can obscure a reluctance to acknowledge responsibility for specific incidents.

In certain contexts, parliamentary commissions have provided an alternative avenue for oversight. Where parliaments are able to exercise meaningful control over the executive and military, such bodies have, at times, compelled the declassification of sensitive information. This can offer a means of addressing problematic incidents without necessarily resorting to criminal proceedings.

Independent international mechanisms also have a role to play. Beyond the fact-finding missions and commissions of inquiry mandated by the Human Rights Council which are more commonly envisaged, panels of inquiry established under the authority of the Secretary-General to investigate specific incidents represent a further option. This is a tool that has arguably been under-utilized to date, and which could be deployed more systematically in response to incidents such as attacks on hospitals.

The IHFFC, established in 1991 and currently recognized by seventy-eight States that have accepted its competence,Footnote ⁶ provides a further example. Despite its tailored and flexible mandate, it has been significantly under-used; to date, it has been activated in only two instances, in 2017 and 2024. This reflects not an absence of available mechanisms, but rather a lack of awareness of them, or more fundamentally, a lack of political will to make use of them. The Commission offers a versatile tool: its mandate can be confined to fact-finding or extended to include good offices aimed at facilitating respect for IHL. Moreover, since it is a permanent body with already established rules and operational guidelines, it can react swiftly to a request and deploy a mission on short notice. Its limited use underscores the broader challenge of securing State acceptance of international scrutiny and oversight.

Claire Bertouille: The mandate of the Office of the Special Representative for Children and Armed Conflict is, in itself, an accountability mechanism aimed at promoting compliance with international law. It can serve as a catalyst for behavioural change among parties to conflict, encouraging engagement with the UN and the adoption of remedial measures to enhance restraint and compliance with IHL.

Action plans are a central component of this framework. Even where implementation remains incomplete, the existence of such processes provides a framework for dialogue, progress and accountability. For non-State armed groups in particular, engagement through action plans offers a credible mechanism for interaction with the UN, supporting improved compliance while also, in some cases, reinforcing internal norms and values conducive to restraint.

At the national level, the mandate also supports efforts to strengthen accountability through the development of domestic legal frameworks. This includes promoting the criminalization of the six grave violations in national legislation, including those relating to attacks on hospitals, which has been achieved in a number of contexts.

Another important dimension of accountability lies in engagement with international human rights mechanisms. The Office of the Special Representative for Children and Armed Conflict regularly contributes to Universal Periodic Review processes and reviews of country reports before the Committee on the Rights of the Child. These processes require States to report on implementation, identify gaps and respond to recommendations, thereby providing an additional layer of scrutiny and accountability.

One of the major stumbling blocks to accountability is ensuring transparency, such as declassifying military information and reporting publicly. What approaches have best worked to make such information available to domestic and international investigative bodies while protecting national security concerns?

Claude Maon: From MSF’s experience, the most effective approaches to transparency combine legal pressure with sustained political advocacy. Litigation before domestic courts has, in some instances, compelled States to declassify operational military records. In parallel, MSF’s systematic independent documentation – through what may be described as its own fact-finding processes – has enabled the establishment of an alternative factual record capable of challenging official military narratives and stimulating public debate.

A well-known example is the attack on the MSF hospital in Kunduz, Afghanistan. In the immediate aftermath, the narrative advanced by the United States referred to a loss of protection of the facility. Through its own investigation, however, MSF was able to demonstrate that it retained control of the hospital at the time of the attack and that the legal basis for such a claim could not be sustained. The initial narrative was subsequently abandoned and replaced by the characterization of the incident as a mistake in the fog of war, which remains the prevailing account.

A key factor in enabling this shift was the existence of detailed and credible internal fact-finding investigation conducted by MSF. However, conducting such investigations requires significant resources and technical capacity, which many medical actors – particularly public hospitals and smaller non-governmental organizations – do not possess. This underscores the need to strengthen independent fact-finding mechanisms capable of investigating attacks on health-care facilities. When their findings are made public, they can contribute to informed public debate and, in some cases, create pressure for further disclosure, including the declassification of relevant information.

At the international level, existing mechanisms – such as the Secretary-General’s reporting under Security Council Resolution 2286, and the MRM – also play an important role by establishing structured expectations for transparency and reporting.

Mr Gérard, are there action plans linked with State armed forces or non-State armed groups listed in the Secretary-General’s annual reports on children and armed conflict that have proven effective in changing the behaviour of those who have violated IHL, particularly regarding the protection of medical facilities?

Nicolas Gérard: A number of action plans developed with parties listed in the annexes to the Secretary-General’s reports include provisions relating to the protection of health-care facilities and personnel. Historically, these action plans have focused primarily on ending the recruitment and use of children, as well as the killing and maiming of children. In recent years, however, greater emphasis has been placed on addressing attacks on hospitals, often in conjunction with attacks on schools. For example, the action plan signed with the government of South Sudan contains commitments relating to the protection of hospitals, such as reviewing military planning and rules of engagement, and ensuring that any health-care facility used by the military is vacated.

A key area of focus concerns the military use of health-care facilities. Action plans typically include commitments to vacate hospitals used by armed forces or armed groups; they also provide for integrating protections for health-care facilities into military orders and directives issued to commanders and rank-and-file personnel, as well as codes of conduct, with the aim of preventing attacks. In addition, such plans may establish internal disciplinary measures within armed forces or armed groups for violations of these directives. All action plans also require armed forces or armed groups to designate child protection focal points who can be consulted when planning operations.

All the mechanisms mentioned above help ensure that the protection of hospitals – and their importance in the context of child protection – is taken into account at the operational level. More broadly, efforts have been made to integrate the protection of health care into military doctrine, rules of engagement and training materials for both armed forces and non-State armed groups, as applicable.

Another important component is the inclusion of post-incident review mechanisms – action plans often provide for the systematic review of incidents involving attacks on hospitals and other grave violations. Such reviews are particularly important in contexts where armed forces or armed groups have limited institutional capacity. They contribute to building an evidence base, clarifying the circumstances of incidents and identifying measures to prevent recurrence.

Finally, action plans typically include commitments to conduct training on IHL, particularly with respect to the protection of health care, as well as to criminalize conduct prohibited under IHL and to investigate alleged violations.

Ms Maon, could you share an example from your operational dialogue where engagement led to concrete changes in behaviour by armed groups or State armed forces alleged to have violated IHL in relation to the protection of hospitals?

Claude Maon: An illustrative example can be drawn from MSF’s engagement in Yemen. In 2018, discussions with the Saudi-led coalition led to the development of a practical SOP for the identification and protection of MSF hospitals. Similar SOPs had previously been developed in Afghanistan, in cooperation with Afghan armed forces and security actors, and they were subsequently adapted and implemented in the Yemeni context.

This framework included both visual and GPS-based identification of MSF facilities. It also established a dedicated communication channel between the parties to the conflict and MSF, enabling the rapid exchange of information in cases of suspected military misuse of health-care facilities. This mechanism allowed for the transmission of specific and transparent information regarding the nature of any alleged misuse.

In addition, the SOP provided for advance warning procedures: a minimum of forty-eight hours’ notice was to be given to MSF in situations where concerns regarding misuse arose, allowing time for remedial measures to be taken. The SOP also required advance notification prior to any form of military interference within a medical facility, including actions such as the interrogation or arrest of patients or staff.

We believe these measures contributed to a tangible reduction in attacks against MSF facilities in both countries at the time.