April 2019 marked the fifth anniversary since the start of the conflict in eastern Ukraine, a conflict which began in 2014 and followed in the ill-fated wake of the Ukrainian Revolution and Euromaidan movement. These protests took place after the annexation of Crimea by the Russian Federation, and were part of a broader group of simultaneous pro-Russian protests in southern and eastern Ukraine, leading to armed conflict between the self-proclaimed Donetsk People’s Republic and Luhansk People’s Republic (DPR and LPR, respectively) and the Ukrainian Government. Despite European Union (EU) countries, with the initiative of France and Germany, facilitating the signing of the Minsk Protocol between Ukraine, Russia, DPR and LPR to establish a ceasefire, it did not halt or reduce the intensity of the conflict, unfortunately, since ceasefire violations by both parties became a common occurrence.
In 2019, the active armed conflict in eastern Ukraine continues to take lives and damage homes and civilian structures on the European Union’s doorstep. In excess of 13,000 people have died (approximately 3,000 of them civilians) and 800,000 have been displaced. Around 5.2 million people have been affected by the conflict, of which 3.5 million need humanitarian aid and protection, with old people, low-income workers, people with chronic illnesses, people with disabilities and women and children the most affected. Their main concerns are a lack of security and not being able to abandon their homes, often relying on modest incomes and their families or neighbours to access basic services and food. In short, to survive.
As the conflict intensified, a de facto border of 500-odd kilometres between government-controlled areas and non-government-controlled areas (GCAs and NGCAs, respectively) was erected. As a result, the Ukraine Government established a strict regime of crossings which, since then, has restricted the population’s freedom of movement between the said areas. On the other side of the “line of contact”, de facto authorities have also imposed restrictions upon transferring goods and access to humanitarian workers.
This so-called line of contact divides traditionally united regions, impeding access to essential services, separating families and stopping the population from obtaining any form of support, as well as altering social relationships. Essentially, the conflict has separated rural areas and small cities belonging to the government-controlled area from the major cities of Luhansk and Donetsk, which provide services in the area. Both cities are now located in a non-government-controlled area and, therefore, the people affected by the conflict have to deal with physical and non-physical obstacles to access basic services such as health care and social services.
Despite this, many men, women and families regularly cross the border to see their families, visit properties, withdraw money, receive pension payments (although the Ukraine Government has suspended pension payments for the entire population living in the non-government controlled area) and to gain access to legal services. In 2018, a monthly average in excess of one million people crossing the line of contact was recorded.
Nevertheless, this crossing gives rise to a series of difficulties. There are only five Entry/Exit Crossing Points (EECPs) across the 500-kilometre line of contact and 30,000 people have to cross them each day. Four of those points are located in the Donetsk oblast and can be crossed with vehicles. In the Luhansk oblast there is only one crossing point and pedestrians have to pass over an unstable bridge, damaged by the bombings, and quite possibly surrounded by unexploded ordnance. This means the crossing could last for a number of hours due to queues, processing and long waits.
The health care system has been directly affected by the conflict, which has caused a deterioration in both the quality of services and accessibility. Out of everyone affected, around 1.3 million people in a 20-km radius around the line of contact need basic health care services. It is also important to underline how, among all populations currently receiving humanitarian aid, Ukraine has the highest percentage of elderly people (over 60s), which rises to 30%. Up to 87% of those have specific health care needs that remain unmet.
Access to basic health care has been seriously altered, in both GCAs and NGCAs. Prior to the conflict, people living in conflict-affected areas, now government-controlled areas, depended on health care centres located in Donetsk and Luhansk to receive secondary and tertiary care. For the time being, different limitations — new and existing – faced by health centres, such as movement restrictions, and including line of contact crossings, play an important part.
In a region with an already deteriorating economic situation caused by the conflict, damages to roads, movement restrictions, the lack of public transport and the ensuing rise of transport costs have lowered the population’s capacity to reach health centres. Moreover, the lack of treatments and medicines is a threat to the survival of patients suffering from diabetes, cancer, and cardiovascular illnesses such as high blood pressure, which is extremely common, affecting more than half the population aged 50 and over. Chemists are limited in the areas closest to the line of contact and have raised the prices of almost all pharmaceutical drugs, which further hampers tending to the population’s health. A lack of human resources specialised in health care is also a major cause of reduced availability of health care in these areas, with many specialist staff leaving the zone with the outbreak of the conflict: 1,500 health professionals have left conflict-affected areas since 2014.
Many qualified workers have abandoned non-government-controlled areas and the trade embargo imposed by the Ukrainian Government also reduces the availability of pharmaceutical drugs and medical equipment — the country’s population depends on supplies from the Russian Federation. The conflict has damaged a wide range of health facilities and equipment that was already obsolete before the start of the conflict. One such case is the Luhansk Regional Children’s Hospital.
This separation, its impact, and the general environment created by the conflict has seriously affected the mental health of people living in GCAs and NGCAs. The lack of access to services is coupled with the loss (or separation) of families and friendships, deteriorating living conditions and people unable to guarantee their own or their families’ subsistence, as well as the dangers involved in a permanent conflict. This has immediate and long-term effects on children, families and communities and continues to impede life carrying on normally. The situation affects not only patients but also health care staff, who live in the same communities as the people they support.
Women and girls are the most vulnerable as they are exposed to conflict-related risks and face the possibility of suffering violence and abuse. As gender-based violence increases, so too the general needs. Reports of gender and sexual violence (including conflict-related) are still significantly low and are not adequately addressed with the resources and health services available.
Since the start of the conflict, international humanitarian aid organisations started to provide assistance and support to affected populations located on both sides of the line of contact. However, humanitarian aid agencies operate without a specific mechanism to facilitate access for the country’s population to this type of assistance.
In the non-government-controlled areas, in the regions of Luhansk and Donetsk, registration procedures imposed by de facto authorities largely make access to humanitarian aid difficult.
In territories under government control, health reforms and decentralisation carried out by the government further hinders access to health services: the local civil and military administration is responsible for these conflict-affected areas, and has numerous problems applying new regulations, which in turn negatively impacts communities and people living there.