SURVEY ON MEDICAL ASSISTANCE AT EECP 1 

1. Introduction ...... 2

2. Glossary ...... 3

3. Methodology ...... 4

4. The concept and regulatory framework of the EECP ...... 5

5. Medical care (guarantees, types, entities) ...... 6

5.1 Statutory regulation of medical care ...... 6

5.2 Types of medical care ...... 7

5.3 Medical care players ...... 8

6. Quantitative and demographic data on the EECP crossing ...... 9

7. Factors that cause increased demand for health care at EECPs ...... 11

8. Medical service at EECPs ...... 12

8.1 Health care infrastructure at checkpoints ...... 13

8.2 Premedical care ...... 15

8.3 Primary medical care ...... 16

8.4 Emergency Medical Care (EMC) ...... 18

9. Special aspects of the medical reform implementation in the territory near the line of contact ...... 22

10. Conclusions and recommendations ...... 25

This monitoring was carried out by the Charitable Fund «Right to Protection» (R2P) under the project «Provision of Multi- Sectoral Humanitarian Assistance to Conflict-Affected Populations in Eastern Ukraine» which is implemented by R2P with the financial support of the European Commission, within the framework of civil protection and humanitarian assistance of the European Union within the ACCESS consortium, and with the participation of the «Advocacy, Protection and Legal Assistance to IDPs» project implemented by R2P with the support of the UN Refugee Agency (UNHCR). The views expressed herein should not be taken, in any way, to reflect the official opinion of the European Union, and the European Commission is not responsible for any use that may be made of the information it contains. 2 1. Introduction

1. INTRODUCTION The International Committee of the Red Cross (ICRC) points out that the consequences of the armed conflicts are grave and lasting for the entire population. People who have lost their lives due to the destroyed infrastructure of the healthcare system and the outflow of qualified medical personnel are recognized by the ICRC as indirect victims of armed conflicts1. The armed conflict in Ukraine has been lasting since 2014. Part of the state territory is occupied. The Government of Ukraine does not have an opportunity to influence the provision of access to medical care for civilians in these regions. The 457-km line of contact separates territories in the east of the country into government-controlled areas (GCAs) and non-government controlled areas (NGCAs). In accordance with Article 3 of the Constitution of Ukraine, the protection of life, health, honour, dignity, integrity and human safety, which is the highest social value that the state is obliged to provide through its authorities, at least in the territories controlled by the government. There are five entry-exit checkpoints (EECPs) along the line of contact that are the only “junction points” that connect territories and people separated by the conflict. This is a “visible distance” to the state authorities, a relative security zone and a logistics hub for further movement for residents of settlements along the line of contact and the non- government controlled area (NGCA). Every day, thousands of people cross the EECPs in both directions bringing with them the severity of the conflict and expectations. In summer 2019, CF Right to Protection (R2P) was carrying out an analysis of the needs of the population crossing the EECP. The opinions of those travelling on themost popular services at the line of contact in the Donetsk and Luhansk oblasts were studied in the course of the research. The survey dealt with what services travellers would use at or near the EECP, under what conditions they would do it, and what services, in their opinion, should be present at the EECP. The vast majority of 1,059 respondents spoke in favour of arranging first-aid posts at EECPs2. In 2018, more than 50 people died as a result of shelling or worsening health problems while crossing the line of contact through the EECP3. ПDuring January-September 2019, 38 people died at checkpoints on both sides of the line of contact4, most of them were elderly people. This year, more than 200 cases of hospitalizations in medical institutions for patients from EECPs were recorded. All these people needed emergency medical care. Representatives of various public services (non-medical profile) and non- governmental organizations providing first aid at the EECP had fought for their life and health before the ambulance arrived. Precisely such sad statistics led to a comprehensive study of the problem of accessibility and effectiveness of medical care at the EECP when crossing the line of contact. The objective of the study was to find out the current needs and challenges in accessto medical care that travellers encounter when crossing the EECP, as well as medical

1 ICRC Statement – Strengthening of the coordination of emergency humanitarian assistance of the United Nations. – December 12, 2013 Statement https://www.icrc.org/en/doc/resources/documents/statement/2013/united-nations- humanitarian-coordination-2013-12-12.htm 2 Monitoring survey “Restoration of the Social Ties between TOT Residents by Improving Access to the Most Requested Services” http://r2p.org.ua/wp-content/uploads/2019/09/EECP_Services_R2P_Report_UKR.pdf 3 Humanitarian Response Plan, January-December 2019 – United Nations Office for the Coordination of Humanitarian Affairs https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/ukraine_ 2019_humanitarian_response_plan_ua.pdf 4 Joint Statement: Four Heads of State, Four Humanitarian Issues https://www.clovekvtisni.cz/media/publications/1353/ file/1912---n4-ngos-statement_ukr_v1.pdf 2. Glossary 3

services and other government agencies involved in ensuring the right to premedical care and providing access to emergency medical care (EMC) at the EECP.

2. GLOSSARY SSU AS Separate Structural Unit of the Ambulance Station

MCA Military-Civil Administration SBGSU State Border Guard Service of Ukraine SESU State Emergency Service of Ukraine EMC Emergency Medical Care LoU Law of Ukraine MI Municipal Institution CMU Cabinet of Ministers of Ukraine MNPE Municipal Non-Profit Enterprise “The Concept of Emergency Medical Care System Development” Concept approved by the CMU Resolution No. 383-r of May 22, 2019 EECP Entry-Exit Checkpoint ICP International checkpoint MoH Ministry of Health TMS Temporary medical station NHSU National Health Service of Ukraine NGCA Non-Government Controlled Area JFO Joint Forces Operation PHC Primary Health Care R2P Charitable Organization "Charitable Foundation Right to Protection" GCA Government Controlled Area URCS Ukrainian Red Cross Society RMP Rural Medical Post PMCC Primary Medical Care Centre PUI Première Urgence Internationale 4 3. Methodology

3. METHODOLOGY The implementation of health system reform in Ukraine actually coincided with decentralization processes at the level of territorial communities and local governments. The architecture of these reforms did not take into account the security features, demographic, economic and migration nature of the settlements located near the line of contact in the so-called “grey zone” (as defined by international humanitarian organizations, a 5 km zone along the line of contact). The existing network of primary medical care institutions does not provide for the availability of a single RMP at the EECP; therefore, the study examined the issue of access to the nearest health facilities outside the EECP. Also, a risk analysis of the health system reform implementation in the “grey zone” is carried out according to unified principles with settlements located in other government-controlled areas (GCA). The time frame of this study was the whole of 2018 and 9 months of 2019.A comparative analysis of statistical data on the frequency of requests for emergency medical care (EMC) at both EECPs and ICPs, the procedure for providing such service (care) at the EECPs and ICPs, and factors affecting the frequency of requests for medical care was carried out during the study. The subject of the study was access to medical care at the EECPs of Stanytsia Luhanska, Maiorske, Marinka, Novotroitske, and Hnutove. The objective of the study was to determine the appropriateness of applying uniform procedures for EMC provision at the EECPs and ICPs, as well as to determine measures that can reduce the number of fatal cases at the EECPs. The analysis was carried out based on the following sources: 1) regulations governing the provision of medical care; 2) information from the official websites of local state administrations and local councils; 3) responses of authorities to requests for public information; 4) empirical data was provided by the non-governmental organizations Première Urgence Internationale5 (PUI) and the Luhansk regional organization of the Ukrainian Red Cross Society that directly provided primary medical care at the EECPs in Donetsk and Luhansk oblasts during 2018-2019, and 5) R2P monitoring every working day at three largest EECPs in eastern Ukraine (Stanytsia Luhanska, Marinka, Maiorske) and during 2-4 days a week at the other two EECPs (Novotroitske, Hnutove). In addition, the International Charitable Organization “International Medical Assistance” participated together with the PUI and the Luhansk Regional Organization ofthe Ukrainian Red Cross Society in providing primary health care to civilians at the EECP Stanytsia Luhanska. The information on their work was not covered by the study due to a refusal to provide the requested statistical information. Besides, the survey did not cover the systematic data on the provision of primary and/or emergency medical care by volunteer organizations that purposefully cooperate with the Armed Forces of Ukraine, due to technical issues in generating data.

5 Première Urgence Internationale (PUI) 4. The concept and regulatory framework of the EECP 5

4. THE CONCEPT AND REGULATORY FRAMEWORK OF THE EECP The formation of the EECP began in 2014 after the presentation of the Peace Plan of the President. The SBGSU made steps to equip the security strip along the line of military clashes in the Donetsk and Luhansk oblasts for its implementation. As a result, entry/ exit checkpoints were arranged on the main roads where passport and documents were checked and vehicles were searched6. In the future, EECP as a term acquired its legislative consolidation and determination in a number of orders of the First Deputy Head of the Anti-Terrorist Centre at the Security Service of Ukraine (head of the Anti- Terrorist Operation in the Donetsk and Luhansk oblasts)7 nd CMU Decrees8. According to the latest version of the definition, the EECP is “a complex of buildings, special and engineering structures and technical facilities located on the specially defined land plot, where measures to control the entry and exit of persons, vehicles and goods transported to and from temporarily occupied territories are being taken9. EECPs are the only points using which one can legally get from the GCA to the NGCA and vice versa. Despite the provision that ‘the responsibility for the arrangement, maintenance and service of the entry/exit checkpoints, as well as the territory adjacent to them are the Donetsk and Luhansk oblast state administrations, regional military and civilian administrations or military administrations10», the holder of the books and owner of the EECP has not yet been determined. The standards for the EECP has not been defined as yet. As a result, material resources provided by international organizations (for example, a medical module with necessary medical equipment and medicines donated by the Doctors Without Borders for SESU at the EECP Marinka was used for other purposes11) or purchased from the state budget are misused. A clear regulation of economic relations at EECPs is hindered by the lack of standardization of issues related to the use of the land plots on which the EECP is located, the commissioning of temporary structures belonging to the EECP complex (since the characteristics of these structures do not meet the requirements of State Construction Standards of Ukraine for the types of activities carried out by state bodies at EECPs) and the lack of a budget for meeting the EECP household needs. If the above issues are resolved, the primary medical care stations can be incorporated into the EECP structure and financed from the EECP target budget. Otherwise, the arrangement of medical care at EECPs should take place within the framework of primary care medical reform.

6 The State Border Guard Service of Ukraine exercises control over the security zone along the line of military clashes. – October 22, 2014 7 Orders of the First Deputy Head of the Anti-Terrorist Centre at the Security Service of Ukraine (head of theAnti- Terrorist Operation in the territory of Donetsk and Luhansk Oblasts) “On Approval of the Temporary Order for Monitoring the Movement of People, Vehicles and Goods Along the Contact Line in the Donetsk and Luhansk Oblasts” No. 144 oh of December 29, 2014, No. 27 oh of January 22, 2015, No. 222 oh of April 14, 2017 8 CMU Decree No. 99 of March 1, 2017, “On Approval of the Procedure of Movement of Goods to or from the Area of Conducting an Anti-Terrorist Operation” 9 clause 2 “Entry Procedure for Persons, Movement of Goods in Temporarily Occupied Territories in the Donetsk and Luhansk Oblasts and the Exit Procedure for Persons, Movement of Goods From Such Territories”, approved by the CMU Decree No. 815 of July 17, 2019 10 clause 5 “Entry Procedure for Persons, Movement of Goods in Temporarily Occupied Territories in the Donetsk and Luhansk Oblasts and the Exit Procedure for Persons, Movement of Goods From Such Territories”, approved by the CMU Decree No. 815 of July 17, 2019 11 A medical module was arranged at the EECP Marinka, Rescue workers of the State Emergencies Service of Ukraine received a block module for the EECP Marinka from Doctors Without Borders – February 2, 2018 6 5. Medical care (guarantees, types, entities)

5. MEDICAL CARE (GUARANTEES, TYPES, ENTITIES) The right to medical care is one of the basic ones that directly affect the realization of the right to life and human health. The task of the state is to fill this right with real guarantees of access to timely and high-quality medical care. In accordance with Article 49 of the Constitution of Ukraine “Everyone has the right to health protection, medical care and medical insurance. Health protection is ensured through state funding of the relevant socio-economic, medical and sanitary, health improvement and prophylactic programmes. The State creates conditions for effective medical service accessible to all citizens. State and communal health protection institutions provide medical care free of charge; the existing network of such institutions shall not be reduced. The State promotes the development of medical institutions of all forms of ownership”. In accordance with Article 2 of the European Convention for the Protection of Human Rights and Fundamental Freedoms 1950. “The right of everyone to life is protected by law”. The enforcement of the right to life is impossible without the enforcement of the right to health. Indeed, the normal biological and social functioning of a human is impossible without health. The enforcement of the right to life in full is possible only if the right to health is secured. Moreover, in accordance with the established practice of the ECHR, this right is considered violated not only in case of deprivation of human life, but also in case of serious damage to the human body that did not result in his death, but constituted a serious threat to his life. The state should not only refrain from intentionally depriving a human of his life, but also observe a positive obligation to protect a person’s life from the attacks of third parties or from the risk of illness that could lead to death.

5.1 STATUTORY REGULATION OF MEDICAL CARE There are a lot of norms of international and national character among the sources of statutory regulation of medical care in Ukraine. As for their application procedure at the national level, one of the main documents at present is the Law of Ukraine “On Fundamental Principles of Ukrainian Legislation on Health Care”. The Law of Ukraine “On State Financial Guarantees of Public Health Services” adopted in late 2017, which introduced a new principle of financing the provision of medical services – ‘money follows the patient’ – for various types of medical care, that in fact, began a medical reform in Ukraine. The Law of Ukraine “On Improving Accessibility and Quality of Medical Services in the Rural Area” determined the features of interaction between various authorities, local self-government and amalgamated territorial communities in order to ensure the availability and quality of medical care to residents of cities (except Kyiv and cities of regional significance), villages and townships. To implement the medical reform, the Cabinet of Ministers of Ukraine (CMU) arranged the National Health Service of Ukraine (NHSU) as the central executive body forthe implementation of state policy in the field of state financial guarantees for the provision of medical care to the population12. The NHSU acts as a single national payer/purchaser of medical services and medicines in the country, signs contracts with medical institutions to provide medical services under the state programme of medical guarantees. This is the way the amount of services and medicines to be financed from the state budget is determined. The list of services and medicines, as well as their cost, will be approved by the state budget of Ukraine every year.

12 Cabinet of Ministers of Ukraine Decree No. 1101 of December 27, 2017 “On Incorporation of the National Health Service of Ukraine” 5. Medical care (guarantees, types, entities) 7

5.2 TYPES OF MEDICAL CARE Medical care by type is divided into emergency, primary, secondary (specialized), tertiary (highly specialized), palliative, and medical rehabilitation. Premedical aid is separately emphasized. We studied access to premedical, primary and emergency medical care in our investigation. Premedical aid is urgent actions and organizational activities aimed at saving and preserving a person’s life in an emergency and minimizing the health consequences of such a condition carried out at the scene by people who do not have medical education, but according to their official duties should have basic skills in saving and preserving the life of a person who is in medical emergency and in accordance with the law are obliged to carry out such actions and activities13. This type of aid is called “pre-medical”, as it is provided by people without medical education but trained in basic techniques for saving people in situations that are critical for life and health. Premedical aid begins with the obligation of any person who has found a person in urgent condition to call EMC service or to report a person found in medical emergency and the place of events to employees of the nearest health care institution or any person who is obliged to provide premedical aid and is located near the scene, according to Article 3 of the Law of Ukraine “On Emergency Medical Care”. The range of premedical aid measures includes the following: stemming of blood flow, application of dressing to a wound, artificial lung ventilation, heart massage (including using a defibrillator), and more, depending on the circumstances. The Ministry of Health has developed and approved 29 procedures for providing medical care in the following situations: sudden cardiac arrest, heart attack, suspected spinal injury, head injury, stroke, limb fracture, poisoning, burns, hypothermia/frostbite, overheating, animal and insect bites, spasms, loss of consciousness and other cases14. Leading experts say that in case of 10% of the country’s population knows the rules for providing first medical (premedical) aid, mortality at the pre-hospital stage would reduce by an average of 20%. It is possible to save 26 thousand people annually after reaching this indicator in Ukraine15. Primary medical care is the medical care that provides advice, diagnostics and treatment of the most common diseases, injuries, poisoning, pathological, physiological (during pregnancy) states, and the implementation of preventive measures; referral in accordance with medical indications of a patient who does not need emergency medical care to provide him with secondary (specialized) or tertiary (highly specialized) medical care; emergency medical aid in case of a patient’s physical or mental health disorder that does not require emergency, secondary (specialized) or tertiary (highly specialized) medical care16. As part of the PMC medical reform in Ukraine, only those people who have signed a declaration with a family doctor and only in those medical institutions that work with the NHSU can receive such help for free. The scope of the medical guarantee program at the PMC level is defined in the Primary Health Care Procedure approved by the Ministry of Health order No. 504 of March 19, 201817.

13 paragraph 12, part 1, Article 3 of the Law of Ukraine “On Fundamental Principles of Ukrainian Legislation on Health Care”, clause 4, part 1 Article1 of the Law of Ukraine “On Emergency Medical Care” 14 MoH order No. 398 of June 16, 2014 “On approval of the procedures for the medical care provision to persons in a medical emergency” 15 First Medical (Premedical) Aid, by Prof. Plesh I.A., Assoc. Prof. Khomko O.Yo. – Bukovynian State Medical University. – September 7, 2018 16 Article 351 of the Law of Ukraine “On Fundamental Principles of Ukrainian Legislation on Health Care” 17 MoH of Ukraine order No. 504 of March 19, 2018 “On approval of the Procedure for the provision of primary medical care” 8 5. Medical care (guarantees, types, entities)

Emergency medical care means a medical aid that consists of the emergency medical care workers’ implementation of the emergency organizational, diagnostic and therapeutic measures aimed at saving and preserving the life of people in amedical emergency and minimizing the health consequences of such condition18. An emergency state of a person is defined as a sudden deterioration in physical or mental health, which poses a direct and inevitable threat to the life and health of a person or people around her and arises from illness, injury, poisoning, or other internal or external causes19. From April 1, 2020, the EMC will be provided according to new principles within the framework of the addition to the next stage of the medical service reform in Ukraine. The CMU issued the resolution on approving “The Concept of Emergency Medical Care System Development” (Concept) presenting the main issues of the health care system and identifying the steps to solve them20.

5.3 MEDICAL CARE PLAYERS According to the law, “the persons who are obliged to provide premedical care to a person in medical emergency are rescue workers of emergency services, the state fire department, police, pharmaceutical workers, train hosts, flight attendants and other people who do not have medical education, but in terms of their official duties, they have to possess the practical skills of rendering medical assistance21». According to the Concept, basic knowledge on premedical care should be introduced into the training program for drivers, social workers, educators in preschool educational institutions, teachers of secondary schools and faculty at higher education institutions, workers employed in jobs with increased risk and schoolchildren (grades 10-11) of general secondary education in order to be able (if necessary) to take urgent actions and take organizational measures aimed at saving and preserving the life of people who are in medical emergency and minimize the consequences of such state of health22. The PMC is provided by healthcare institutions and individuals – entrepreneurs who have received the appropriate licence in a prescribed legal procedure23. The PMC is provided by general practitioners – family doctors, doctors and other medical professionals. The Ministry of Health has identified 4 forms of health care institutions providing PMC in cooperation with the NHSU. These are: 1) a primary medical (health) care centre (PMCC); 2) outpatient clinic; 3) Rural Medical Post / paramedic point (RMP/PP); and 4) a temporary medical station24. Each of the mentioned forms is distinguished by the level of ability to cover the needs of people in PMC, the size of its material and labour resources and service area. Innovation in the network of medical facilities is a temporary medical station (TMS), which is arranged with the purpose of increasing the availability of primary medical care (PMC) and pre-medical care for people distant from the location of outpatient clinics and RMP of settlements, employees of enterprises, institutions and organizations. The TMS is a temporary base for outpatient medical personnel, RMP/PP, is not part of the PMCC

18 clause 5, part 1, Article 1 of the Law of Ukraine “On Emergency Medical Care” 19 clause 7, part 1, Article 1 of the Law of Ukraine “On Emergency Medical Care” 20 CMU Regulation No. 383-r of May 22, 2019 “On Approval of the Concept of Emergency Medical System Development” 21 Article 12 of the Law of Ukraine “On Emergency Medical Care” 22 “The Concept of Emergency Medical Care System Development” approved by the CMU Resolution No. 383-r of May 22, 2019 23 part 2, Article 351 of the Law of Ukraine “On Fundamental Principles of Ukrainian Legislation on Health Care” 24 The Ministry of Health order No. 801 of July 29, 2016 “On approval of the Regulations on the Centre of primary medical care and provisions on its units” 6. Quantitative and demographic data on the EECP crossing 9

structure and does not have its own structure. The TMS is created on the initiative of the local government, including the amalgamated territorial community, the management of the enterprise, institution or organization in agreement with the PMCC Chief Medical Officer to whose service area this settlement, enterprise, institution or organization belongs. The TMS is maintained at the expense of its organizer who provides the premises, creates the proper working conditions, provides for its equipping, provides medicines and medical supplies, ensures that the medical worker travels to the TMS and more. The EMC system consists of centres for emergency medical care and disaster medicine, emergency medical aid stations, emergency medical care teams, and emergency medical care departments.

6. QUANTITATIVE AND DEMOGRAPHIC DATA ON THE EECP CROSSING During the nine months of 2019, 10,358,000 people crossed five EECPs in both directions. This is almost 200,000 people more than during the same period of 2018. More detailed information (including monthly) can be found on the SBGSU online platform25. The table below provides comparative statistics on the number of crossings of EECPs and ICPs.

EECP at the administra- EECPs in the east of Ukraine tive border ICP with Year Crimea

Stanytsia No- Rava- Maiorske, Marinka, Hnutove, Chonhar, Ustyluh, Yahodyn, Luhanska, votroitske, Ruska, thous. thous. thous. thous. thous. thous. thous. thous. thous. 2018 3,252 3,075 3,238 2,686 1,369 1,328 3,050 1,750 3,080 2019 (January- 2,670 2,463 2,201 1,985 1,039 1,025 2,140 1,360 2,210 September) Total 5,922 5,538 5,439 4,671 2,408 2,353 5,190 3,110 5,290 It has already been mentioned that R2P monitors work at EECPs recording violations of the rights of people affected by the conflict, as part of the Advocacy, Protection and Legal Assistance to the Internally Displaced Population Project, which is implemented with the UNHCR 26support . 24,177 people were interviewed during 201827, аand 19,739 people during the nine months of 201928. As a result of the survey, a generalized age profile of people going through EECP was obtained. This portrait indicates that the vast majority of people going through the EECP are people over 60 years of age.

25 SBGSU EECP: Monthly crossing of the line of contact 26 Monitoring is carried out using anonymous and voluntary surveys of persons over 18 years of age. Monitors come up to every fourth person in line. If the person refused to participate in the survey, the monitors asked the next person in line. The survey was conducted only at the GCA. 27 United Nations High Commissioner for Refugees Online Platform on 2018 EECP Survey Results 28 United Nations High Commissioner for Refugees Online Platform on 2019 EECP Survey Results 10 6. Quantitative and demographic data on the EECP crossing

2018 2019 (JANUARY-SEPTEMBER) respondent age respondent age 60+ 18�24 60+ 18�24 57% (13823) 13% (3124) 66% (12993) 10% (2080)

35�59 35�59 24% (4666) 30% (7230)

According to the Luhansk and Donetsk MCA29 the vast majority of people going through the EECP in eastern Ukraine are internally displaced persons – pensioners. They have to cross the line of contact for the sake of identification with Oshchadbank and the execution of the legislative requirements for the extension of the IDP certificate, which is a prerequisite for receiving a pension (once every 59 days)30. These data completely coincide with the findings of the R2P monitoring study indicated above. Thus, in most cases, the movement of people through the EECP in the east of Ukraine takes place due to the motives for maintaining the main source of livelihood (pension payments), and not the desire for travel, the nature of work or other factors that prevail at the ICPs. In addition, the generalized profile of people crossing EECP is influenced by increased levels of psychological anxiety and age-related changes in people’s health.

Line of people for the ATM at EECP Stanytsia Luhanska

29 The Donetsk oblast development strategy for the period till 2027, 2019. P. 19-20 30 Social and economic analysis of Luhansk oblast, 2019 – P. 37 7. Factors that cause increased demand for health care at EECPs 11

There are often reports in the network of fatal cases while crossing the EECP inthe east of Ukraine. At the same time, such reports are not available at the EECP on the administrative border with Crimea or ICPs. It is presumed that public service personnel works according to the same algorithms (control measures, communication with travellers, etc.) both at the EECPs and ICPs. Since the quantitative crossings of the checkpoints are approximately the same, it is therefore obvious that the reason for the increased mortality rate at the EECPs compared to the ICPs is not the number of people crossing the EECPs or the actions of public services at the EECPs, but the factors associated with the consequences of the armed conflict for people. Such factors are the deterioration of people’s health through the destroyed infrastructure of healthcare facilities, the comfort of travel conditions, the comfort of staying at a checkpoint (protection from the sun, rainfall, access to drinking water, places of rest, etc.) and safety issues. Priority is given to the implementation of best practices when developing any organizational decisions in the system of public authorities. This method is justified when the values of all variables coincide with the “sample” example. At the beginning of the conflict, the Government of Ukraine extrapolated the principles of interaction between public authorities and the population being applied at the state border of Ukraine, to the EECP at the line of contact. Analysing the effectiveness of these measures over the course of six years, only factors of restraining aggression are taken into account, and to a lesser extent, ensuring the full range of human rights guaranteed by the state. Despite civilian casualties at the EECP, it is time to move away from template algorithms and to equip checkpoints and adapt them to modern challenges, guaranteeing the protection of the life, health, honour, dignity, integrity and safety of people travelling across the line of contact.

7. FACTORS THAT CAUSE INCREASED DEMAND FOR HEALTH CARE AT EECPS The need for medical care at the EECP is due to several factors, both subjective (general state of human health) and objective (security situation, travel conditions and waiting time at the EECP). Subjective factors. According to the Protection and Health Care and Nutrition clusters, more than half of families living near the line of contact do not have access to medical services. Almost 40% of families living within 20 km of the line of contact have significant difficulties in gaining access to medical services. The closer to the line ofcontact, the more difficult it is to access such services. 57% of families do not have safeand appropriate access to hospitals and medical services within 5 km of the line of contact. The lack of medical workers who have long left the eastern part of Ukraine in search of a safe place and/or better opportunities makes access to medical services even more difficult. All conflict-affected areas report a shortage of essential medical supplies, equipment and basic goods. At the same time, the cost of medical services continues to grow. About 40% of the population in the government-controlled areas of Donetsk and Luhansk oblasts suffer from psychological trauma and the resulting stress, depression, anxiety disorders and post-traumatic syndrome that cause psychosomatic disorders. At the same time, there is a lack of experience in treating patients with mental illnesses31.

31 Operational report of November 4, 2019 – United Nations Office for the Coordination of Humanitarian Affairs (OCHA) 12 8. Medical service at EECPs

Objective factors. Complaints about the lack of basic, minimal conditions of protection and comfort have been constantly repeated since the opening of the EECP. Significant progress was made during 2018-2019 in arranging EECPs to improve crossing conditions. However, such improvements have unevenly influenced all EECPs. There is still a lack of seats and sunshades case of bad weather, lack of basic services, including water supply and maintenance of sanitary facilities, cooling stations in summer and heating ones in winter – especially at the so-called “zero” checkpoints (the area between the EECPs at the GCA and NGCA). Imperfections of the EECP arrangements are a natural occurrence in the absence of a person/structure responsible for the arrangement and maintenance of the EECP. A separate issue is the conditions of taking from the line of contact to the EECP the privileged groups of people, such as elderly people aged 60+, pregnant women, people with disabilities and other serious health disorders, people with mobility impairments.

8. MEDICAL SERVICE AT EECPS There is no strategy for the provision of medical services at the EECPs by state authorities or local governments at present. However, premedical, primary and emergency medical care is constantly provided at the EECPs. According to the combined data of the PUI, the URCS Luhansk Oblast Organization, and SESU in the Luhansk Oblast, during 2018 and nine months of 2019, 65,869 consultations were provided in pre-medical and primary care. The number of cases of medical care/consultation during January-September 2019

Main Department of the URCS Luhansk Oblast PUI Total SESU in Luhansk oblast Organization EECP 2018 January - 2018 January - 2018 January - September September September 2019 2019 2019 Hnutove 240 754 - - - - 994 Maiorske 7,736 3 677 - - - - 11 413 Marinka 4,653 2 107 - - - - 6 760 Novotroitske 5,292 2 786 - - - - 8 078

Stanytsia - - 11 439 9 117 13 351 4 717 38 624 Luhanska Total 65 869 The demand for medical care at EECPs has been steadily high since the beginning of the work of medical stations. However, the resources of non-governmental organizations that provide it are reducing, which is associated with a decrease in donor funding. Since the state is the guarantor of the right to medical care, eventually the state will need to get actually involved in the process of providing people with access to medical care at the EECP. 8. Medical service at EECPs 13

8.1 HEALTH CARE INFRASTRUCTURE AT CHECKPOINTS The EECP prototype was the ICP on the border of Ukraine. Now “departmental regulations and instructions do not provide for the presence of medical workersat checkpoints at the state border of Ukraine and at entry-exit checkpoints”32. УHowever, taking into consideration the high level of need for such assistance at the EECP, some state and non-governmental organizations have created conditions for the provision of premedical and PMC near the EECP in the east of Ukraine.

NGO medical station at EECP Stanytsia Luhanska

Due to the nature of the security and the conditions for crossing the line of contact, temporary SES locations were arranged near EECPs. SES assistance points are designed to arrange appropriate sanitary, hygienic, household conditions and psychological assistance, as well as to bring information on the actions of the population inthe conditions of terrorist attacks in the territory of Donetsk and Luhansk oblasts, the procedure for detecting explosive objects, sudden shelling, and relieving social tension, which may occur at assistance points and at EECPs. In accordance with the CMU Decree33 representatives of the National Police are also present at the EECP, they are obliged to ensure compliance with public order and security. Representatives of SESU and the National Police are mandated by law to provide premedical care34. There are no representatives of other services or organizations that are required to provide premedical care at EECPs. SESU representatives are on duty at EECP twenty-four-seven. The work schedule of the National Police is the same as that of the EECP. Since the beginning of the EECP functioning, primary medical care stations were arranged and operated only with the support of various non-governmental, volunteer and international humanitarian organizations. The PMC at EECPs in Donetsk Oblast is provided by PUI representatives. The PUI staff at the EECP as of the end of September

32 SBGSU Administration letter No. 26/Р-2000 of October 24, 2019 33 p. 2, c. 4 “Entry Procedure for Persons, Movement of Goods in Temporarily Occupied Territories in the Donetsk and Luhansk Oblasts and the Exit Procedure for Persons, Movement of Goods From Such Territories”, approved by the CMU Decree No. 815 of July 17, 2019; 34 Article 12 of the Law of Ukraine “On Emergency Medical Care” 14 8. Medical service at EECPs

2019 consisted of 1 doctor, 5 paramedics, 9 nurses, 9 drivers/assistants and 5 technical workers. Due to the change in the organization’s work strategy in Ukraine since October 2019, the position of a doctor has been replaced by paramedics. All PUI employees have completed PMC training course. One module is equipped at each of the four EECPs in the Donetsk oblast where every day, starting from 8:45 am (with an error of up to 15 minutes, depending on the individual characteristics of various EECPs), the PMC is provided up to 3:30-4 pm. The PMC is provided by the representatives of the International Medical Care, the URCS Luhansk Oblast Organization and the SESU at the EECP Stanytsia Luhanska. Also in Stanytsia Luhanska, there is an experience of attracting medical personnel from a local healthcare institution to provide medical assistance directly in the EECP to those who cross the line of contact. There are 2 medical care stations at the EECP Stanytsia Luhanska now. The schedules of organizations have slight differences, SESU staff work according to the EECP work schedule, and other organizations from 8 am to 4 pm. 5 medical workers and 18 other specialists (including volunteers) who help doctors in their work are added to providing primary medical care at the EECP Stanytsia Luhanska. Every medical aid station in Donetsk and Luhansk oblasts is provided with the necessary medical and pharmaceutical preparations including a defibrillator for providing PMC to patients. The emergency medical care at EECPs is provided by emergency medical aid stations of the EMC and disaster medicine oblast territorial centres, nongovernmental organizations, as well as military ambulances. Currently, the provision of EMC at EECPs along the line of contact is provided by the following organizations and separate divisions:

Distance from the EECP to EECP Emergency medical service Health care institution a health care institution

Stanytsia Luhanska unit of the Luhansk city Stanytsia Luhanska District 3.5 km ambulance Territorial Medical Association EECP Stanytsia Luhanska unit No. 6 in Shchastia of the Luhansk city CI Shchastia Town Hospital 60 km ambulance station

Bakhmut unit of SSU AS in Kramatorsk CNPE Bakhmut EECP Maiorske Multidisciplinary Intensive 24 km Care Hospital NGO ASAP Rescue

Marinka district unit of SSU AS in Donetsk (team site bases in Marinka, Kurakhove, CNPE Kurakhivka Town EECP Marinka 20 km Krasnohorivka and in five other rural Hospital settlements

Volnovakha unit of SSU AS (team site bases EECP CNPE Volnovakha Central in Volnovakha, township of Novotroitske 20 km Novotroitske District Hospital and three more settlements)

Kalmius district unit of SSU AS (team site bases in Mariupol, Hranitne and village of CNPE Mariupol Emergency Charmalyk) EECP Hnutove Care Hospital of Mariupol City 28 km Council military ambulance based in the village of Pavlopil 8. Medical service at EECPs 15

8.2 PREMEDICAL CARE According to observations of R2P monitors, representatives of the National Police are not always present at EECPs, as they may be absent from EECPs as part of their duties. The SESU representatives are on duty at EECP around the clock, but their locations can be at a considerable distance from EECP terminals. For example, at the EECP Marinka, the SESU tent is located 700 m from the EECP entrance on the GCA side and almost 1 km from the entrance to the first control terminal at the EECP from the NGCA. At the EECP Hnutove, the SESU tent is located at a distance of 770 m from a motor transport stop where the people from the NGCA arrive. At the EECP Novotroitske, the SESU tent is located at a distance of 320 m from the EECP entrance at the GCA side. A sudden deterioration in people’s health can occur at any of these intervals and the prompt provision of medical care can save someone’s life. Usually, the waiting time for the EMC to arrive at the EECP is about 30 minutes. In the absence of qualified measures of premedical care within 30 minutes, the onset of inevitable consequences for a person’s life in critical condition may occur.

Distance from EECP Marinka to SESU tent

The dominant causes of death in Ukraine and at the EECP are blood circulatory system diseases, external causes of death (accidents, road accidents, violent acts) and growths. 90.1% of deaths among patients with coronary heart disease occur outside the hospital, 9.9% of patients with this diagnosis die in the hospital. The chances that in the event of an accident or a heart attack, a person’s life will be saved and negative health consequences minimized, depend on the start date of the care and the start date of the critical procedures for survival at the prehospital phase, which should be minimal, as well as effective hospital treatment and rehabilitation. Each of the listed links in Ukraine is arranged inefficiently35. In cases associated with cardiac arrest, premedical care includes the need for cardiopulmonary resuscitation including the use of an automatic external defibrillator.

35 “The Concept of Emergency Medical Care System Development” approved by the CMU Resolution No. 383-r of May 22, 2019 16 8. Medical service at EECPs

According to observations of R2P monitors, on all five EECPs, the defibrillator is owned by representatives of non-governmental organizations, namely PUI International Medical Assistance, and therefore the possibility of its use is limited by the work schedule of PUI representatives at the EECP. Only at the EECP Stanytsia Luhanska, SESU employees have the opportunity to use the defibrillator during the entire EECP work schedule. Every 5 years, persons who are required by law to provide premedical care should undergo career enhancement training36. Maintaining the relevance of knowledge and practical skills of providing medical care is especially relevant in the context ofthe case that took place at the EECP Stanytsia Luhanska when a person with a stroke was transported to an ambulance in a wheelchair, which is directly counter-indicative in this case and contradicts the Procedure for the provision of medical care for victims of suspected stroke37 38. The interest of the public and civil services in the courses of providing premedical care since the beginning of the armed conflict has increased. The SBSU administration stated that in accordance with the training plan for SBGSU personnel, tactical medical care and primary medical care classes are held with all categories of military personnel. However, according to the business and official duties, neither the representatives of SBSU nor representatives of other services at the EECP are obliged to provide premedical care to the population. The Concept of Emergency Medical Care System Development notes that the current approach to training people who are obliged to provide premedical care is “ineffective because there is no effective mechanism for monitoring knowledge on the results of educational activities; there is no register of people who have undergone first-aid training, there is no mechanism promptly involving them in first aid in the event of an accident or emergency; volunteers decide to save the person before ambulance arrival, not protected by the legislation of the prosecution in the event when the person’s life still cannot be saved”.

8.3 PRIMARY MEDICAL CARE The reform of the PMC system and the decentralization of local self-government unevenly affected the territories of Donetsk and Luhansk oblasts, especially those located near the line of contact, including settlements near EECPs. Formally, in accordance with the developed and approved plans on the formation of capable primary medical care networks in Donetsk39 and Luhansk40 oblasts, each of the settlements near the line of contact should have access to the PMC provision station, which is located no more than seven kilometres away along a paved road41. However, in fact, these criteria are not met, since some settlements are fully or partially isolated, there is no transport connection or PMC stations are understaffed.

36 clause 11 “Procedure for the training and professional development of persons who are required to provide medical care” approved by the CMU Decree No. 1115 of November 21, 2012 37 MoH order No. 398 of June 16, 2014 “On approval of the procedures for the medical care provision to persons in a medical emergency” 38 the need for transportation in this way was due to the limited access of transport to the territory of the buffer zones “between zeros”, but read about it in the section on EMC 39 Order of the Head of the Oblast State Administration, Head of the Oblast Military-Civil Administration No. 669/5-18 of May 29, 2018 “On approval of the Plan of a capable network of primary medical care in Donetsk oblast” 40 Order of the Head of the Oblast State Administration, Head of the Oblast Military-Civil Administration No. 423 of May 30, 2018 “On approval of the Plan of a capable network of primary medical care in Luhansk oblast” 41 capability criteria of the PMC network were established by the Procedure for the formation of capable primary medical care networks approved by the joint Order of the Ministry of Health and the Ministry of Regional Development, Construction and Housing and Communal Services of Ukraine No. 178/24 of February 6, 2018 8. Medical service at EECPs 17

Local self-government bodies have not made a decision yet to establish PMC stations permanently or temporarily based at one of the EECPs. Due to the lack of a specific structure, EECP status and activities that can be carried out there (except for performing state functions), individual entrepreneurs with a licence to engage in medical activities are also not able to provide PMC within the framework of medical reform. Of the entire range of measures that the PMC determination includes (see clause 5.2), the most frequent need at the EECP is the provision of emergency medical care in case of a patient’s physical or mental health disorder that does not require emergency, secondary (specialized) or tertiary (highly specialized) medical care. Thus, the medical care at the EECP has no signs of dynamic monitoring of the patient’s health status, mandatory or preventive interventions (vaccination and inoculation)42. Therefore, in the case of providing PMC at the EECP for budgetary funds within the framework of medical reform, it is necessary to revise the obligations to conclude declarations with a family doctor at the EECP for the provision of one-time medical care. All primary medical care at the EECP was provided outside the reform processes, using resources of nongovernmental organizations and SESU, the functions of which do not include the provision of primary medical care on a regular basis. Statistical data on the amount of PMC provided at each EECP during 2018 and 9 months (January-September) of 2019 is shown in the table on section 8 of this study. State authorities have long recognized the need to create medical services at checkpoints, but activities in this direction are inconsistent and unsystematic. The opening of medical stations was announced at the renovated EECP Chonhar and EECP Kalanchak43, however, at the time of this study preparation, they were not put into operation. These and other problems of access to medical care near the line of contact were also discussed during a field meeting of the Verkhovna Rada of Ukraine Committee on Human Rights, De- occupation and Reintegration of Temporarily Occupied Territories in Donetsk, Luhansk Oblasts and the Autonomous Republic of Crimea, the city of Sevastopol, National Minorities and Inter-Ethnic Relations in Kramatorsk on October 23, 201944. As already noted, the demand for primary medical care at EECPs is consistently high, but neither government nor local governments follow the patients but act within their templates. Non-governmental and international organizations immediately understood the extent of the problem and got involved in the process of providing such assistance, but their resources are exhausted. Since in the Donetsk oblast, the EECP work schedule is longer than the PUI medical station (2 hours in winter, 3 – in spring/autumn, and 4 hours – in summer), therefore, officers of the state service at EECPs have repeatedly encountered real difficulties in organizing the medical care at the site. The insufficient amount of visualized information (pointers or other signs of attracting attention) was revealed in the location of medical care stations at EECPs during the monitoring study. This is especially true concerning the EECPs in the Donetsk oblast. Information on the location of medical care modules is available only on the modules themselves. Due to the lack of signs at the EECP territory and other visual aids about the procedure on obtaining first aid and the procedure for dealing with cases of sharp

42 The list of medical services for the provision of primary medical care – Appendix 1 to the Procedure for the provision of primary medical care, approved by the Ministry of Health Order No. 504 of March 19, 2018 43 Bus stations, post office, CAS and first aid post will work at EECP Chonhar and Kalanchak. – Ukrinform, November 15, 2019 44 http://kompravlud.rada.gov.ua/news/main_news/74090.html 18 8. Medical service at EECPs

deterioration of health, the citizens have the impression that they are left alone with their problems. As a result, according to the PUI doctors, they have to deal with the results of self-medication directly at the EECP, for example, when in cases of a significant increase in blood pressure caring people from the line give the patient “heart” nitroglycerin pills but it only worsens the patient’s condition.

Comment received by the R2P monitor from an SBGSU employee: * 08.27-30 The SBGSU employees “ working at the EECP Novotroitske periodically complain about the absence of medical personnel at the EECP after 3.30 pm. According to them, there are cases when citizens ask for medical help after 3.30 pm, especially in the hot season. During the reporting week, one person felt unwell, the PUI employees were no longer there, the ambulance did not come for unknown reasons. First aid was provided by military doctors.

8.4. EMERGENCY MEDICAL CARE (EMC) According to statistics provided by the health departments of the Luhansk and Donetsk Oblast MCA and Kherson, Lviv, Volyn Oblast State Administrations, at the EECPs in the east of Ukraine, almost three times more EMC cases were registered during 2018 – nine months of 2019 than at the EECPs that had been selected for comparison.

number of ambulance visits number of hospitalized people number of fatalities EECP/ICP January - January - January - 2018 2018 2018 September 2019 September 2019 September 2019

EECP Stanytsia Luhanska 365 109 130 83 5 7

EECP Maiorske 84 18 5 0 0 1

EECP Marinka14 56 46 32 32 2 5

EECP Novotroitske14 51 26 6 6 1 1

EECP Hnutove14 3 2 2 0 0 0

EECP Chonhar 26 11 1 1 0 1

ICP Rava-Ruska 28 15 18 12 0 0

ICP Ustyluh 4 9 1 2 0 0

ICP Yahodyn16 11 15 3 3 0 0 8. Medical service at EECPs 19

It is worth noting that these statistics do not fully reflect the need for EMC, since they record only successful cases of such aid, bypassing situations where the ambulance team of communal healthcare institutions was not available for various objective reasons. To support this point, we present the statistics obtained from the PUI, whose staff at EECP Hnutove in January-September 2019 made 7 cases of referral to EMC (including military doctors), while the EMC public service recorded only 2 cases of EMC team visits to the EECP. The most common obstacles between an emergency patient and an EMC team are the shortage of personnel at ambulance stations in settlements near EECPs and the line of contact in general, EMC team engagement with the other patient and the inability to travel to the patient due to threats to the health or life of medical workers. The latter reason for the inability to provide medical care was voiced by the CNPE Oblast Centre for Emergency Medical Care and Disaster Medicine of the Department of Health of Donetsk Oblast MCA45, but was not presented in the Department’s statistics. If it is not possible for EMC stations to send an ambulance to EECPs, military doctors and volunteers (ASAP Rescue) come to provide medical care for the civilian population in the most dangerous or most inaccessible (poor roads, adverse weather conditions, etc.) places. Special attention should be paid to the issue of the effective operation ofthe communication with the EMC dispatcher service. During studying the issue of access to medical care, R2P monitors knew of cases of automatic connection of a call to EMC at NGCA in the event of a call in the immediate vicinity of the line of contact close to large cities of Donetsk oblast. It was also found out about the widespread practice of calling an ambulance to the EECP using the numbers of mobile operators that are not in the public domain. Naturally, people who travel through the EECP do not know such numbers. The presence of shortcomings in the system of central operational dispatching is also confirmed by the social and economic analysis of the Luhansk oblast for 2019 prepared by the Luhansk MCA that says there is no centralized dispatching in the Luhansk Oblast Centre for EMC and Disaster Medicine46, as well as data from NHSU panels47 on both oblasts and theses of the Concept48 for the EMC system development. As already noted, the work schedule of medical services at 4 of 5 EECPs is shorter than that of the checkpoint. Therefore, the order of calling EMC has two options for the development of events depending on the time of its occurrence – “during the work of doctors” or “after the work of doctors”. If a person’s health suddenly worsened at the EECP “during the work of doctors”, the following algorithm works: having noticed medical assistance, the EECP officer (regardless of the type of state structure at service) by means of official communication (personal mobile phones are forbidden to use during service) sends a message to the officer on duty. After that, the officer on duty informs the doctors about the place of the emergency at the EECP. Doctors using their own vehicles (not intended for transporting patients) go to the scene (the distance can be from several meters to several kilometres when the incident occurs at “zero” checkpoints), analyse the situation, provide primary medical care and, if necessary, call EMC.

45 CNPE Oblast Centre for Emergency Medical Care and Disaster Medicine of the Department of Health of Donetsk Oblast MCA letter No. 01/1038 of December 12, 2018 46 Social and economic analysis of Luhansk oblast, 2019 47 The analytical panel of the National Health Service of Ukraine 48 “The Concept of Emergency Medical Care System Development” approved by the CMU Resolution No. 383-r of May 22, 2019 20 8. Medical service at EECPs

If a person’s health suddenly worsened at the EECP “after the work of doctors”, then, noticing the need for medical assistance, the EECP officer communicates the information about the situation to the officer on duty, he reports to EMC or military doctorsor volunteers. It is worth paying attention to the fact that the opportunity of going the EMC team to the “zero” checkpoints is not always possible both for security issues and bureaucratic reasons. Therefore, it is not uncommon for a patient to be transported by several vehicles: from the “zero” to the entrance to the EECP or to the nearest settlement to the EECP, and then to the medical institution.

EECP Stanytsia Luhanska

According to the regulations, the EMC team must arrive at the scene within the city in an emergency within 10 minutes, and in settlements outside the city within 20 minutes from the moment of receiving the call by the dispatcher. These standards, taking into account weather conditions, seasonal characteristics, epidemiological situation and road conditions can be exceeded but not more than 10 minutes49. Responding to the R2P request, the Departments of Health noted that the arrival standards for calls were not violated, however, the Concept approved by the CMU states that “due to the lack of precise control of the visits of emergency (ambulance) medical teams through GPS navigation and unified operational dispatcher information systems there is a significant risk of understating official travel times50. Local monitors claim that there are few violations of the timelines for arrival at the scene, much more often EMC teams do not come to the site. According to the information collected by R2P monitors, the EMC team does not come to the EECP Hnutove quickly at all; however, the official response to the request for the reasons for the failure to come

49 CMU Decree No. 1119 of November 21, 2012 “On Standards of Emergency (Ambulance) Medical Care Team Arrival in the Scene” 50 “The Concept of Emergency Medical Care System Development” approved by the CMU Resolution No. 383-r of May 22, 2019 8. Medical service at EECPs 21

on the call indicates that such cases were not recorded during 2018-2019. According to informal explanations, the reason for refusing to arrive at the call were security factors and team engagement with other calls. “Military” ambulance based 4 km away in the neighbouring village of Pavlopil is an alternative to the communal EMC service at the EECP Hnutove. This service responds to calls from the EECP and takes the patient to Pavlopil, where they deliver him to the civil ambulance that takes the patient to the hospital. Similar difficulties with access to EMC exist across the entire line of contact, and not just at EECPs. For example, according to the people living in Lebedynske of Volnovakha district the emergency medical care teams do not come to this settlement. When calling for ambulance they are redirected to military doctors who take the patient to the checkpoint at the entrance to the city of Mariupol where the patient is taken by the EMC team. Also, according to residents of the village of Staromarivka of the Hranitne village council of Volnovakha district (located between the “zero” checkpoints) doctors come on foot to the village only in emergency cases. Patients who need urgent hospitalization, local residents deliver the patient by car to the checkpoint nearthe village of Hranitne and call the ambulance to village of Hranitne. Then the medical workers, with the help of the locals who brought the sick person, transport the patient using a litter to the ambulance. In settlements near the line of contact, access to medical services is also complicated by the lack of public transport, road damage and restrictions on traffic through checkpoints. Restrictions to movement, in particular, due to the presence of landmines or constant shelling, also mean that ambulances cannot reach patients. As a result, the organization of mobile clinics and humanitarian activities aimed at providing assistance in these isolated settlements are very important51. According to the Health and Nutrition Cluster, more than 1,500 health professionals have left the conflict-affected areas since 201452. СThe EMC system at the line of contact also suffers from a significant staff shortage. Usually, the EMC team consists of 3 people: a paramedic, a nurse, and a driver; also teams, the composition of which is strengthened by a doctor53. The table below shows the data on vacant positions in EMC units that serve EECP in eastern Ukraine as of late November 2019. Their analysis makes clear the depletion of the human resources in the EMC system and, as a result, the inability to timely respond to challenges near the line of contact and at EECPs in particular.

51 Operational Update of November 4, 2019 from United Nations Office for the Coordination of Humanitarian Affairs 52 Humanitarian Needs Survey 2019 United Nations Office for the Coordination of Humanitarian Affairs https://www. humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/ukraine_2019_humanitarian_ needs_overview_ua.pdf 53 clauses 6, 7 of the “Standard provisions on the emergency (ambulance) medical care team” approved by the CMU Decree No. 1114 of November 11, 2012 22 9. Special aspects of the medical reform implementation in the territory near the line of contact

EECP EECP Stanytsia Luhanska EECP Maiorske EECP Marinka EECP Hnutove Novotroitske Staff Stanytsia- Bakhmut unit Marinka district Kalmius unit No. 6 in Volnovakha unit Luhanska of SSU AS in unit of SSU AS in district unit of Shchastia of SSU AS unit Kramatorsk Donetsk SSU AS number of full- 2 4 11 11 8 9 time EMD teams

doctor 2,5 3,25 14 9 1 15

paramedic 3,5 4 4 4 2 6

nurse 0 0 0 15 2 0

driver 0 1,5 1 7 7 4 In general, the described above difficulties with access to primary and emergency medical care at the EECP and along the line of contact are the consequences of the implementation of fundamental reforms of local self-government and health care without taking into account the particularities of territories and communities where the lifestyle is significantly different from the rest of Ukraine.

9. SPECIAL ASPECTS OF THE MEDICAL REFORM IMPLEMENTATION IN THE TERRITORY NEAR THE LINE OF CONTACT The implementation of medical reform has given rise to the involvement of local authorities and the amalgamated territorial communities (ATC) as owners ofPMC facilities located in their territory in the process of providing medical care at the local level. Since neither the EECPs nor the settlements located near the line of contact belong to cities of regional significance, therefore, local authorities, in addition to performing the functions of the medical institution owner, are also responsible for developing a strategy for the healthcare system development in the region and its implementation. Local self-government bodies in accordance with clause 5 of Article 4 of the Law of Ukraine “On improving the availability and quality of medical services in rural areas” of November 17, 2017, ensure the availability and quality of medical services, solve the issue of providing medical and pharmaceutical workers with housing, company vehicles, and appropriate conditions of labour, landline and mobile communication, access to the Internet, mobile computer hardware and software products, professional literature, should introduce additional incentives for recruitment of highly qualified medical staff, determine the needs of local communities in health professionals and form an order for training or advanced training of specialists. Now decentralization processes in this region are hindered by the ongoing armed conflict. The activities of existing local self-government authorities at the level of village and township councils are actually paralysed and are formal in nature. Military and civil administrations at the level of villages, towns, and some districts have concentrated their activities on measures to ensure national security and defence, resist and deter armed aggression and do not actively participate in development programs. Traditional “pre- conflict” transport routes, administrative division of territories of districts within the Donetsk and Luhansk oblasts, a system of redirection from one specialist to the other 9. Special aspects of the medical reform implementation in the territory near the line of contact 23

in the medical industry, and the activities of social services on social accompanying of lonely, weak and other people who need care, as well as the procedure for allocating funds for these purposes have undergone significant changes and have not adapted to new living conditions in the region. As a result, the level of satisfaction of the basic needs of people in this territory is reduced. The role of local self-government bodies and ATC in providing medical care to residents of settlements near the line of contact and EECPs. In 2017, UAH 119,607,100 was allocated for the development of a health care system in rural areas of the Donetsk oblast, and UAH 87,540,500 – for the Luhansk oblast. In 2018, UAH 29,901,800 was additionally allocated for the Donetsk oblast and UAH 21,885,100 – for the Luhansk oblast. The subvention was directed at the implementation of construction projects (new construction, restoration, major repairs, including the preparation of project documentation) of communal health institutions in rural areas, taking into account the needs of the population for medical care, the need to ensure its proper quality, timeliness, accessibility for citizens, effective use of material, labour and financial resources; the acquisition of medical equipment, equipment and means; development of telecommunication infrastructure, including access to the Internet, provision of modern technical and information and programming tools; provision of official housing (including construction and acquisition) and company vehicles (including for servicing residents of remote settlements located in the territory of the health care institution), medical workers of communal health institutions working in rural areas54. A prerequisite for the allocation of the subvention was the 10% co-financing of projects from the local budget. However, only a small part of these funds was used during 2017-201955, which indicated a low level of local self-government authorities’ activity in the development of the health system. Due to the non-use of funds, the period of the subvention realization was extended for 2020. In accordance with the reform plan of primary, emergency and secondary medical care, the maintenance of the buildings of healthcare institutions and filling them with appropriate material and technical resources is assigned to the budgets of local self- government bodies. The source of expenditures for these purposes is the local self- government bodies and ATC’s own budget, which is mainly formed from the payment of corporate income tax, single tax, rental payments, administrative fines imposed by local executive authorities and executive bodies of local councils and excise duty retail sales of excisable goods. Since over the past five years, “life has stood still” in these territories, then revenues to local budgets are scanty and are not able to cover part of the costs of local self-government bodies in medical reform. Taking into account the organizational and economic weakness of local authorities due to the ongoing armed conflict, itis unlikely that such bodies can be included in the reformed process of providing medical care to local residents on an equal basis with other regions of Ukraine that have not suffered from armed aggression. In the context of the socio-economic situation in the territories near the line of contact and at EECPs, local self-government authorities do not consider it necessary to place health institutions in locations places where such medical centres had not worked before

54 clause 4 “The procedure and conditions for the provision of subventions from the state budget to local budgets for the implementation of measures aimed at developing the health care system in rural areas” was approved by the CMU Decree No. 983 of December 6, 2017 55 Report on the results of the audit of the effectiveness of the use of subventions from the state budget tolocal budgets for the implementation of measures aimed at developing the health care system in rural areas, approved by the Accounting Chamber resolution No. 32-1 of November 12, 2019 24 9. Special aspects of the medical reform implementation in the territory near the line of contact

the conflict began or to restore old health institutions destroyed during hostilities. Also, local self-government bodies almost do not take advantage of the opportunity to invest in housing (construction or repair) for PMC doctors, company transport for them and other additional incentives to attract doctors using the budget subvention. Boththe Government and the Parliament have created a regulatory field that allows bringing some public services closer to remote settlements (Oshchadbank mobile offices, mobile CAS, MIA mobile service centres). In 2017, the concept of “mobile medical rooms” was introduced into the Law of Ukraine “On improving the availability and quality of medical services in rural areas”, but this tool has not yet been implemented. In a situation where there are significant difficulties in providing medical care in remote settlements, an alternative may be measures designed to bring patients to medical care centres through the restoration of roads to remote settlements and establishing regular transportation services. However, none of these methods is implemented locally and people remain isolated from medical care along the entire line of contact, including EECPs. The role of the central executive bodies on issues of healthcare provision in bringing medical services closer to residents of settlements near the line of contact and EECPs. In the range of 20 km along the line of contact, there are about 600 settlements where 3.2 million people live according to UN estimates56. All of them, to a different extent, have difficulty accessing medical care. According to the concept of primary medical care reform, local health care institutions are autonomous communal or private institutions. The activities of the doctors of these institutions are financed by the National Health Service of Ukraine withinthe procurement of medical services to meet the medical needs of the population. The standards for the remuneration of labour and determining the maximum number of patients are the same for Ukraine, without taking into account the social and economic, demographic and security issues of settlements near the line of contact, including EECPs. Cabinet of Ministers of Ukraine Decree No. 70857 of September 5, 2018, is not applied in this case, since it only applies to workers whose registered place of work is the settlement at the line of contact and does not apply to home visits to patients living at the line of contact. Due to the above reasons, the level of signing declarations with family doctors in the region is low. For example, only about 460 thousand signed declarations58 (21% of the total registered population) in the Luhansk oblast59 and about 1.35 million (32.5% of the total registered population)60 – in the Donetsk oblast as of the end of 2019. However, doctors are paid by the NHSU precisely depending on the number of such declarations; the more declarations, the higher the salary. At the same time, the salary of a doctor working near the line of contact does not include any additional incentives for work related to the risk to life due to the ongoing armed conflict. Therefore, due to the lack of adequate material support for the work of medical institutions, the insufficient

56 Access to medical services in Ukraine in terms of healthcare protection. July 2019 57 CMU Decree No. 708 of September 5, 2018 “On the peculiarities of the remuneration of workers involved in ensuring the conduct of the anti-terrorist operation, workers involved in the implementation of measures to ensure national security and defence, repulse and deterrence against armed aggression of the Russian Federation in Donetsk and Luhansk oblasts, as well as employees of state and municipal institutions, entities, organizations financed from the budget and located in settlements located at the contact line” 58 Electronic map for primary medical care, NHSU 59 Social and economic analysis of Luhansk oblast, 2019 60 The Donetsk Oblast Development Strategy till 2027 10. Conclusions and recommendations 25

number of signed declarations due to the difficulties in transportation between a doctor and a patient and uncompetitive salaries, there is a low level of interest of professional doctors to this region, an outflow of personnel and a decline of the medical institutions’ infrastructure.

10. CONCLUSIONS AND RECOMMENDATIONS The crisis in eastern Ukraine has become a long-term event. The long-term consequences are becoming more serious and deepen segregation in the quality of life of the population and access to basic public services between territories located near the line of contact and other areas controlled by the government of Ukraine. In the long run, morbidity and mortality from diseases that have not been treated, and injuries caused by the ongoing crisis, will become an obstacle to the processes of renewal and development, and can also affect the lives of future generations. Since the beginning of the conflict, medical care provided at EECPs by non-governmental and international organizations has become an affordable alternative to providing the population with PMC within the framework of the state healthcare system. The armed conflict and its consequences for people living near the line of revealed that the primary health care system was not ready to adapt to the new conditions of the administrative structure in the event of a breakdown in established links in the local network of medical institutions. However, the presence of compensatory mechanisms did not contribute to the re-adjustment of communal health institutions to new living conditions in the region, and the combination of security, economic and social problems caused the outflow of professional medical workers from the region. As a result, access to state-guaranteed primary and emergency medical care near the line of contact is not provided for a number of reasons that are systemic in nature. These reasons are: • an ongoing armed conflict; • the unavailability of capable territorial communities near the line of conflict and EECPs and effective local self-government bodies; • the unavailability of the EECP specific structure and the person responsible for its maintenance (balance holder); • the lack of sufficient filling of the budgets of local self-government bodies for the maintenance and development of health care institutions in the settlements near the line of contact and the EECPs; • the unavailability of consideration of geographical features (mine pollution of territories, changes in routes and schedules of public transport, deterioration in the quality of road surfaces between settlements in the region), factors of internal migration processes and population needs when determining the network of PMC stations in settlements near the line of contact and EECPs; • the absence of additional financial guarantees for primary health care workers in conditions of increased intensity and psychological and emotional stress in regions with a difficult security situation (both in the context of hostilities and in relation to the general epidemiological environment); • the lack of professional personnel for the health care system in settlements near the line of contact and EECPs. 26 10. Conclusions and recommendations

As a result of the data obtained, it was found that in order to take effective measures to prevent deaths at EECPs, it is not enough to be guided only by quantitative indicators of border/line of contact crossings and the experience of the checkpoint operation on the state border of Ukraine. In order to provide basic access to medical care, a permanent PMC station should be arranged at EECP to provide primary medical care in case of a patient’s physical or mental health disorder, which does not require emergency, secondary (specialized) or tertiary (highly specialized) medical care. Such a PMC station can function both within the framework of medical reform and outside it, as part of the EECP complex. These options have both advantages and disadvantages, however, none of them can be implemented in the current legal environment. In order to provide the population with effective access to emergency and primary medical care at EECPs and near the line of contact, it is necessary that: • Committees of the Verkhovna Rada of Ukraine on national health, medical care and medical insurance, on human rights, de-occupation and reintegration of temporarily occupied territories in the Donetsk, Luhansk oblasts and the Autonomous Republic of Crimea, the city of Sevastopol, national minorities and interethnic relations, as well as social policy and of the protection of the rights of veterans should hold a joint meeting with the aim of legislative regulation of access to medical and social security for residents of settlements near the line of contact during the JFO and reintegration period. • The Cabinet of Ministers of Ukraine should determine the list of settlements adjacent to the ‘grey zone’ line of conflict, where a special procedure will be in place to ensure that the population has access to basic medical care and social assistance services until the end of the armed conflict. • Committees of the Verkhovna Rada of Ukraine on national health, medical care and medical insurance, on human rights, de-occupation and reintegration of temporarily occupied territories in the Donetsk, Luhansk oblasts and the Autonomous Republic of Crimea, the city of Sevastopol, national minorities and interethnic relations should ensure the allocation of funds in the state budget of Ukraine for the payment of an allowance to the official salary for medical workers who provide medical assistance to residents of settlements adjacent to the line of contact and EECPs regardless of the location of the medical institution where these people work during the JFO. • The Ministry of Social Policy, together with the Ministry of Health should develop and coordinate amendments to the Ministry of Labour and Social Policy and the Ministry of Health joint Order No. 308/519 of October 5, 2015 “On consolidation of the wage conditions for workers of health care and social protection ofthe population institutions” in order to ensure adequate remuneration for primary medical care workers for work in conditions of increased intensity and psychological and emotional stress in settlements adjacent to the line of contact and EECPs during the JFO. • The Cabinet of Ministers of Ukraine should develop and approve the requirements for the arrangement of EECPs, which would provide for the presence of a health care station and service zone in the structure of EECPs. • The Cabinet of Ministers of Ukraine should determine the balance holder of EECPs in order to ensure uninterrupted electricity and water supply, sanitary and hygienic needs of people going through EECPs, proper arrangement of EECP territory and economic support of EECP infrastructure. 10. Conclusions and recommendations 27

• The Health Departments of the Luhansk and Donetsk oblasts, together with local authorities, should conduct a thorough analysis of the needs for medical care and social support for vulnerable segments of the population of settlements near the line of contact, taking into account the peculiarities of transport connections between these settlements and the nearest multidisciplinary healthcare institution and make appropriate changes to the structure of health care institutions in the region. • The Health Departments of the Luhansk and Donetsk oblasts should ensure the presence of medical personnel at the EECPs in order to provide primary medical care to vulnerable groups of population. • State Emergency Service of Ukraine should develop and place in the places of mass gathering at EECPs information on the procedure for applying for premedical and emergency medical care and an algorithm of actions in the event of a sharp deterioration of health at EECPs. • The State Border Guard Service of Ukraine, Centres for Emergency Medical Care and Disaster Medicine in Donetsk and Luhansk oblasts and other interested bodies should coordinate the procedure for ambulance access to the line of contact at “zero checkpoints” in order to provide medical care to people in emergency situations.