Table of Contents

1. Executive Summary…………………………………………………………………………………………………………………………………2

2. Background…………………………………………………………………………………………………………………………………………….5

3. Objectives……………………………………………………………………………………………………………………………………………….6

4. Logistics………………………………………………………………………………………………………………………………………………….6

4.1: Banking Infrastructure…………………………………………………………………………………………………………….6

4.2: Hotel Accommodations…………………………………………………………………………………………………………..7

4:3: Transportation………………………………………………………………………………………………………………………..7

5. Communications…………………………………………………………………………………………………………………………………….8

6. Security…………………………………………………………………………………………………………………………………………………..8

6.1: Threat Assessment………………………………………………………………………………………………………………….8

6.2: Hazards…………………………………………………………………………………………………………………………………..9

6.3: Security Checkpoints………………………………………………………………………………………………………………9

6.4: Travel Between Ukrainian-held Territory and the Self-proclaimed Donetsk People’s Republic.10

7. Rapid Assessment Findings……………………………………………………………………………………………………………………11

7.1.: Gender-based Violence………………………………………………………………………………………………………..11

7.2: Child Protection…………………………………………………………………………………………………………………….15

7.3: Mental Health and Psychosocial Support………………………………………………………………………………18

7.4: Health…………………………………………………………………………………………………………………………………..22

8. Conclusion……………………………………………………………………………………………………………………………………………27

9. References……………………………………………………………………………………………………………………………………………28

10. Annex A: Agenda for Assessment Mission…………………………………………………………………………………………..29

11. Annex B: Local and International Organizations Engaged in MHPSS Activities or Services……………………32

1. Executive Summary

Since January 15, 2015, hostilities between Ukrainian and separatist forces have increased and the overall situation in Eastern Ukraine has drastically deteriorated. On January 23, after days of heavy fighting between the Ukrainian Government forces and separatist forces which resulted in dozens of civilian casualties, the self-proclaimed Donetsk People’s Republic (DPR) leader rejected calls for a truce and both sides publicly stated they are gearing up for further conflict. Civilians in conflict-affected areas of Donbas face immediate security threats due to an increase in hostilities since the middle of January. Assessment Mission International Medical Corps deployed a Security Manager to Ukraine in December 2014 to conduct a security assessment, followed by the deployment of a multi-sectoral assessment team in January 2015 to conduct a rapid needs assessment. The primary objectives of the security assessment were to: 1) identify the threats to International Medical Corps staff and programs, 2) recommend appropriate risk mitigation and 3) assess whether or not the level of risk is within International Medical Corps’ acceptable levels. The primary objectives of the rapid needs assessment were to: 1) identify and assess key humanitarian needs in the areas of protection (gender-based violence and child protection), mental health and psychosocial support and health and 2) identify current gaps in meeting humanitarian needs.

International Medical Corps’ assessment team consisted of 8 people, including the Country Director, technical specialists (health, protection, mental health and psychosocial support), local translators and a security manager. For the rapid needs assessment, the team used qualitative methods, including key informant interviews and focus group discussions. Team members met with a variety of key stakeholders, including representatives from Ministries, UN agencies, international NGOs, local NGOs and community- based organizations; city officials; health facility staff and health workers; civilians, including IDPs and host communities; and military personnel.

The team traveled by road from Kiev to Mariupol and surrounding rural areas. Two members of the assessment team traveled by road from Mariupol to Donetsk city. Generally, the team found that access to and from the DPR was possible, although humanitarian personnel should be mindful of security checkpoints and recent permit requirements for all persons crossing the frontline. Summary of Findings Protection: Gender-based Violence and Child Protection Gender-based violence (GBV) has been recognized by the humanitarian community as a human rights violation as well as a public health concern, to which women and girls are particularly vulnerable in emergency settings and conflict contexts. The risk of GBV, particularly the use of sexual violence by armed actors against women and girls in the region is a growing concern. Even before the crisis other types of GBV, such as intimate partner violence and sex trafficking, were being reported. Elderly women are also facing substantial obstacles in accessing basic services as their mobility both due to chronic illness such as arthritis and hypertension can be significantly limited.

Caregivers and service providers consistently spoke of the negative impact the conflict is having on children’s wellbeing often describing increased fear, anxiety and aggressive behaviors in children. For families with mothers who relocated with children to safer areas and fathers stayed behind to look after property and assets this has created additional stressors and anxiety for IDP children. Families living in

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collective centers also described frequent bullying in schools and sometimes general mistrust in accessing other government supported social services.

While social services, schools, and medical care are functioning in many areas in Mariupol, all of these services are stretched to capacity and few providers have substantial training in working on GBV and Child Protection issues, and almost no one has expertise in working on these issues in humanitarian contexts. Furthermore, large networks of local volunteers are doing remarkable work in providing basic inputs and in some cases services to conflict affected populations but few if any have received training in best practices, PSEA, IASC guidelines or do no harm principles. Mental Health and Psychosocial Support The conflict in Eastern Ukraine has seriously affected the mental health and psychosocial well-being of the affected population, including people living in the conflict area, IDPs and host populations. There are many accounts of people with concerns about the future, of people feeling hopeless and insecure, and children being afraid of loud noises and wetting their beds. These problems can have immediate as well as long- term consequences for individuals, families and communities in a divided part of the country.

Mental health care in Ukraine is mainly focused on specialized care, taking place in and around psychiatric clinics and institutions. Psychosocial support is a relatively new concept. People are used to coping with their problems on their own (also with negative coping mechanisms such as alcohol abuse) or within family circles. In the current situation there is a huge gap between needs and available MHPSS activities and services. There are only few community-based initiatives or services integrated into primary health care. Staff and volunteers of local NGOs and agencies are trying to fill this gap and support the affected population. Service providers such as staff working in general health care, psychologists and social workers similarly have limited experience in and skills in psychosocial support.

Health Ukraine’s health system was generally limited prior to the conflict. In the DPR, the health system is now visibly collapsing. Excessive shelling has damaged several health facilities and some evidence suggests that some health facilities in the DPR have experienced looting and many facilities lack food and water for patients. Some health staff have left the area or no longer present to work due to lack of payment, and supply chains are broken. The combination of physical infrastructure damage and lack of staff has meant that government health service provision is nonexistent in many rural areas of the DPR and at a minimal level in others.

Health workers in Mariupol city and surrounding rural areas indicated that facilities can currently manage providing very basic health services to host communities and IDPs but any rise in IDPs would strain the health system. Health facilities in the rural areas of Mariupol have limited lab capacity and many do not have maternal health services available. Financing for health services is limited in all areas. Health facilities in both Mariupol and Donetsk lack essential medicines, medical equipment and consumables. In the DPR, the shortage of medicines, supplies and equipment is dire, and these facilities are also in urgent need of consumables, food and water to care for patients.

Access to primary, secondary and tertiary care is limited in Mariupol and critically compromised in Donetsk. Facilities that are still operational in the DPR need assistance in building capacity to triage and provide urgent care to war wounded patients. The current lack of local capacity and referral mechanisms in many areas have increased the need to bring health services directly to communities. In Donetsk and rural areas

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of Mariupol there is a need for increased mobile medical units, especially to reach rural populations. There is also a need to increase the number and types of specialists in the units. Summary of International Medical Corps’ Recommendations Based on assessment findings, International Medical Corps recommends humanitarian actors support the following interventions to meet the needs of conflict-affected persons in Donetsk Oblast: Gender-based Violence • Build capacity of available medical and social services in international and national GBV guidelines • Make services available through governmental as well as civil society actors to facilitate ease of access for survivors who might be concerned with impartial treatment. • Information regarding available services needs to be made available through traditional IEC materials as well as confidential hotline to minimize any potential risk associated with reporting. • Pre-position post-rape kits in key hospitals and health centers. • Train formal and informal actors across sectors in the IASC GBV guidelines as well as PSEA. Child Protection • Aid workers in regular contact with children should be trained in child protection principles as well as PSEA. • Volunteers & service providers in regular contact with conflict-affected children should be trained in Psychological First Aid to be able to provide basic psychosocial support to children and their parents. • Psychosocial opportunities for conflict-affected children should be expanded to minimize negative coping and enhance children’s wellbeing. Mental Health and Psychosocial Support • Improved cross-sectoral coordination, information sharing and dissemination of best practices for MHPSS response to the crisis. • Support capacity development of local agencies and organizations responding to MHPSS needs among the affected population. • Engagement of affected families and communities in promotion of psychosocial well-being and self-care. Health • Support health facilities in the DPR and Mariupol in building capacity to handle patient surge and trauma-related injuries, as well as the ability to provide primary health care and other essential services to conflict-affected persons, by training service providers and distributing essential medications, supplies, consumables and equipment. • Facilitate staffing support for health facilities in the conflict zone and surrounding areas by providing incentives for work and salary support. • Improve the availability of and accessibility to primary health services among rural and marginalized populations through the deployment of mobile medical units. • Continue to advocate to authorities in both the DPR and Ukrainian-held territories to facilitate access and travel across the frontline for humanitarian actors providing essential services.

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2. Background

Conflict between pro-Russian separatists and Ukrainian Government forces continues despite the signing of a ceasefire on September 5, 2014 and a nine-point memorandum on September 18, agreed in Minsk, Belarus between separatists and the Government of Ukraine (GoU). The conflict began following the Ukrainian revolution in February 2014, which resulted in culminated in President Victor Yanukovych leaving the country and being dismissed by Parliament. Russia then proceeded to annex Crimea, sparking pro- Russia protests in Donetsk and Luhansk oblasts that quickly turned into armed separatist movements. The Donetsk People’s Republic (DPR) and Luhansk People’s Republic (LPR) have since been in armed conflict with the Government of Ukraine.

Since January 15, 2015, hostilities have increased and the situation has drastically deteriorated. On January 23, after days of heavy fighting between the Ukrainian Government forces and separatist forces which resulted in dozens of civilian casualties, the self-proclaimed DPR leader rejected calls for a truce and both sides publicly stated they are gearing up for further conflict. Civilians in conflict-affected areas of Donbas face immediate security threats due to an increase in hostilities since the middle of January. Presidential Decree 875 After armed groups organized elections on November 2, 2014, in areas under their control, the GoU decided to temporarily relocate all State institutions and organizations present in areas controlled by the armed groups to areas controlled by the GoU. This includes the relocation of social, medical and educational institutions, the judiciary, penitentiary facilities, state enterprises, as well as banking services. As of December 1, all allocations from the State budget (including for social payments) to areas not controlled by the Government were ceased.

To continue receiving social payments, residents of Donetsk and Luhansk regions (under the control of the armed groups) were required to register by December 31 in the territory under the control of the GoU to prevent national budget funds falling into the hands of the armed groups who had taken control of social institutions, including local branches of the Pension Fund, as well as banks.1 The implementation of these measures have already had considerable consequences for the population in the separatists-held areas. It means a lack of public services, including health services, and no access to social payments for those unable to register with the Government. Few people in the DPR/LPR are receiving payments. This has led to increased numbers of IDPs, as people relocate to register in areas where they may receive their benefits. On the other hand, others such as the elderly and disabled are unable or unwilling to leave their homes, thus increasing their vulnerability, as many cannot access social benefits. Representatives from several governments and agencies present in Ukraine are lobbying for this decree to be reconsidered, especially because of the actual impact it has on the most vulnerable people. Displacement and Humanitarian Needs Access to conflict-affected areas is also increasingly challenging for non-governmental organizations (NGOs), due to new bureaucratic procedures put in place by the GoU and the DPR authorities. The United Nations Strategic Response Plan for Ukraine (SRP) in 2015 emphasizes the need to 1) respond to the protection needs of displaced and other conflict-affected people, with regard to international humanitarian norms and standards, 2) provide life-saving assistance and ensure non-discriminatory access to quality essential services for displaced and other conflict-affected people, with emphasis on the most vulnerable, and 3) improve access of displaced and conflict-affected people to high-impact early recovery activities.

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More than one million people have been displaced from their homes since the start of the conflict, including over 920,000 IDPs and nearly 600,000 refugees who fled to neighboring countries. More than 5,000 people have been killed and over 10,000 injured since the start of the conflict.1 In addition to the displaced, an estimated 5.2 million people currently reside in conflict-affected areas. As of January 19, an estimated 1.4 million people remained vulnerable and in need of humanitarian assistance. These 1.4 million civilians were estimated to be vulnerable pre-conflict and so, disproportionately affected by the conflict.

3. Objectives In December 2014 International Medical Corps staff conducted a scoping mission in Eastern Ukraine with the primary objective of better understanding key humanitarian needs. Following the scoping mission, International Medical Corps deployed staff to conduct two assessments: a security assessment and a multi- sectoral rapid needs assessment.

The primary objectives of the security assessment were to: 1) identify the threats to International Medical Corps staff and programs, 2) recommend appropriate risk mitigation and 3) assess whether or not the level of risk is within International Medical Corps’ acceptable levels.

The primary objectives of the rapid needs assessment were to: 1) identify and assess key humanitarian needs in the areas of protection, mental health and psychosocial support and health and 2) identify current gaps in meeting humanitarian needs.

4. Logistics On January 10, 2015, International Medical Corps deployed an assessment team to Ukraine. The assessment team traveled by road from Kiev to Mariupol on January 14. On January 17, two members of the assessment team traveled by road to Donetsk city while other members of the team continued work in Mariupol and surrounding rural areas.

International Medical Corps’ assessment team consisted of 8 people, including the Country Director, technical specialists (health, protection, mental health and psychosocial support), local translators and a security manager.

4.1: Banking Infrastructure Due to inflation and the overall economic situation, banking infrastructure in Ukraine remains inconsistent. ATMs in Kiev were functioning and currency exchange services are available; however, banks generally do not have dollars available. The International Medical Corps assessment team visited three different banks in effort to access a Western Union transfer. Only one bank was able to cash the transfer but, even so, dollars had to be pre-ordered and were unavailable on the same day. Banks in Mariupol indicated that they could pre-order dollars but funds cash would not be available for at least 10 days. In separatist-held areas, there is no banking system, meaning no functioning ATMs.

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Humanitarian personnel should also be aware that recent legislation has affected banking access for both foreigners and Ukrainian citizens. In Kiev, banks informed International Medical Corps staff that Ukrainian citizens are liable to pay taxes on all wire transfers (e.g., Western Union), regardless of the amount. Foreigners can cash wire transfers without problem as long as funds can be pre-ordered by a bank and do not exceed UAH 150,000 (approximately $9480 or €8440, and the National Bank of Ukraine exchange rate applies). Foreigners are required to open bank accounts to cash and access wire transfers exceeding UAH 150,000. Foreigners also may be liable to pay fees if they cash multiple wire transfers within a 30 day period and the total amount of withdrawals exceeds UAH 150,000. It is unclear if this is true across the board, but foreigners should be mindful that they may encounter challenges with the banking system.

4.2: Hotel Accommodations Accommodations are available in Mariupol and Donetsk cities. In Mariupol, hotels are open and fully functional, including restaurants, hot water, electricity and wireless Internet. Some hotels sporadically experience blackouts and not all have generators. Supermarkets in Mariupol are functioning.

Hotels are available in Donetsk, although many are occupied by military personnel, and others have been closed due to the displacement of staff. One and two-bedroom apartments are also available for rent. Heavy shelling continued during the time International Medical Corps staff were in Donetsk, particularly north of the city. This impacted staff activity as damage to a substation caused an electricity outage, requiring staff to relocate to alternative accommodation.

4:3: Transportation Fuel is available in Ukrainian-held areas and generally available in the DPR, although some fuel stations in the DPR are closed. Vehicles are available for rental in both areas, and drivers are generally available for hire. However, there are fewer vehicles and drivers available in the DPR. Some sources suggest that drivers in the DPR are currently difficult to find because of the increased number of journalists entering the area (who are hiring drivers and renting vehicles). International Medical Corps staff found it easier to travel into the DPR (from Mariupol) with a vehicle that had DPR license plates. It is still possible to travel into the DPR by car with non-DPR license plates, but clearing through checkpoints was perceived as easier with DPR plates.

Trains are still functional from Kiev to Kharkiv, Dnipropetrovsk and Zaporizhia. Trains from Kiev to Mariupol are no longer running after a bridge in Mariupol was bombed in December 2014. There are no trains going into the DPR territory.

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Fuel station in Donetsk City (January 2015)

5. Communications Cellular services, including mobile Internet, are currently functioning in Mariupol and Donetsk. Because of damage to substations which resulted in electricity outages in Donetsk, internet connectivity also went down at times.

6. Security In December 2014, International Medical Corps deployed a Security Manager to Ukraine to conduct a security assessment of conflict-affected areas, including Donetsk. The Security Manager was in-country for 4 weeks to assess threats, hazards and considerations for travel between Ukrainian-held territory and the self-proclaimed Donetsk People’s Republic.

6.1: Threat Assessment The primary threat to International Medical Corps staff and property in Donbas is posed by artillery and rocket fire. Donetsk is regularly shelled with the airport and north of the city being under almost constant artillery barrages. Mariupol city was also attacked with GRAD rockets during the assessment period.

In addition, the threat posed by small arms fire, other indirect and direct fire weapons, explosives, land- mines and Explosive Remnants of War remains credible and significant. The threat of physical and sexual assault and illegal detention also remains.

There have been reports of improvised explosive devices (IEDs) in Kharkiv, along with frequent non-violent protests and expressions of opposition to the DPR/LPR. The threat environment of Kharkiv is similar to that of Zaporizhia.

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6.2: Hazards Road Traffic Accidents (RTA) The road conditions in Eastern Ukraine are generally poor, especially off the main arterial routes. International Medical Corps staff and other humanitarian actors will likely travel from the city to program areas. Driving standards in Eastern Ukraine can sometimes be unpredictable, with high speed, drunk driving and poorly maintained vehicles all evident. Together with other factors such as snow, rain and damage to roads increases the likelihood of road traffic incidents. Road travel during nighttime hours should be avoided, especially when traveling through checkpoints.

Disease/Illness/Medical The medical facilities in Donbas have suffered greatly from lack of supplies and staff moving out of the area for safer locations. Currently, emergency medical care capabilities in Donbas are generally poor. Whenever possible, humanitarian staff should seek medical treatment outside of the Donbas region. For minor illness and injury, it is recommended that the Greek Medical Center (65 Grecheskaya Street, Mariupol, Donetsk Oblast) is used for treatment and stabilization. Behavior Humanitarian actors should be mindful that security is directly related to behaviors and interactions with people. Humanitarian staff should follow their respective organization’s Code of Conduct and present themselves humbly, openly and with respect to all individuals, with cultural sensitivity at the forefront. It is imperative that humanitarian actors continually observe situational awareness, as well as use the internal systems in place for their safety (e.g., movement tracking, “check ins”, varying routines/locations and regular training on kidnap avoidance/survival, detecting surveillance, and other mitigation trainings).

6.3: Security Checkpoints In anticipation for travel, and in light of the recent destabilization in the Donbas region, humanitarian staff should understand the importance of only carrying appropriate and necessary items with them. It should be expected that personnel at checkpoints, in both Ukrainian-held and separatist-held areas, will stop and search vehicles. Personnel at checkpoints may also wish to look in-depth into belongings, documents and electronic devices. Items may be placed on the uncovered ground when being searched, taken away for copying or passed from person to person. While the majority of personnel at checkpoints are sensitive and respectful, it should be expected that sensitive and personal items may be taken out and made visible to all.

Humanitarian staff should also be aware that personnel at checkpoints may use military or armed individuals’ personal mobile phones to photograph documents, items on mobile phones (including photographs, SMS and call logs), and even the faces of people in transit. It should be considered that photographs or information may not always be taken in the context which is intended. For example, photos of trainings may appear differently to personnel at checkpoints, personal photos or information may be interpreted as linked to professional roles, and photos of other contexts or of the crisis may be deemed controversial. Searches may be carried out by well-trained military, police or intelligence personnel but also may likewise be carried out by individuals who have little training or idea as to what he/she is looking for, and thus projecting suspicion onto the search.

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Humanitarian personnel, as neutral actors, are encouraged to take a transparent approach. Humanitarian staff should not be alarmed or feel the need to “sanitize” their belongings, which may in itself be suspicious, but rather humanitarians should be prepared for the possibility that their personal and professional belongings may be searched. Humanitarians should not feel discouraged from carrying their personal or professional belongings if carried for a purpose. If ready to explain the purpose of items in a polite manor, staff will likely not encounter problems.

6.4: Travel Between Ukrainian-held Territory and the Self-proclaimed Donetsk People’s Republic Access by road was proven using both the H15 to and from Zaporizhia and the H20 road to and from Mariupol to Donetsk via Volnovakha. To access the DPR from other parts of Ukraine, a buffer zone or no man’s land must be crossed. Access to the DPR (the width of which varies dependent on the ground and situation) is controlled at both ends of what is essentially an access corridor. There are 7 such corridors which have been established to provide access into the Anti-Terrorist Operation (ATO) zone.

A number of checkpoints exist along the both the H15 and H20. Some are operated or controlled by armed personnel while others have the structure for a checkpoint in place but no personnel present. These are either old disused checkpoints or surge checkpoints. Some sources suggest that the personnel operating or controlling the checkpoints are reduced or simply not present during darkness hours.

Most of the checkpoints consist of chicanes leading to a central inspection area controlled by two to six armed personnel. A fabricated building and reinforced bunker are common at Ukrainian military checkpoints, as are Armored Personnel Carriers (APCs).

The time taken to transit a checkpoint usually takes 5 to 15 minutes. The majority of personnel simply ask to see identification (international or national passport) and to inspect the vehicle, including the luggage storage compartment. International Medical Corps staff had letters of intent/support (produced by their headquarters office) to show personnel. These letters indicated the purpose of travel and it was the International Medical Corps’ Security Manager and assessment team’s perception that these letters, while not essential, are most helpful in the decision process of the checkpoint personnel. Documents are often taken to a building/hut for further inspection by an officer but returned within five minutes. A calm, respectful and patient approach by International Medical Corps staff was also believed to contribute to unhindered access.

Any and all corridors may be closed at any time by either side of the conflict area and are a focus for continuing flash points, mostly involving indirect fire. A number of impacts from artillery/mortar rounds can be observed on the roads near some checkpoints; however, these are almost indistinguishable from the many potholes on the roads.

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7. Rapid Assessment Findings 7.1: Gender-based Violence Methodology For the purposes of this assessment and in-line with global best practices on rapid GBV assessments predominantly qualitative data collections methods were used, namely semi-structured key informant interviews and focus group discussions with service providers, government officials, and adult women from the affected populations.

Data Collection Data was collected over the course of 7 days in Mariupol and two rural raions, and 4 days in Donetsk city. Key informant interviews were carried out with three social workers, 8 health workers, one police officer, two representatives of civil society, ten city officials, four international organizations and one international non-governmental agency. In addition, one semi-structured focus group discussion was carried out with adult IDP women as well as individual interviews with three internally displaced women.

Limitations and Assumptions This assessment focused on clarifying what response services are currently available to survivors as well as existing capacity of the available services. That said, this assessment does not constitute a full service mapping and is not intended to substitute ongoing efforts from the GBV sub-cluster to map existing GBV services nationwide. Additionally, due to time limitations, in-depth capacity assessments were not carried out with each service provider, rather efforts focused on determining if critical supplies existed, prior specialized training had been received and if minimum standards and best practices were being applied.

Furthermore, this assessment captures perceptions of safety and security as it pertains to GBV as it relies on qualitative data. This assessment does not capture the scale of the problem as it relates to incidence or prevalence of gender-based violence as this was neither appropriate for the context nor feasible in terms of time and resources. Rather, this rapid GBV assessment in accordance with international guidelines explores conflict-affected communities’ perceptions of risk, threats and services as they pertain to GBV. Findings Mobility and Access to Basic Services Consistently, women and girls reported the biggest threat to their safety was the deteriorating security conditions in their point-of-origin, and that the active conflict particularly the shelling was the most significant factor in their decision to relocate. In some cases, women had relocated with their children to safer environments, usually urban, leaving husbands or male family members behind to look after property and other assets. Additionally, lack of basic services was another determining factors in their decision to relocate.

Displaced women spoke of limited shelter and income-generating options as two of the greatest challenges they faced in their host communities. Women spoke of few employment options available to them, and the limited child care options also made it difficult for women with younger children to look for or sustain employment. Additionally, women consistently explained that one of the greatest hurdles they faced was in accessing government benefits, citing lack of clarity at the local level on policies over eligibility. Compounding this problem is the lack of supporting documentation that many women and their families are facing; key identity documents either being destroyed or left behind or lost in transit.

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In Mariupol city, women living in collective centers spoke of a decrease in the frequency of NFI distributions made by local volunteer organizations since the onset of the crisis. Winterization and hygiene supplies were reportedly in short supply, and menstrual hygiene supplies were not consistently included in the distributions.

Elderly women living in collective centers are facing substantial obstacles in accessing basic services as their mobility both due to chronic illness such as arthritis and hypertension is limited. Yet in some cases volunteer organizations were no longer distributing NFIs and supplies directly to collective centers. Instead, individuals were being asked to travel across town to warehouses to pick up basic supplies, a feat that most elderly women assessment team staff spoke with stated was not within their physical capacity to carry out. Elderly women consistently reported that they had to depend on other IDPs’ willingness to seek out medication, groceries, and NFIs on their behalf due to age-related physical limitations.

Women of child-bearing age spoke of increased difficulty in accessing contraception largely due to increases in the prices of contraceptive commodities locally and limited income.

Sexual violence There are conflicting reports on the issue of conflict-related sexual violence. In areas assessed by International Medical Corps, documented reports of sexual violence at health facilities or police units do not currently exist. In major urban centers service providers and some local officials did not believe the issue to be a significant problem. That said, international organizations reported that rumors of the use of sexual violence by armed entities were not uncommon; however, firsthand accounts had not been documented through the official human rights monitoring mechanism.

Farther removed from major urban areas and closer to the front line/buffer zone various entities spoke of the use of sexual violence by armed actors as extremely problematic but that survivors were hesitant to come forward. There is no systematic monitoring or mandatory aggregate reporting mechanism for GBV cases within the health system. Additionally, police do not have jurisdiction over crimes committed by members of the national military and are required to hand over such cases to the military for additional investigation and prosecution. Consistently, respondents associated alcohol use by armed actors as a contributing factor to the instances of sexual assault that they were aware of.

Anecdotal accounts across multiple sources of information indicate the use of sexual violence by both pro- Russian and pro-Ukrainian forces and such accounts corroborate what individuals the assessment team spoke with reported. La Strada, a national women’s organization, noted a spike on their national hotline in March 2014 of women calling in to report sexual assault by armed actors in Crimea. Human Rights Watch has documented numerous accounts of torture, including the use of threats of sexual assault and forcible stripping of detainees. As well, the United Nations noted “undocumented reports of high levels of sexual violence in the conflict area, which require substantial medical, psychosocial and legal redress” in its 2015 strategic plan for Ukraine released in December (2014).

Intimate Partner Violence Almost everyone International Medical Corps spoke with reported intimate partner violence (IPV) as a problem prior to the conflict. Notably, the Mariupol police department responded to approximately 4,800

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IPV related incidents in 2014 across the oblast. With the onset of the crisis, respondents noted that cramped living conditions, stressors related to displacement and limited resources had in some cases/localities increased the of instances of IPV. Most respondents associated IPV with instances of alcohol consumption either by one or both partners. Analysis of the police data for the increase or decrease of reported cases has not been conducted, and the police departments are not able to desegregate cases by displacement status. In some instances, services providers felt that limited income had contributed to reduced alcohol consumption and therefore decreased IPV.

Trafficking and Survival Sex There is no clear data or information on whether or not the crisis has increased human and sex trafficking. That said this is an area of significant concern as Ukraine has historically been both a country of supply as well as demand for trafficking and the challenges women are facing in identifying income generating options could leave them particularly vulnerable to exploitation.

Response Services • Clinical Management of Rape services are not readily available across the sites that International Medical Corps accessed. Service providers had not been trained in relevant protocols and no post- rape kits were found at health facilities. There was also a lot of confusion as to what level of care (primary or secondary) post-rape care could be found. In some instances medical personnel spoke of survivors needing to go to hospitals in order to access this care or the offices of specialized health personnel namely ob/gyn physicians. • Psychosocial Support is provided predominantly through social workers at the Social Support Centers for Family and Youth and these services are available to survivors. Per the Director of Social Services in Mariupol, the government social workers have not received training in how to work with GBV survivors and have not received training case management. International Medical Corps found this to be true as well of volunteer social workers who were operating through the civil society networks assisting IDPs. While psychosocial support is available, it is not specialized and application of guiding principles and other best-practices vary. • Legal Aid provided to IDPs has focused primarily on helping them understand eligibility for governmental benefits and/or obtaining new documentation. While International Medical Corps did not carry about a comprehensive mapping of legal support services, legal services for survivors of GBV did not seem to be a focus area for the legal aid providers International Medical Corps spoke with. • Safety & Security Services are limited. The police department does have units dedicated to intimate partner violence and other domestic disputes, and their procedures do allow them to detain an abusive spouse for a cooling off period. The procedures emphasize mediation with police officer involvement. IPV cases are referred to social services for follow-up but nature and depth of follow- up is unclear. There are no open shelters for women seeking temporary shelter for life-threatening situations in the oblast.

Risk Reduction & Mainstreaming While there are numerous governmental and civil society actors providing support to conflict-affected communities, very few are versed in humanitarian principles and ones encountered had never been trained the IASC Guidelines for GBV in humanitarian settings. Overall, while capacity is higher than many humanitarian contexts, best practices were not being implemented and it was not uncommon to find

Emergency Assessment- Eastern Ukraine 13 shared bathing facilities for men and women in collective centers, lack of gender segregated shelter options for unaccompanied women, and limited knowledge on the gendered risk associated with humanitarian aid. Recommendations • Targeted capacity-building of available medical and social services in best practices and international and national GBV guidelines should be prioritized so that survivors can access appropriate and safe care through existing service providers. • Services should be made available through governmental as well as civil society actors to facilitate ease of access for survivors who might be concerned with impartial treatment. • Information regarding available services needs to be made available through traditional IEC materials as well as confidential hotline to minimize any potential risk associated with reporting. • Post-rape kits should be prepositioned in key hospitals and health centers to ensure that survivors of sexual assault can access potentially life-saving care. • Humanitarian workers as well as informal/volunteers networks delivering aid should be trained in the IASC GBV guidelines as well as PSEA to minimize any potential harm to beneficiary populations.

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Above: Collective Center in Mariupol City which houses 145 IDPs, 45 of which are children. The building is a former naval school which the city government converted into IDP housing.

Left: Communal shower in the Collective Center, located in the basement of the building. The door to the shower area does not have a lock and is used by males and females.

7.2: Child Protection Methodology For the purposes of this assessment and in-line with global best practices on rapid Child Protection (CP) assessments predominantly qualitative data collections methods were used, namely semi-structured key informant interviews and focus group discussions with service providers, government officials, and adult women from the affected populations.

Data Collection Data was collected over the course of 7 days in Mariupol. Key informant interviews (KIIs) were carried out with three social workers, 8 health workers, one police officer, three representatives of civil society, one governmental representative from the Office of Child Services, one governmental representative from social services, eight city officials, three international organizations and one international non- governmental agency. In addition, one semi-structured focus group discussion was carried out with adult IDP women as well as individual interview with three internally displaced women.

Limitations and Assumptions The assessment team conducted interviews with representatives from caregivers, organizations that provided service to children and youth as well as those that monitor CP issues. These findings should not be considered comprehensive of all possible child protection concerns that might exist in the assessed region as our data collection was limited. Due to staffing and time constraints International Medical Corps included child protection questions in various KII and focus group discussions but was not able to carry out

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an in-depth stand-alone assessment. These findings represent the concerns raised most consistently from a convenience sample of service providers, government officials and parents. Findings Psychosocial Wellbeing Psychosocial wellbeing of children was raised as a concern across almost all respondents. Key informants as well as focus group participants consistently spoke of the negative impact that the conflict was having on children’s wellbeing. They described increases in aggressive behavior particularly amongst boys under 12, inability to sleep/nightmares, fear of being left alone, and increased levels of anxiety as common. In some cases, mothers had moved to safer areas with their children leaving husbands and father’s behind to look after property and other assets. This breaking-up of the family unit was often described as a significant source of stress both for the primary caregiver as well the children. Government services are stretched to capacity and the availability of child care of after school care is limited. For single-parent households this is a particular concern as it limits the ability of the primary caregiver to seek employment options and also ensure their children are under appropriate and safe supervision.

Unaccompanied or Orphaned Children Unaccompanied or orphaned children were not widely reported by service providers though government officials did raise the current status of some residential care facilities as a concern. Governmental capacity to monitor the status of residential facilities for children with special needs or other forms of institutionalized care in buffer or DPR controlled areas was limited and conditions in these institutions was not clear. Reports regarding occupancy as well as conditions varied. The impact of the conflict of street children needs to be assessed more thoroughly as most local representatives International Medical Corps spoke with described declining numbers of street children but not much understanding as to why these numbers were declining and/or where the children were going.

Access to Education Access to education varied across assessed sites. In major urban areas with relative security contexts, such as Mariupol, schools were still functioning and open to IDP children though government officials voiced concern about resources and local budgets being at or over capacity. While schools that are functioning are open to IDP children, families International Medical Corps spoke with talked of pervasive bullying due to perceived political affiliations of IDP families versus host communities.

Child Sexual Exploitation and Abuse Child sexual exploitation and abuse is a concern largely because there is little information regarding the problem and most national or local agencies support humanitarian assistance initiatives have not been trained in PSEA. Social services have had a few reported cases of child sexual abuse from within family systems. Recommendations • Humanitarian workers as well as informal/volunteer networks delivering aid and in regular contact with children should be trained in child protection principles as well as PSEA to minimize any potential harm to beneficiary populations. • Service providers in regular contact with conflict-affected children should be trained in Psychological First Aid to be able to provide basic psychosocial support to children and their parents.

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• Volunteers, teachers and other service providers working directly with children should be trained in appropriate psychosocial support for children. • Psychosocial opportunities for conflict-affected children should be expanded to minimize negative coping and enhance children’s wellbeing.

Above: One of the rooms in the Collective Center in Mariupol City which the assessment team visited. A family of 5 moved to this collective center from Donetsk, along with 2 children they are caring for on behalf of friends. All 7 of them arrived 6 months ago and explained they only anticipated staying for 1 week. They have collected belongings and furniture during the past 6 months but only came with some clothing and basic household goods.

Right: Door to bomb shelter in basement of the building. Residents explained that there is no light inside the bomb shelter.

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7.3: Mental Health and Psychosocial Support Methodology Data Collection Representatives of different agencies and organizations as well as IDPs living in the collective centers have all been very forthcoming and willing to share information and ideas regarding mental health and psychosocial support (MHPSS) needs. The data presented in this assessment are collected through: 1) a desk study, 2) meetings with representatives from relevant local and international organizations and agencies, 3) a site visit to a collective center in Mariupol and 4) attendance of a training session for 27 psychologists in Kiev, organized by the Rinat Akhmetov Foundation.

The desk study included a review of literature related to MHPSS in Ukraine. As part of the desk study, the International Medical Corps’ MHPSS specialist exchanged emails with MHPSS coordinators and experts from member organizations of the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings that have activities within Ukraine, including WHO, UNHCR, UNICEF, the Child Protection Working Group, International Organization for Migration, IFRC Psychosocial Reference Center, Save the Children, MSF Belgium, and ACT Alliance.

Meetings with representatives from relevant local and international organizations and agencies active in MHPSS took place in Kiev, Dnipropetrovsk, Mariupol and Donetsk (additional information is included in Annex A). For the site visit to the collective center in Mariupol city, which housed 145 people, including 45 children, the MHPSS specialist used qualitative methods, including observation; semi-structured key informant interviews at the site, including interviews with a nurse, social worker and IDPs living in the center; and general discussion with residents.

Limitations and Assumptions Two main factors affected International Medical Corps’ ability to carry out the MHPSS assessment: mobility and limited access due to the security situation in Donetsk. Although roads are relatively good and the team did not encounter any problems at checkpoints in Ukrainian-held territory, travel from Kiev to Mariupol and back took 3 days. Additionally, during the time of the assessment fighting in and around Donetsk intensified and the MHPSS specialist did not enter Donetsk. However, another member of the assessment team, a public health specialist who was in Donetsk, could meet with relevant MHPSS actors on behalf of the MHPSS specialist.

Findings Laws and Policies Related to MHPSS A mental health policy is in place in Ukraine, initially formulated in 1987 and there is a law on psychiatric care (2000).2 According to the Constitution (1996) healthcare is provided by the government free of charge, but existing literature.3,4,5 Verbal accounts indicate that people have to contribute out of pocket for all health services, including for MHPSS.

The change from institutionalized to community-based care has been difficult. The number of hospital beds (including psychiatric hospital beds) is cut, but because of lack of infrastructure, transportation or actual clinics, the money is not redirected to community based care.3 Funding is bed-based, rather than that the money follows the patient.6 90% of the estimated Mental Health budget is allocated to psychiatric hospitals.7 Price for medication, stigma, lack of mental health services on primary health care level and lack of peer support are all mentioned as challenges to community based care.5,8 Furthermore there is a lack of

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consumer participation8 and resistance from the established Mental Health workers to change the system.8 There are only few user groups.8 Furthermore, the Presidential Decree 875, as described above, has an impact on the most vulnerable of the population, including those suffering from mental health and psychosocial related problems.

Attitude towards MHPSS Mental health care is mainly taking place in and around psychiatric clinics and institutions, and psychosocial support is a relatively new concept and often not well understood.6 It has, just as all terms starting with “psych,” a negative connotation in Ukraine. In Soviet times psychiatry was used as form of political repression. People that challenged the Soviet system were considered mentally ill and were often diagnosed with Schizophrenia.3 In Ukraine, this adds to the stigma that is normally associated with mental health problems.

MHPSS Needs and Concerns in the Current Crisis The events in the past year have seriously affected the mental health and psychosocial well-being of the Ukrainian people, especially of those living in the conflict areas, IDPs and host communities. People are concerned about their future and express feelings of hopelessness. There are many rumors about potential attacks, adding to feelings of insecurity. While many of these rumors are false, some are not, such as for example the rumor that Mariupol would be attacked within a week actually happened on 24 January. Amongst the IDPs, men and women are worried about jobs and about relatives still in the conflict area. Elderly people are lonely and concerned about their pensions.

Parents report that their children are scared and afraid of loud noises, such as the sound of rain on the rooftops. Some children have become aggressive, others withdrawn. Some are having sleeping problems and nightmares, and may wet their beds. One local NGO mentioned that some adolescents, both boys and girls, went to the frontline. The boys went to fight, but it is not clear what the girls are doing.

While many IDPs stay with relatives, some are living in community collective centers. Community collective centers are buildings made available by the municipality to temporarily house IDPs. The center International Medical Corps visited was based in a former naval school. The facilities were very basic and up to 8 people were sharing rooms. The residents share one kitchen, four toilets and a shower. There are separate toilets for men and women, but there is no separate shower for men and women. The sharing of facilities causes frictions. While some people try to keep the place clean for their children, others leave a mess behind. The younger residents were very concerned about finding a job and to be able to take care of and provide for their children. The team did not meet elderly men but did meet a group of 10 elderly women. Their family members brought several of these women to safety. However, instead of feeling safe they felt lonely and were worrying about their children in the conflict zone. Some thought there was no hope and were close to tears. They felt all they had worked for in their lives had been lost (see also under heading ‘MHPSS in Community Collective Centers in Mariupol’).

The political conflict is reflected in many levels of the population. There are disputes between residents of the community collective centers, sometimes ending in physical fights. There are disputes between the host population and IDPs, but also between members of the same families. Some members of the host population complain that the IDPs receive more services that them. This has led to tensions, and some IDP children are bullied at schools and called ‘terrorist’, ‘separatist’ or ‘BOMZH’ (an abbreviation for homeless people) by their classmates.

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People in psychiatric hospitals are very vulnerable in the current situation. There are, for example, confirmed reports that the Slavyanoserbsk general and psychiatric hospitals and the Lyutikovskiy were in catastrophic conditions with no heat and little food. Some of the patients have been in the psychiatric hospitals for over 20 years. Patients were literally starving and in critical need of heaters, warm clothing, additional blankets, hygiene items etc. Humanitarian aid has now reached the patients.8,9 The situation of people in these hospitals and in psychiatric hospitals in the conflict zones should be closely monitored.

MHPSS Capacities and Supports While the needs are increasing, the population affected by the conflict will not easily look for MHPSS services and activities. There is a huge gap between what people can manage on their own and the specialized care provided in institutions.

MHPSS on the Level of Basic Services and Security The ongoing fighting, the lack of reliable information on the situation in their home-towns, the lack of information on changing policies related to documents needed for registration and allowances, and the restricted passage to and from the ATO zone, all contribute to feelings of stress and insecurity.

Many staff and volunteers, such as people handing out food and non-food items and schoolteachers, are trying to fill the above-mentioned MHPSS gap. However, they are not properly equipped to deal with people in distress. Staff and volunteers hear terrible stories on a daily basis and people share their concerns and problems with them. Sometimes staff and volunteers encounter aggression from the affected population. IFRC and the Ukrainian Red Cross Society staff indicated that young volunteers that helped during the protests on Maidan left the organization, as they could not handle the stress anymore.

MHPSS at Family Level People are used to trying to cope with their problems on their own (and also with negative coping mechanism such as alcohol and drug abuse), or within family circles. There are strong family links, involving extended families.7 The current MHPSS needs are more than what many individuals and families can cope with. Some contacts mentioned that roles within families have changed because parents cannot take care of their children as usual, resulting bigger responsibility for children in the household.

MHPSS in Community Collective Centers in Mariupol There are 10 community collective centers in Mariupol with an average of 150 residents. This number is fluent as people are going back and forth. Group and community-based activities to address MHPSS issues are not very common and the elderly residents in the center International Medical Corps visited were very clear that they do not want any group activities. This may of course change in the coming period and their needs should be re-assessed in the near future.

MHPSS in the Health System Although mental health care is officially part of the national primary healthcare system, actual treatment of severe mental health disorders is not available at the primary level. Primary health care professionals mainly refer people with mental health problems to specialized care. There is no regular training on mental health topics for primary health care professionals. Mental health disorders are mainly treated by psychiatrists, and in specialized institutions. Many of these institutions are large state-owned psychiatric hospitals, often built more than 100 years ago. Only psychiatrists can prescribe psychotropic drugs. There are some outpatient services, but these are mainly related to the psychiatric hospitals. There is little

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experience in multidisciplinary teamwork and little experience in inter-sectorial work or case management.4

Professionals in the primary health care, including doctors, nurses and feltschers (who are similar to nurse practitioners), are not equipped to deal with the current MHPSS problems (such as stress-related issues, loneliness, and alcohol abuse) people present. Furthermore, several primary health care facilities In Donetsk have been destroyed. The system in health facilities in the host areas is overstretched.

Capacity of Local Psychologists and Local NGOs The Master’s degree education of psychologists takes 5 years and there is no internship during which the students have the opportunity to work under clinical supervision. Immediately after graduation, psychologists see their first clients (also without clinical supervision). They have no formal training on conflict-related stress. Only 30-40% of graduates actually practice due to low salary (approximately USD $100/month) and usually take up other jobs. Psychologists work in private practices and do more social work than actual psychological care.

The Rinat Akhmetov Foundation has started a training program aimed at 300 psychologists who work in schools, social institutions, etc. The first training took place in December with 180 psychologists attending in Kiev and 80 in Mariupol. The training consists of 6 blocks of three days each and includes lectures, practical exercises, and case studies. These blocks were developed in collaboration with Association of Psychologists, the Association of Psychiatrists, and the Israel Trauma Coalition. There is still some flexibility in the program and the Rinat Akhmetov Foundation expressed interest in collaboration with international specialists. The training, travel costs and if needed hotel costs is covered by the Rinat Akhmetov Foundation. The Foundation does not hire these psychologists.

The MHPSS consultant participated one afternoon in the training program, the module on children affected by conflict. There were 26 participants, of which 24 women and 2 men. The trainers were for the University of Lviv. They were very engaging and participants were active.

There are some local NGOs in Ukraine, some of which operate in Donbas region, that provide psychosocial support services. Some local NGOs work through volunteer networks, collaborate with social workers or provide support to specific target populations (e.g., HIV/AIDS patients, victims of sexual abuse). Many of these networks have adapted their activities to the current situation. A more comprehensive mapping of psychosocial support services, as provided by local NGOs, is needed to better understand gaps in existing services.

MHPSS Coordination among Humanitarian Actors In July 2014, a MHPSS Working Group, co-chaired by WHO and UNICEF, was established. Members are mainly from the health and protection sectors, based in Kiev. The group has started with mapping ‘Who is doing What, Where and When in MHPSS (the 4W’s) and meets every second Tuesday of the month. Recommendations • Improved coordination, information sharing and dissemination of best practices for MHPSS response to the crisis, including a comprehensive assessment of MHPSS problems among conflict- affected persons, mapping of available resources and services and information dissemination about available services and referral pathways.

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• Support capacity development of local agencies and organizations responding to MHPSS needs among the affected population, including orientations on Psychological First Aid for key volunteers and staff in affected areas, training and supervision for staff in the provision of basic psychosocial support interventions and activities, and further collaboration between humanitarian actors and WHO on capacity development for capacity development of primary health care staff in MHPSS assessment/triage and referral. • Engagement of affected families and communities in promotion of psychosocial well-being and self-care, including development of messages and strategies to promote family and community well-being and dissemination of media messages and information on MHPSS well-being and coping strategies to host communities and IDPs.

7.4: Health Methodology Data Collection The data and information for this assessment were obtained from 1) visits to health facilities and community-based structures (including a collective center in Mariupol), 2) participation in the NGO Coordination Forum and meetings with members of the Health Cluster in Kiev, and 3) interviews and informal discussions with key stakeholders in Kiev, Dnipropetrovsk, Mariupol and Donetsk (see Annex A; includes representatives from Ministries, UN agencies, international NGOs (INGOs), local NGOs and community-based organizations; city officials; health facility staff and health workers; civilians, including IDPs and host communities; and military personnel).

For the health assessment, International Medical Corps staff (2 public health specialists, accompanied by translators) conducted a total of 34 semi-structured Key Informant Interviews (3 in Kiev, 2 in Dnipropetrovsk, 23 in Mariupol and 6 in Donetsk) and 18 informal discussions with key stakeholders. Health facilities visited include the Greek Medical Center in Mariupol City, Volodarskiy Center of Primary Healthcare, Volodarskiy Сentral District Hospital and Dental Department of Pershotravnevy Сentral District Hospital. Of the KIIs, 8 were with health workers and health facility staff; 7 with representatives from INGOs; 7 with representatives from UN agencies, including WHO, OCHA, UNDSS and UNHCR; 4 with representatives from local NGOs; and 8 with city and raion officials, including those from the Department of Healthcare for Mariupol, State Emergency Services and Raion Administration Chiefs.

Limitations and Assumptions In both Mariupol and Donetsk meetings and site visits were limited due to time and security constraints. The team therefore focused on qualitative data collection and did not carry out any sampling of affected communities. Data was collected over the course of 7 days in Mariupol city and surrounding rural raions and 4 days in Donetsk city. Due to time constraints and new bureaucratic procedures, assessment staff were unable to visit health facilities in the DPR. Findings Health Infrastructure Ukraine’s health system was generally limited prior to the conflict. In the DPR, the health system is now visibly collapsing. Excessive shelling has damaged several health facilities; in some cases, water and electric systems are damaged due to shelling and continued fighting hinders entities from accessing and repairing

Emergency Assessment- Eastern Ukraine 22 systems. Anecdotal evidence also suggests that some health facilities in the DPR have experienced looting and many facilities lack food and water for patients. The recent Presidential Decree 875, which de- registered health facilities in the DPR and cut off critical supply chains and financial support to such facilities, has contributed to the further decline of health infrastructure in the DPR. While some health staff have left the area or no longer present to work due to lack of payment, many health staff, particularly in Donetsk city, continue to provide critically needed services despite the fact that they have not been paid, in some cases for up to six months. In Mariupol city, providers have taken pay cuts and generally are still presenting for work. The combination of physical infrastructure damage and lack of staff has meant that government health service provision is nonexistent in many rural areas of the DPR and at a minimal level in others.

As rural areas surrounding Mariupol did not have robust health infrastructure prior to the conflict, health facilities in these areas were not equipped to handle the surge in patients (IDPs) in the summer. Health workers indicated that facilities can currently manage providing very basic health services to host communities and IDPs but any rise in IDPs would strain the health system. City health officials in Mariupol indicated that there have not been any disease outbreaks in collective centers; however, if there were, the city likely could not handle disease containment. Health facilities in the rural areas of Mariupol have limited lab capacity; facilities do not have diagnostic capacity to confirm HIV, hepatitis and other diseases and therefore send samples to Mariupol.

Many key informants explained that financing for health services is limited; 2014 budgets did not include funds that would support patient surge and therefore it has been challenging in both Mariupol city and surrounding areas to have funds re-allocated. Anecdotal evidence indicates Mariupol city has spent UAH 900,000 (approximately USD $57,600) addressing health needs of IDPs in the city but there are still gaps in service availability and provision.

Human Resources for Health The lack of adequate staffing in the DPR has put an increased dependency on humanitarian organizations to provide basic and emergency trauma care. Organizations, such as MSF Belgium and ICRC, are filling critical gaps in health service provision by providing essential drugs, supplies, consumables, food and water to facilities, as well as training on war surgery. MSF Belgium also has mobile medical units with expatriate and national staff. However, both agencies emphasize that despite their ongoing responses there are still significant gaps in meeting health needs. Doctors and nurses that have been displaced from the DPR are experiencing challenges in finding jobs in Mariupol and surrounding areas, primarily because there is hesitancy to hire staff who may relocate after a short period and there is difficulty in verifying credentials and licensing. It is unclear how humanitarian organizations wishing to hire local medical staff may be affected by the difficulties in verifying credentials and licensing of medical staff who have left the DPR and wish to work in other areas, as there does not appear to be a clear process in place to facilitate verification of credentials and licensing.

Many key informants in Mariupol and surrounding raions identified lack of staff as a challenge, although reasons for why there are inadequate numbers of staff vary. In rural raions, staff capacity, particularly for specialty care, was limited prior to the conflict. Therefore, some facilities have felt the effects of not having adequate staffing when their patient load increased due to the influx of IDPs. Most key informants in Mariupol and surrounding areas explained that facilities have adequate numbers of nurses but need doctors and specialists, such as pediatricians, family doctors, psychiatrists, addiction specialists,

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ophthalmologists, ENTs, gynecologists and dentists. Some key informants also underscored the need for stimulation packages to support health staff salaries, as a means to secure staffing.

Availability of and Access to Quality Health Services Access to primary, secondary and tertiary care is limited in Mariupol and critically compromised in Donetsk. Prior to the conflict, Donetsk had strong capacity to provide specialty care (e.g., chronic disease support) and the nearest tertiary referral center to Mariupol was in Donetsk. The capacity of these services has been severely weakened by the conflict and the recent Decree. Patients are now referred to Mariupol for many specialty services and tertiary care but facilities in Mariupol do not have such services available. There is a need to build capacity for advanced levels of care in Mariupol as the area is absorbing IDPs and still must be equipped to handle the needs of the host population. Furthermore, while facilities in Mariupol appear to be able to currently handle patient needs, facilities require support in improving capacity so they are prepared to handle future patient surge.

IDPs in Mariupol city are renting flats or living with families or in collective centers, which are abandoned buildings that the city government has transformed into IDP housing. Social workers in Mariupol city work with collective centers to link IDPs to essential services. There are no collective centers in rural areas and IDPs are therefore renting flats or living with families; consequently, there is no clear mechanism to reach IDPs and link them with essential services.

Accessibility is also generally limited due to patients’ lack of transportation, concerns about attacks on roads and road blockages, and ability to pay for services, all of which are particularly challenging for disabled and elderly populations. Some facilities outside of Mariupol have transportation available to move patients but there is nowhere to take patients, as they types of services needed are unavailable. Health officials in one rural raion noted that the host population and IDPs are also hesitant to present for care at the central hospital because military personnel have occupied the hospital’s basement. There is concern among the community that the hospital will therefore be a target for shelling.

The current lack of local capacity and referral mechanisms have increased the need to bring health services directly to communities. In Donetsk and rural areas of Mariupol there is a need for increased mobile medical units, especially to reach rural populations. There is also a need to increase the number and types of specialists in the units, as the referral system does not always include mental health services or support for survivors of violence. In both Donetsk and Mariupol, key informants noted the need for mental health services to be integrated with primary health care. Not all facilities have psychiatrists or psychologists on staff, and therefore many key informants identified the need for medical staff to be trained in providing psychosocial support.

Key informants also identified the lack of maternal health services, including prenatal care and delivery, as a challenge in both Mariupol and Donetsk. Many maternity clinics in rural areas of Donetsk have been shut down. Rural areas around Mariupol lacked capacity to provide maternal health services prior to the conflict and therefore referred patients to Mariupol city for care. Patients are still referred to Mariupol city, Dnipropetrovsk or Kharkiv but patients cannot always access services in other areas due to limited transportation, road blockages and overall security concerns.

Facilities that are still operational in the DPR need assistance in building capacity to triage and provide urgent care to war wounded patients. Anecdotal evidence indicated that in the DPR some emergency service providers are bringing patients to the frontline area and doing a “hand off” with ambulances on the

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Ukrainian-held territory so that patients can be taken for treatment in Dnipropetrovsk, Mariupol or Kharkiv. The transportation of patients to the frontline is due to the lack of medicines, equipment and staffing in the DPR. It is unclear if the accessibility of health services will become more challenging due to permits required to cross the frontline.

Essential Medicines, Supplies and Equipment Health facilities in both Mariupol and Donetsk lack essential medicines, medical equipment and consumables. In the DPR, the shortage of medicines, supplies and equipment is dire, and these facilities are also in urgent need of consumables, food and water to care for patients. In Donetsk, the Donetsk Oblast AIDS Center is now required to cross the frontline and pick up antiretroviral drugs (ARV) in Sloviansk or Mariupol and bring them back into the DPR for distribution, causing ruptured supply chains and delays in access to treatment. Due to displacement, many healthcare providers have lost track of patients and therefore are unable to provide follow-up or monitor adherence to treatment for HIV and MDR-TB patients.

In Mariupol, the situation is serious but some health workers noted that the situation is not as critical as it was during the summer when significantly more IDPs moved into the area. For example, HIV patients in Mariupol were able to get a 6-month stock of ARV prior to leaving the city in the spring of 2014. Facilities were not restocked and Mariupol received tens of thousands of IDPs over the summer, none of whom could access ART due to stock outs. However, while the number of IDPs currently in Mariupol is less than previous months, health facilities have rarely been restocked and therefore the need for essential medicines, supplies and equipment is continuous. Health workers noted that if there was a drastic influx of IDPs facilities would not be equipped to provide care. This is especially the case in rural raions which had inadequate stocks of medicines and supplies even prior to the conflict.

Ukraine’s Ministry of Health has requested WHO to, for a temporary period, take over responsibility for the procurement and distribution of all essential medicines required by the health system. Currently, drug importation can only be facilitated through WHO, UNICEF or ICRC. It is unclear if there are any issues with delivery of medicines to “unregistered” facilities. Health workers in Mariupol and Donetsk both noted that the primary challenge to the local procurement of pharmaceuticals and consumables is due to the lack of supply chains from other parts of the country, as some supply lines to facilities have been cut off. Broken supply chains and overall inflation have caused the price of many essential pharmaceuticals to substantially increase. Pharmaceuticals are generally transported by road but road blockages have significantly limited the movement of all commodities. Many health facilities in Mariupol and surrounding areas received pharmaceuticals from Donetsk but accessibility is now extremely difficult. Anecdotal evidence also indicated that some facilities in DPR go to Mariupol and Sloviansk to pick up medications, pending accessibility.

Some medications which previously were available to select groups (e.g., disabled, veterans, elderly) free of charge in health facilities are now only available in pharmacies for a fee and some are costly. Access to contraceptives, including condoms, is also limited in rural raions and some health workers asked if it would be possible to receive donations of contraceptives. In both Mariupol and Donetsk the lack of essential medicines for elderly people and those with chronic conditions (e.g., diabetes, heart disease, TB, HIV/AIDS, cancer) remains a significant concern. Elderly and disabled persons are also unable to go into the city to get medicines. Health facilities reported high needs for antibiotics, wound dressings, insulin and dialysis. Health workers in Mariupol also noted the need for radiology and diagnostic equipment, particularly mobile x-ray and ultrasound machines.

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Recommendations • Support health facilities in the DPR and Mariupol in building capacity to handle patient surge and trauma-related injuries, including training for service providers and distributing essential medications, supplies, consumables and equipment (e.g., antibiotics, insulin, wound dressings, mobile x-ray and ultrasound machines). • Facilitate staffing support for health facilities in the conflict zone and in surrounding areas, particularly for doctors, by providing incentives for work and salary support. • Strengthen the capacity of health facilities to provide primary health care and other essential services, such as maternal care and diagnostic testing, to conflict-affected persons, including IDPs and host communities. • Improve the availability of and accessibility to primary health services among rural and marginalized populations through the deployment of mobile medical units and include specialists in units to provide care to populations who otherwise cannot access healthcare services. • Continue to advocate to authorities in both the DPR and Ukrainian-held territories to facilitate access and travel across the frontline for humanitarian actors providing essential services.

Above: Medicine stock supply at one of the health facilities visited

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8. Conclusion Humanitarian organizations will continue to play a critical role in meeting the needs of conflict-affected persons in Eastern Ukraine, especially if the conflict continues to intensify. The International Medical Corps assessment mission focused on health, protection and mental health and psychosocial support needs but interventions in other sectors are also critically needed among IDPs, host communities and those still in the conflict zone. The challenge of providing humanitarian assistance has been exacerbated by the intensifying conflict and increasing bureaucratic requirements that impact travel across the frontline and operations within the conflict zone. In spite of these challenges, humanitarian actors must continue to find ways to provide essential services to conflict-affected persons, particularly the most vulnerable.

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References 1. Office of the United Nations High Commissioner for Human Rights. Report on the human rights situation in Ukraine 15 December 2014. http://www.ohchr.org/Documents/Countries/UA/OHCHR_eighth_report_on_Ukraine.pdf

2. WHO Mental Health Atlas, 2005 http://www.who.int/mental_health/evidence/mhatlas05/en/

3. Shelly Ann Yankovsky, Medicalizing Suffering: Postsocialist Reforms of the Mental Health System in Ukraine. PhD dissertation, University of Tennessee 2013. http://trace.tennessee.edu/utk_graddiss/1798

4. Dr. Richard Styles, American Medical Centre volume 4, issue 6 June 2010.

5. Mental Health Care in Ukraine: Twenty Years after the Soviet Union (2011-11-14). Somatosphere.net Science, Medicine and Anthropology

6. Oral account during MHPSS WG meeting

7. Transition of Adult Mental Health Services in Ukraine (1991-2006) Olga Golichenko. Master in International Health (KIT, Royal Tropical Institute, the Netherlands)

8. http://www.un.org.ua/en/information-centre/news/1937

9. http://www.ird.org/media/press-releases/ird-partners-with-un-to-deliver-emergency-aid-to- ukraine

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Annex A: Agenda for Assessment Mission

The agenda below reflects the majority of meetings International Medical Corps staff had during the assessment mission. Assessment team members had different travel routes depending on the availability of meetings relevant to their respective technical sector. Names and positions of some individuals from key informant interviews have not been included in this agenda for privacy concerns (e.g., civilians, including IDPs and host communities; local authorities, including law enforcement and social services).

Date Geographic Activity/Meetings Location

12 January Kyiv La Strada, Director

Hippocrates Greek Medical Foundation, Director

13 January Kyiv NGO Coordination Meeting

13 January Kyiv WHO, Head of Office and WHO Consultant on MH

Rinat Akhmetov Foundation

UNICEF, Chief of Child Protection

UNFPA, Programme Officer, Gender Focal Point and Country Representative

Women’s Consortium of Ukraine, Child Protection Coordinator

MHPSS Sub-cluster Working Group Meeting

14 January Kyiv UNDSS Security Briefing

15 January Dnipropetrovsk Save the Children, Head of Dnipropetrovsk Office and staff

16 January Zaporizhia Security Briefing with International Medical Corps Security Manager

Mariupol Mayor’s Office, Deputy Mayor

Center for Social Services for Family, Children and Youth, Director

17 January Mariupol Mariupol Youth Union, Director, Hotline Specialist and Project Coordinator

Rinat Akhmetov Foundation- Mariupol, Psychologist

OCHA, Head of Mariupol Office

OSCE, Monitoring Officer and Human Rights Focal Point

Visit to Community Collective Center in Mariupol City

Donetsk People in Need, Emergency Coordinator

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Date Geographic Activity/Meetings Location

MSF Belgium, Field Coordinator, Medical Coordinator and Regional Coordinator

ICRC, Head of Sub-delegation in Donetsk

18 January Mariupol UNHCR, Associate Field Officer and Protection Assistant

Focus Group Discussion at Community Collective Center in Mariupol City

19 January Mariupol Greek Medical Center, Hippocratic Greek Medical Foundation, Various health staff

Volodarskiy Site Visit, Municipal Healthcare Institution/Volodarskiy Center of Primary Healthcare and meeting with Chief Doctor and staff Volodarskiy Raion State Administration, Deputy Head and staff

Site Visit, Volodarskiy Сentral District Hospital, and meetings with Chief Doctor and staff

Mangush Site Visit, Dental Department of Pershotravnevy Сentral District Hospital in Mangush and meeting with Chief Doctor, Pershotravnevy Сentral District Hospital Pervomaysky Raion State Administration, meeting with Head and staff Donetsk Most (Bridge) Center for Social Development Donetsk Oblast Charitable Foundation, Director

20 January Mariupol Department of Healthcare, Department Head

ICRC, Head of Mariupol Office

State Emergency Services for Donetsk Oblast, Deputy Head of the Department of Emergency Response and Chief Psychologist for Department of Emergency Response

Donetsk International Relief & Development, Logistics Manager

Responsible Citizens, Volunteer Coordinator

21 January Kyiv WHO, Head of Office and WHO Consultant on MH

Rinat Akhmetov Foundation

IFRC/ Danish Red Cross Society / Ukrainian Red Cross Society, Head of mission, and Local PS Focal Point

Dutch Embassy, First Secretary and Senior Officer - Political Department

22 January Kyiv Ukrainian Psychiatric Association, President

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Date Geographic Activity/Meetings Location

23 January Kyiv Attendance of training for psychologists, organized by the Rinat Akhmetov Foundation in Kiev. Topic: children affected by conflict

26 January Kyiv ECHO Partners Meeting with Director General

Danish Refugee Council, Senior Protection Specialist

27 January Kyiv NGO Coordination Meeting

MHPSS Sub-cluster Working Group, WHO Consultant on MH and WHO Consultant on PSS and MEPUs

28 January Kyiv U.S. Embassy Meeting for Humanitarian NGOs

29 January Kyiv International Medical Corps Informal Security Briefing for NGOs

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Annex B : Local and International Organizations Engaged in MHPSS Activities or Services

The below information is prepared on January 25, 2015 and only reflects the data collected by IMC’s assessment team in the period from January 12-23, 2015. More detailed mapping of available services and support is needed in the coming months.

WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) UN Agencies WHO 1. Mobile Emergency Primary Health Care Units Kiev, Mariupol and other MEPU: 6 months (MEPU). There are 2 psychiatrists in the team. areas Capacity building of the team includes one session on MH (topics: basic tools, relaxation, depression and PTSD and 1 session on GBV (by La Strada). Partners: Red Cross, IMC (3 MEPUs) 2. Policy making on level authorities 3. Co-chair MHPSS WH UNICEF 1. Works in total with 11 Community Prevention Kharkiv, Dnipropetrovsk 9 months, UNICEF is Centers (CPC). CPCs are places where all and 2 more areas (unclear applying for money to affected community members can access on those locations). expand information but with a specific focus on UNICEF only works in the providing affected women, adolescents and post-conflict areas. girls’ and boys’ protection and building resilience. 2. So far UNICEF is supporting one center in Mariupol (in collaboration with Deputy Mayor) 3. Training and weekly supervision school psychologists 4. Mapping of services and referral 5. Co-Chair MHPSS WH UNHCR Mainly active in protection, winterization and Across affected areas Ongoing rehabilitation of institutions International Agencies and NGOs

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WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) IFRC Reference Center/Ukrainian Red • Active in PSS programming since a half year The Ukrainian Red Cross Ongoing Cross Society • Basic PSS training to volunteers + nurses has local branches all over working at Maidan Ukraine; also in Mariupol • ToT for 17 people in community PSS with the and Donetsk. Icelandic RC Society. 2/17 trainees are based in Donetsk. They will do a refresher course in the coming month. • They have now 159 volunteers trained in basic community PSS.

IOM IOM has been active on MHPSS for more than 15 Dnipropetrovsk Ongoing years and provides professional psychological Kharkiv assistance to IDPs through local NGO partners Ivano-Frankivska Khmelnytska Vinnytska Zaporizhia

MSF Belgium Medical Currently MH activities in Ongoing 1. Since years MFS Belgium has a MDR-TB Donbas region with project in prisons in Donetsk (managed the mobile teams. last months in remote control). They work as close as 2. MSF did donations and will start mobile possible to the front line clinics (primary health care) in different and during the last month locations. it was possible to enter to Mental Health DPR and LPR territories. 3. Had MH activities in 2014 for some months in Lugansk, Artemovsk, Kiev. Donetsk (and stopped Current MH activities focus on: recently in Mariupol). 4. MH support for population affected by MSF works directly in the violence and displacement (psycho- conflict zone and has education, counseling/PFA) indicated that the need is

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WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) 5. Training of local professionals (psychologists so high, that IMC can in schools, social services, city councils, easily complement in the hospitals, etc.), teachers and medical staff + region. stress management activities 6. According to the OSCE they have 12 local psychologists working for them MSF Holland Needs assessment, mainly health Affected areas January Danish Refugee Council Support most vulnerable IDP families: financial Dnipropetrovsk- 750 Since beginning of support, UAH 4500 per household, one-time aid, households November 2014 and winterization in. It is planned to launch Zaporizhia- 750 similar project at the end of January in Mariupol. households Donetsk- 500 households Developing a project on protection of children’s Mariupol (pending) rights and PSS, together with other organizations. Save the Children PFA for children training in collaboration with Kiev Currently Women Consortium Ukraine. Participants Have opened office in Ukrainian professionals – Government and civil Dnipropetrovsk society, academics, front-line aid workers, law experts, psychologists, teachers etc. The training took hold very well and was replicated many times since then. They will evaluate the outcome PFA training in the coming months. ACT Alliance • It is planned to provide refugees/IDPs with Kiev area and the Donetsk the assistance of professional psychologists region ACT partners in Ukraine: with special emphasis on supporting women • Russian Orthodox Church and children. • Hungarian Interchurch • Professionals with respective experience, familiar with local conditions will provide their services to the refugees and IDPs in counselling sessions and visiting them where they are staying.

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WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) • The recommendations of these experts after the project completion can be used by local social services and health authorities (including correctional care for children) to further work with refugees and IDPs. • The project will pay for the work of the specialists, premises for their work will be provided by local authorities or parishes. Three specialists will be hired in each of the project regions.”

People in Need • Food distributions and food security – ECHO Donetsk Ongoing • Food distributions through WFP – 15,000 food kits – short project from end of December through end of February • OFDA is funding a food voucher and cash project – partnerships with local supermarkets ($300 vouchers for vulnerable groups), • Institutional support for homes for retired and disabled persons • Preparing for a shelter project with UNHCR – emergency shelter for 100 households • Main concern is not necessarily IDPs, but rather vulnerable and marginalized persons among both IDPs and host communities • Distribution NFIs and hygiene kits with funding from the Czech MFA • Launched a health project with the support of the Czech MFA Terre des Hommes Needs assessment, mainly on child protection Kiev and to be decided Currently

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WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) Médecins du Monde Is said to start with MHPSS The team didn’t meet with MdM. Details not known Local Organizations La Strada Started in Ukraine against human trafficking, but Kiev, Kharkiv. Ongoing They have an now also: GBV, gender, women’s rights extensive 1. Toll free hotline for adults and children (used network, are very by both sexes) well respected, 2. PSS support through Skype they hope to 3. Face to face support, mainly in Kharkiv : 344 expand. psychological consultancies; 186 legal Current focus on consultancies Kiev and Kharkiv 4. Information booklet on psychosocial support and psychological first aid, approved by the Ministry of Education Rinat Akhmetov Foundation 1. Works with 8 psychologists: 2 in Donetsk, 3 in 1. Donetsk, Mariupol, 1. Ongoing One of the main Mariupol, 1 in Kiev, 1 in Kharkiv and 1 in Kiev, Kharkiv and local actors on Zaporizhia. These psychologists mainly work with Zaporizhia 2. December 2014 – MHPSS capacity children and families affected by the conflict March 2015 building 2. Capacity development of 300 psychologists 2. Capacity development So far in December one module provided by the mainly for psychologists Israeli Trauma Coalition: a first introduction for working in affected areas 180 participants in Kiev and 80 participants in in Donetsk and Lugansk Mariupol Next training in January. Curriculum will be sent later. They are still looking for additional modules 3. Mainly in Kiev 3. To be started and are interested in PFA. February

3. Advocacy + awareness raising: will organize Round Table Discussion with relevant partners to develop strategy to raise awareness amongst general public and media. Stigma prevention. But

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WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) also how to raise awareness amongst health professionals about addressing people with MHPSS problems. YMCA Ukraine In Ukraine since 1993. Has 23 branches Don’t Laugh at Me! project, developed in the US Including the ATO area (in and approved by the Ministry of Education of Antratsyt, and in Krasnyi Ukraine, to Ukrainian schools to prevent bullying Luch). and to support integration of displaced children in the Ukrainian schools. NaUKMA Implementing partner UNICEF targeting school psychologists

Women Consortium Ukraine Arranged the Psychological First Aid training for Save the Children MH Services Maidan Work with IDPs In all regions, but not Information Support to soldiers and families of soldiers many in Lugansk and provided during Training, including on PTSD Donetsk MHPSs WG Social services Mariupol Youth Union They work in several MHPSS related areas such as Mariupol Ongoing on juvenile justice (in collaboration with UNICEF), provision of coal, wood and food for displaced people (with IOM), support to People Living with HIV/AIDS, and victims of sexual abuse. It is a youth volunteer organization. Their activities have changed since the conflict. They work with a volunteer, a psychologist from Donetsk, on the mapping of needs and capacities. Most (Bridge) Originally working for people living with HIV/AIDS Donetsk Ongoing but is working now also on humanitarian issues. They are highly regarded by INGOs working in the area and have socials workers and a psychologist. Responsible citizens Volunteer group, that is distributing food and Donetsk Ongoing NFIs to people in small villages across Donetsk

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WHO (which organization and WHAT (what exactly do they do? e.g. What WHERE (Where do they WHEN (Is their work Comments contact) mental health problems do they address? work /what areas do planned, ongoing or What activities do they do?) they cover?) ending soon? If ending, when?) Local Authorities in Mariupol Deputy Mayor Mariupol Is active in MHPSS and used to be the head of a Mariupol Currently community center Director of the Center for Social Mariupol Currently Services for Family, Children and Youth

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