The impact of economic sanctions on health and health services in the Eastern Mediterranean Region: What are the consequences?

The impact of economic sanctions on health and health services in the Eastern Mediterranean Region: What are the consequences?

1. The impact of economic sanctions on health and health services in the Eastern Mediterranean Region: What are the consequences? Iman Al Shankiti The WHO representative for Syria a.i 16 October2024

2. Objectives 2 C ontinue dialogue and awareness-raising among Member States on the impact of sanctions on health, access to health services and other sectors that can impact health; Propose the establishment of a systematic monitoring and reporting mechanism on the impact of sanctions on health and health services; and Establish and/or leverage potential high-level advocacy and communication channels for reporting on the impact of sanctions on health and health services.

3. Mr Stefan Priesner UN RC, I.R. Iran since 2021 3 Mr Priesner has extensive experience in international development and management issues and has been working with the United Nations since 1996 . He has provided policy advice to governments and overseen the formulation and delivery of a range of complex, multi-disciplinary development programmes in various countries in the Asia/Pacific and Eastern Europe . Before his current post, Mr. Priesner was the UN Resident Coordinator (UNRC) for Malaysia, Singapore and Brunei Darussalam from May 2017 to July 2021.

4. Mitigating Humanitarian Impact of Unilateral Sanctions: UN-Iran Experience Stefan Priesner, UN Resident Coordinator in I.R. Iran 16 Oct 2024

5. 5 Impact of unilateral sanctions Unilateral sanctions could create an unpredictable and often confusing operating environment. According to the report of Ms. Douhan , Special Rapporteur, unilateral sanctions impact people’s right to healthcare, create challenges for the procurement and delivery of medicines, medical equipment and other humanitarian goods [A/HRC/51/33]

6. 6 UN sanctions have lapsed Note: UNSCR 2664 (2022) approved a humanitarian exemption to asset freeze measures imposed by UN sanctions regimes Unilateral sanctions are in effect (US, Canada, UK, EU, Switzerland) Impact on UN activities in Iran Including in the areas of cooperation with international businesses, resource mobilization, procurement and shipping, and cash assistance. Unilateral sanctions in Iran

7. Case studies from the UN in Iran Procurement of Bandages for Butterfly disease affected children Procurement of COVID vaccines Procurement of high-value medical equipment for Iran using World Bank sovereign loan

8. 8 Challenges: Resource mobilization Procurement Cash assistance Solutions: Advocacy with donors UN procurement Alternative modalities for cash assistance Experience of the UN in Iran

9. 9 The United Nations could increase its comparative advantage in mitigating the humanitarian impact of sanctions in Iran by: Advocating for mixed and innovative financing models Engaging with the Government to highlight the opportunities of UN support (beyond procurement) Engaging with Member States on the impact of unilateral sanctions on UN operations, clarifying legal frameworks and identifying practical ways to address overcompliance. Looking forward

10. Thank You!

11. Mr Emmanuel Tronc Syria Country Office Director 11 As focal point for the Damascus INGOs forum for sanctions related issues, advisor for local & international organizations and researchers , Emmanuel h as spent nine years in Syria, exploring the impact of unilateral coercive measures on the population and the delivery of humanitarian aid through research, publications and interventions in international events based on systematic & systemic approaches. He is a Chemistry engineer with eighteen years ’ experience in the humanitarian & development fields in the Middle East and Latin America.

12. Systemic assessment of UCMs impact on Health in Syria Emmanuel Tronc HEKS/EPER Country Director October 16 th , 2024

13. Classification based on causal links and intentionality Impact on Health sector Impact on determinants of health Conclusions 13 Introduction

14. Least Targeted … …Most impacted

15. 2.1. Direct impact on Health Sector Private industry, trade & services Food / agriculture Public Sector Sovereign ministries Sectoral Restrictions Designation of individuals and entities Dual Use Goods Overcompliance Informal sector Energy Sector Finance sector Transport sector Health sector WASH sector Population’s Health Communication sector Conflict and consequences Local normative framework Natural factors Education sector Health Sector Direct : Indirect : Population’s health Situation: Others :

16. 2.1. Direct impact on Health Sector Private industry, trade & services Food / agriculture Public Sector Sovereign ministries Sectoral Restrictions Designation of individuals and entities Dual Use Goods Overcompliance Informal sector Energy Sector Finance sector Transport sector Health sector WASH sector Population’s Health Communication sector Conflict and consequences Local normative framework Natural factors Education sector Health Sector Direct : Indirect : Population’s health Situation: Others :

17. 2.2. Indirect impact on Health Sector Private industry, trade & services Food / agriculture Public Sector Sovereign ministries Sectoral Restrictions Designation of individuals and entities Dual Use Goods Overcompliance Informal sector Energy Sector Finance sector Transport sector Health sector WASH sector Population’s Health Communication sector Conflict and consequences Local normative framework Natural factors Education sector Health Sector Direct : Indirect : Population’s health Situation: Others :

18. 3.1. Indirect impact through targeted sectors Private industry, trade & services Food / agriculture Public Sector Sovereign ministries Sectoral Restrictions Designation of individuals and entities Dual Use Goods Overcompliance Informal sector Energy Sector Finance sector Transport sector Health sector WASH sector Population’s Health Communication sector Conflict and consequences Local normative framework Natural factors Education sector Health Sector Direct : Indirect : Population’s health Situation: Others :

19. 3.2. Indirect impact through “non targeted” sectors Private industry, trade & services Food / agriculture Public Sector Sovereign ministries Sectoral Restrictions Designation of individuals and entities Dual Use Goods Overcompliance Informal sector Energy Sector Finance sector Transport sector Health sector WASH sector Population’s Health Communication sector Conflict and consequences Local normative framework Natural factors Education sector Health Sector Direct : Indirect : Population’s health Situation: Others :

20. Aggravating factor Beyond exemption and licenses Need for monitoring Bullet point four 20 Conclusions

21. Professor Alena Douhan UNSR UCMs since 2020 21 Doctor Douhan is a Professor of International Law at the Belarusian State University and the Director of the Peace Research Center and Associated Member of the Institute for International Law of Peace and Armed Conflict at Ruhr University Bochum. Professor Douhan received her PhD at the Belarusian State University in 2005 and obtained Dr. hab. in International Law and European Law in 2015 (Belarus) . Professor Douhan worked at the UN Office in Minsk (2001-2005) and at the Economic Court of the Commonwealth of Independent States (2006-2008).

22. Notion and impacts of unilateral coercive measures Prof. Alena Douhan , Dr. Dr. hab. UN Special Rapporteur on the negative impact of unilateral coercive measures on the enjoyment of human rights The Impact of Economic Sanctions on Health , 15.10.2024

23. Unilateral sanctions Economic, financial, trade, transport, insurance, cyber etc. Sectoral Targeted Financial (SWIFT); Cyber/ defamation/ disinformation/ misinformation etc. Sanctions enforcement Secondary sanctions Criminal charges Civil penalties Administrative/ customs limitations, seizures Maximum pressure campaigns Unofficial pressure Reputational risks Over-compliance Zero-risk policies Discharge of any nexus to the countries under sanctions C omprehensive impact is to be assesed

24. Reasons and consequences of over-compliance M ultiple, over-lapping, confusing and fast changing sanctions regimes; U ncertainty: scope of sanctions, complicated regulation; exemptions; licensing; A ctive use of non-binding instruments to enforce/ enterprete binding ones treated as binding ( QA, Guidances , etc. ) ; E normous costs of sanctions compliance “due diligence” Costly, lengthy and limited de-listing/de-penalization process – access to justice; Prohibition of permitted activity by other means (no way to pay/ to insure/ to deliver); Reputational risks H igh risk of high penalties in general/ for lawyers / for humanitarian workers “presumption of legality” of UCMs N on-selectivity; D iscrimination and isolation of nationals/ companies of CuS; Isolation of peoples under sanctions B reach of co-operation networks even in the recognized emergency situations; N on-efficacy of humanitarian carve-outs; C hellenges andhigh cost of the delivery of humanitarian assistance; Non-implementation of humanitarian resolutions of the UN Security Council; Unwillingness/ fear to access justice;

25. R ight to health (report A/HRC/54/23) Challenges Impediments in delivery of medicine, medical equipment, tests, raw materials, spare parts, adaptive equipment -- Unavailability of life-saving medicines from monopolist producers; Multiplying costs of medical goods; Unavailability of rescue equipment; Limited access for cooperation for medical professionals and students, access to the newest knowledge; Limited access to teaching materials, equipment and databases; Undermined decease prevention capacities Deteriorating labor environment, insufficiency of medical professionals Deteriorating environment; Growing poverty rates, inability to pay for health insurance, medicine, medical treatment ; Reduced access to clean water and sanitation, transportation; I nefficacy and inefficiency of humanitarian exemptions; G rowing mortality rates, reduction of life expectancy; T ransportation/ electricity/ access to health facilities Access tp justice to protect the right to health

26. Monitoring tool. R ight to health S y ria Indicators Date of the imposition of sanctions:2011 Date of tightening of sanctions: 2019 Date of partial lifting of sanctions:2023 Most recent year Unit of measure Possible impact (yes/no) Mortality rate 361.7(2010) 523,3 523.3(2019) 523.3(2019) Crude death rate per 10000 population Yes Life expectancy 73,1- 74.3 (2010) 72.7(2019) 72.4(2021) 72,2 - 72.4(2021) years No Proportion of the target population covered by all vaccines included in their national programme-Diphtheria tetanus toxoid and pertussis (DTP3) immunization coverage among 1-year-olds (%) 72 54 46(2022) 46(2022) % Yes Proportion of the target population covered by all vaccines included in their national programme-Pneumococcal conjugate vaccines (PCV3) immunization coverage among 1-year-olds (%) Data not available Data not available Data not available Data not available % - Proportion of the target population covered by all vaccines included in their national programme-Measles-containing-vaccine second-dose (MCV2) immunization coverage by the locally recommended age (%) 71 54 38(2022) 38(2022) % Yes Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis Data not available Data not available Data not available Data not available % - Health worker density and distribution 13.965(2010) 11.856(2016) Data not available 11.856(2016) Medical doctors (per 10 000 population) Yes Maternal mortality 23,73114 - 52 33,04469 29.9(2020) 62 (202 1 ) per 100 000 live births Yes Coverage of essential health services 58.25(2010) 61,6   64.13(2021) % Yes Infant mortality rate 17.9 - 18.3 [14.6-21.4] 20.4 [11.1-26.2] 17.8 [9.1-25.1](2022) 17.8 [9.1-25.1](2022) ‰ No [1] Submission of Syria [2] Submission of Syria [3] Submission of Syria [4] Submission of Syria [5] Submission of Syria

27. M ost vulnerable groups W omen C hildren P regnant women/ women delivering babies P eople suffering from rare, severe, chronic deceases (communications – shifting responcibility ) P ersons with disabilities

28. Right to health (legal norms) P rinciples of international law ICCPR: right to life, freedom from torture ICESPR; CRC; CEDAW; CRPD ILO Labor environment / security standards; WHO standards; ICAO security, emissions standards; Guiding principles on Business and Human rights (obligation of due diligence, duty of case); SDGs etc. States are under obligation to make sure that their activity or activity of private businesses under their jurisdiction or control does not violate the right to the highests attainable level of health including extraterritorially – States are mutually responcible if they do not ensure relevant human rights (GC 14, CESCR)

29. references Sanctions research platform: https://sanctionsplatform.ohchr.org Sanctions monitoring tool: https://ucmmonitoring.ohchr.org Monitoring toll survey: https://survey.ohchr.org/762521?lang=en Guiding principles on UCMs, business, over-compliance and HR https://www.ohchr.org/sites/default/files/documents/issues/ucm/events/international-conf-sanctions-business-hr/gps-sanctions-business-hr-09-09-2024.pdf Conference on sanctions, business and HR: https://www.ohchr.org/en/events/events/2024/international-conference-sanctions-business-and-human-rights

30. T hank you for your attention

31. Last year the subject was introduced in RC 70 to inform MS and provide a forum for discussion. The below paper was presented The impact of economic sanctions on health and health systems in low-income and middle-income countries: a systematic review and narrative synthesis 2023 31

32. Problem statement

33. NEW paper published in BMC Public Health 17 August 2024 Direct and indirect effects of economic sanctions on health: a systematic narrative literature review 33

34. Access HSD Research and HIS HCWF Financing Raw materials Medical equipment Vaccines, chlorine tablets OOP & catastrophic HE income inequality Public budget spending on health labor outflow and migration Geographical distribution Performed health services Surgeries, quality, diagnostic services Access to scientific resources and virtual sites Direct impact of Sanctions on Health Declined Health Outcome Life expectancy, mortality rates , Poverty related diseases

35. Indirect impact of sanctions on health Socioeconomic Unemployment, and low wages Increased poverty Trade barriers Purchasing power Early life conditions Adverse long term health outcomes Underweight children and MCBA . Food & agriculture Food prices Food security Agriculture Imports – financial transactions . Risky behavior & addiction Suicide, violence, drug use and trafficking, Stress & MH Fear and uncertainty Life expectancy SDH

36. Al-Ani ZR, Al-Hiali SJ, Al-Farraji HH. Secular trend of infant mortality rate during wars and sanctions in Western Iraq. Saudi Med J. 2011;32(12):1267–73. Approximately two-thirds of deaths occurred during the neonatal period, and one third in the post neonatal periods.  

37. Moving Forward Recommendations 37

38. 38 Let's all contribute towards LEAVING NO ONE BEHIND The cost of inaction is too high