This article is part of AOAV’s examination of the health impacts from explosive violence. The full report, Blast injury: the reverberating health from the use of explosive weapons, can be found here. The summary and key findings can be found here.
- Among families within 20km of the contact line in eastern Ukraine, 40% face significant challenges accessing healthcare services.
- In one survey of IDPs in Ukraine, those who had paid for care in the 12-months prior to the questionnaire had an average bill of $107.
- Of 120 Syrian refugees AOAV surveyed across Lebanon, 86% of those who answered had not been offered psychological support.
- Of the 3,000 rescue workers that volunteer for the Syrian Civil Defense (the White Helmets) less than 5% are women – this often inhibits the rescue of women after incidents of explosive violence.
An ability to access healthcare is determined by many variables. These include aspects already discussed in this report – such as infrastructure and personnel – but also include factors such as the quality of the roads, and the presence of unexploded ordnance making reaching facilities unsafe. Other hidden or unconsidered considerations include the costs of getting to hospital by displaced families often living below the poverty line and access to reliable and safe transport, especially for women and children.
Research into explosive weapons and access to healthcare by AOAV has already established that access to treatment for injuries from explosive weapons is likely to be gendered. Of 2,741 civilians treated at Camp Bastion in Helmand, Afghanistan, for instance, less than 1% were female. It was found that women are frequently less able to access treatment due to cultural and religious inhibitory factors, ones often exacerbated by conflict. For example, in some cases women may not be rescued from the rubble until family members or other women can do so, due to the concern that body parts or hair may be exposed. Though, in areas where these norms occur, women are also less likely to have roles in healthcare or be first responders. For example, of the 3,000 rescue workers that volunteer for the Syrian Civil Defense, the White Helmets, less than 5% have been women. This is despite the fact that the addition of female volunteers is said to have a significant impact on ensuring injured females receive treatment. Other reasons for the reduced access to medical care, include the need to wait for family to accompany them to hospital, or a lack of female health professionals.
In this section, AOAV examines some of the key barriers to accessing healthcare due to the use of explosive violence in Syria and Ukraine.
In August 2019, it was reported that more than half of families living near the ‘contact line’ could not access healthcare. As you get closer to the contact line, the less access to healthcare there is. Among families within 20km of the contact line, 40% face significant challenges accessing healthcare services. Within 5km, this rises to 57% of families without access. Humanitarian aid also struggles to reach these areas. There are many physical barriers to access for the settlements closest to the contact line, such as damaged roads, the presence of mines, and the continued threat of shelling.[i] These barriers can also prevent ambulances reaching these areas.
As there is a shortage of medical supplies and equipment across the conflict-affected areas, costs for medical care continue to rise. In August 2019, OCHA reported on shortages of medication for diabetes, cardiovascular conditions, cancer, and other non-communicable diseases.
Shelling and landmines have isolated some 70,000 people living in about 60 communities in areas close to the contact line. Half of them are elderly. 35% have a disability and/or a chronic illness.
In Avdiivka for example, just north from the city of Donetsk, there is no specialised medical infrastructure at all. Before the conflict it was unnecessary for such services, as the city was so close to Donetsk, a 15-minute drive away. The border between the two towns, however, has meant that – today – the closest hospital with maternity services lies 50 miles away. Even the main road cannot be used out of the town, with locals taking a rough, mud road instead. The maternity ward in Avdiivka was closed in March 2019 due to a lack of specialist care and employees, which was thought to have resulted in a mother and baby dying during childbirth.
Those that need to access specialised services often have to choose between travel costs or things like essential repairs to homes or even food. For victims of explosive violence, there are additional challenges in terms of prioritising healthcare, largely around the widespread lack of public understanding of the need for continuing care post-blast.[ii] The Protection Cluster in Ukraine, for instance, has to highlight the need for survivors accessing rehabilitation, functional prosthetics and psychosocial support to raise public awareness of such needs.
Though IDPs are meant to be able to access free healthcare this is not, in practice, the case: many have to pay formal and informal payments for healthcare and medicine. One study found that all of Ukraine’s war-injured relied on treatment paid for by charitable foundations and international organisations. With the average income in Ukraine still less than 40% of its pre-conflict level, people struggle to pay for care.
In August 2019, it was reported that the Ukraine
Humanitarian Fund was expected to distribute US$3.2 million to
address these challenges of accessing healthcare, including mobile clinic
services. It is hoped this will target the 1.3 million people in need of access to
healthcare in the east. The amount of money, however, seems
small in regard to the challenge faced.
While self-diagnosis of mental health issues was an issue before the conflict, a lack of healthcare access has exacerbated this. In one study of mental health among IDPs, of the 703 respondents who had experienced a mental or emotional problem in the 12-months prior to the survey, just a quarter had been able to seek some kind of care. More common was accessing care or support at a pharmacy, with 48% doing this. Other ways of accessing care or support included: family or district doctor/paramedic (38%); internist at a polyclinic (33%); internist/neurologist at a general hospital (31%); psychologists visiting communities (27%); and NGO/volunteer mental health/psychosocial centre (21%). The most common type of care provided was medication.
Of those who had not sought care, the main reasons given were: a belief they could self-prescribe medications (34%), they could not afford to pay for the medication (27%) or health services (23%); they were not aware of where they could find help (23%); a poor understanding by health care providers (24%); poor quality of services (15%); and stigma/embarrassment (8%).
For those who had paid for care in the 12-months prior to the questionnaire, their bill came to an average of $107. For those who had paid for medicines, it was an average of $109 for the medicines. The average monthly wage in Ukraine at that time was $193 – though this is likely to be significantly lower in the conflict-affected areas and for IDPs – especially among the elderly. This gap in mental health support in Ukraine is being exploited by those offering unqualified assistance for money. The lack of quality care can intensify trauma and can re-traumatise individuals using these services.
Another barrier to healthcare in Ukraine is the stigma still attached to mental health and mental health support. Archaic images of mental health support as being inpatient care in Soviet-era asylums are pervasive but inaccurate. This even leads to funding constraints as even government officials are influenced by these misconceptions.
The quality of psychological care in Ukraine has always been mixed, a situation fuelled by a lack of professional education, expensive training and non-compliance to certain standards and ethical norms. And such an absence of quality care is made increasingly apparent by the heightened need of IDPs.
Explosive violence has devastated healthcare in Syria in a variety of ways. While, of course, the destruction of healthcare systems in Syria has severely limited access, other factors have also played their part. With more than 80% of the population living below the poverty line, the WHO has asserted that many cannot afford even the fees of transportation to hospitals. Damaged roads, alongside continuing conflict and insecurity, can further prevent civilians from reaching healthcare facilities.[iii]
Such access is crucial. With many blast injuries, patients require
multiple surgeries, often long after the event. Of those seeking surgeries from
the ICRC in Lebanon, following blast injuries incurred in Syria, most were
‘cold surgeries’. This refers to scenarios where the injured had received treatment
in a Syrian field hospital but due to inadequate healthcare caused by the
conflict, further trauma, or lack of rehabilitation, they required further
surgery. Most of the current surgery on blast injuries by the ICRC in Lebanon
is now, therefore, corrective.[iv] This exemplifies the poor
levels of healthcare available in areas of Syria experiencing explosive
Refugee populations also face difficulties accessing healthcare, particularly in those states neighbouring Syria. In Lebanon, for example, many refugees cannot access healthcare due to the costs and distance from healthcare centres.
Doctor’s appointments cost between 8,000 and 16,000 LBP, or about $4-9, a price that is still difficult for refugees to afford, bearing in mind that 70% of Syrian refugees live below the poverty line. The 2017 Vulnerability Assessment Report conducted by UNHCR, Unicef and the World Food Programme (WFP) found that the main reasons that households did not receive required care were because of the cost of drugs (33%), consultation fees (33%), uncertainty about where to go (17%), and not being accepted at the facility (14%).
There have even been reports of some people travelling back to Syria to receive treatment, due to the high costs of medical care in Lebanon. Because, whilst the UNHCR covers 85% of primary healthcare costs for refugees in an attempt to expand accessibility, this does not go far enough to relieve the financial burden or to address transportation difficulties.
The data available from the UNHCR also doesn’t appear to accurately reflect the situation on the ground. While a survey conducted by UNHCR, Unicef and (WFP) found that many refugees that required primary health care services were able to access them (89%), the survey only reached households with a landline, only surveyed registered refugees, and relied on partner healthcare providing organisations to carry out fieldwork. Therefore, it is likely that less vulnerable refugees were surveyed. For example, 591 cases were removed from the random sample due to safety or security concerns – the self-same safety and security concerns that may prevent these refugees from accessing healthcare in the first place.
Instead, media reporting suggests a far greater number than 11% cannot access healthcare. Additionally, when AOAV conducted fieldwork in Lebanon, many refugees we spoke to said they were unregistered, decreasing healthcare access further.
One NGO that AOAV met in Lebanon, Endless Medical Advantage (EMA), had recently dealt with a case of a young girl of about 18 months, with severe burns over her body as a result of an accident in her tent – a situation which occurs all too commonly in camps. The girl was rushed to a local hospital who bandaged her but provided no further treatment as the family could not pay. Under the direction of EMA, the family took her to another hospital, but they refused to treat her as they didn’t have a specialised burns unit. After calling around, another hospital in Beirut said they would take her. The family drove two hours through the night to go to the hospital and when they arrived the hospital stated they would require $10,000 to admit her, which the family could not afford.[v] Endless Medical Advantage and other NGOs started calling MPs and alerting media to highlight the case, and eventually another hospital said they would treat her in Tripoli. Endless Medical Advantage told them they would cover the 25% cost that UNHCR wouldn’t cover. This meant that, more than 24 hours after the burns were first caused, the young girl was admitted to the hospital where she would receive treatment for a month. Without the pressure by EMA and other NGOs, this young girl’s burns would likely have proved fatal.
While these costs were covered by EMA and, as the girl was a registered refugee, by the UNHCR, many similar situations occur where refugees cannot get the treatment they desperately need.
It is of little surprise, then, that in a survey conducted by AOAV, 85% of refugees living in Lebanon who replied to the question as to whether healthcare was easy to access, said it was not. And 82% of those who had visited a healthcare provider, said they were unsatisfied with the treatment they received. Many also complained about the costs – with refugees saying they went without medication, including for diabetes.
AOAV met with one mother whose child had passed away four months before the researchers’ visit; she claimed that she could not afford the surgery her daughter needed. The operation, it was stated, would have been curative. Other parents told of similar treatments or operations they could not afford for their children; including severely disabled children unable to access care or assistance. The parents of another boy who didn’t receive treatment risked returning to Syria for treatment. Another refugee told AOAV about a Syrian who had recently been hit by a car. They took him to hospital, but the centre allegedly would not accept him until they paid 200,000LBP (about $130); they were unable to pay. The refugee was unregistered, so the hospital refused to assist him, and he died. These incidents were confirmed by a local healthcare organisation, who revealed that such incidents were not rare.[vi]
Accessing psychological support is also difficult. Of the 120 Syrian refugees AOAV surveyed across Lebanon, 96 (86%) of those who answered, said that they had not been offered psychological support. Also, 87% (112) of those that answered reported being unable to access psychological support. There are many reasons why these answers may have been given; some, for instance, may be unaware of where support can be accessed. Yet, among those refugees AOAV spoke to in Lebanon, the lack of psychological support appeared to be a key complaint.
An additional key area in which all Syrian refugees seemed to lack access was dental care; with few prioritising such treatment. This gap was identified as key by Endless Medical Advantage.[vii] They said that almost all the patients they see need dental care.
While much has been done to ensure access to primary
healthcare in Ukraine, Syria and host communities, many of those injured by
explosive weapons will have complex health needs. Such needs require specialist
care, but often access to specialist services is unavailable. There are many
reasons for this, including damage to healthcare and loss of medical personnel,
but these also involve complex issues around access to transport and treatment costs.
[i] Right to Protection, ‘Humanitarian access in eastern Ukraine: an overview’, 2019.
[ii] Protection Cluster Ukraine, ‘Mine Action in Ukraine’, March 2019.
[iii] World Bank Group, 2020, ‘The Mobility of Displaced Syrians: An Economic and Social Analysis’, International Bank for Reconstruction and Development / The World Bank. Available to download: https://openknowledge.worldbank.org/handle/10986/31205; and Kherallah, et al. 2012, ‘Health care in Syria before and during the crisis’, Avicenna Journal of Medicine, Jul-Sep 2012, Vol 2, Issue 3.
[iv] Interview with ICRC representative in Lebanon, February 3rd 2020.
[v] Interview with Dr Feras Alghadban and Asma Patel, Endless Medical Advantage, February 3rd 2020.
[vi] Interview with Dr Feras Alghadban and Asma Patel, Endless Medical Advantage, February 3rd 2020.
[vii] Interview with Dr Feras Alghadban and Asma Patel, Endless Medical Advantage, February 3rd 2020.
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