Since Russia’s full-scale invasion of Ukraine in February 2022, the conflict has wrought devastating damage on civilian infrastructure, with medical facilities becoming frequent and deliberate targets. This unprecedented assault on healthcare has forced Ukraine to innovate urgently, including relocating field hospitals underground to protect patients and medical personnel. This article explores the scale of attacks on Ukrainian health facilities, the development and features of underground hospitals, and the grave implications for international humanitarian law and human rights.
Systematic Targeting of Medical Facilities in Ukraine
The Russian military has repeatedly attacked hospitals and health centers across Ukraine, violating the Geneva Conventions that protect medical personnel and infrastructure during armed conflict. According to the Ukrainian Ministry of Health, more than 300 medical facilities have been destroyed and over 2,000 damaged since the invasion began. The World Health Organization (WHO) recorded 2,215 attacks on healthcare in Ukraine from February 2022 to January 2025, with the highest number in March 2022 alone at 464 attacks. These assaults have included the use of heavy weapons, cruise missiles, and aerial bombardments deliberately targeting hospitals.
One tragic example is the July 2023 attack on Okhmatdyt, Ukraine’s largest children’s hospital in Kyiv, which was partially destroyed by a Russian cruise missile, killing two adults. The targeting of medical facilities has also extended to maternity wards and pediatric centers, severely impacting vulnerable populations such as pregnant women and children.
Pavlo Kovtoniuk, an analyst on Russian attacks on healthcare, notes that Moscow has employed this tactic in previous conflicts like Chechnya and Syria without accountability. He warns that if left unpunished, such destruction will become a normalized weapon of war. This systematic violation of international humanitarian law underscores the urgent need for global attention and action.
The Legal Framework and Its Breach
The Geneva Conventions of 1949 and the 1977 Additional Protocols explicitly protect medical facilities, personnel, and the wounded during armed conflict. These laws prohibit attacks on hospitals and ambulances and require parties to the conflict to respect and safeguard medical missions. Despite these clear legal protections, the repeated targeting of Ukrainian healthcare infrastructure represents a flagrant breach of these international norms.
The deliberate bombing of hospitals not only causes tragic loss of life but also disrupts essential medical services, exacerbating the humanitarian crisis. The destruction of healthcare infrastructure violates the principle of distinction, which requires combatants to differentiate between military and civilian objects, and the principle of proportionality, forbidding attacks causing excessive civilian harm relative to the military advantage gained.
Underground Hospitals: An Innovative but Forced Adaptation
In response to the relentless attacks, Ukraine has pioneered the construction of underground hospitals designed to withstand bombardments and ensure continuous medical care. Lieutenant Colonel Roman Kuziv, responsible for military health centers in eastern Ukraine, explains that burying hospitals under six meters of soil was a necessary adaptation after one medical center was bombed 16 times. This approach reflects a grim acceptance that the protections once afforded by international law are no longer respected by Russian forces.
The first underground hospital entered service in 2024, with others under construction. These facilities are built using thick metal modules manufactured by Metinvest, a Ukrainian industrial conglomerate that has shifted its production to support the war effort. The structures have been rigorously tested against live fire, mortars, 120-mm projectiles, and eight-kilogram TNT devices dropped by drones to ensure resilience.
Features and Capacity of Underground Hospitals
The underground hospitals meet NATO Role 4 standards, providing comprehensive surgical and intensive care capabilities close to the front lines. A typical facility covers approximately 400 to 500 square meters and includes:
- Two operating rooms capable of performing up to four simultaneous surgeries.
- Intensive care units equipped with cardiac monitors, defibrillators, ventilators, and patient warming systems.
- Independent power generators and water wells ensuring operational autonomy during attacks.
- Modern sterilization equipment and medical lighting to maintain hygiene and safety standards.
These hospitals can accommodate over 100 patients daily, stabilizing wounded soldiers and civilians before transfer to rear medical facilities. The underground location offers protection not only from direct strikes but also from chemical, biological, radiological, and nuclear threats, as highlighted in WHO’s guidelines on hospital shelters.
Impact on Maternal and Child Health
The war’s toll on maternal and child health has been severe. The national preterm birth rate in Ukraine is around 6%, but in frontline regions such as Kherson Oblast, it nearly doubles to 11.8%, with the highest stillbirth rates recorded there. Constant shelling and the threat of air raids disrupt prenatal care and childbirth, forcing many women into underground maternity wards designed to protect them during labor.
For example, Kherson has implemented three underground departments in medical facilities, including a maternity ward operating since early 2025. Despite being hit by multiple direct and near misses from shelling, these bunkered units allow continuous perinatal services, reducing the need for dangerous evacuations during childbirth.
The Scale of Healthcare Infrastructure Damage
The destruction of healthcare infrastructure in Ukraine is staggering. WHO’s national survey of 617 health facilities revealed that 128 are fully damaged and 280 are non-functional, with many requiring urgent renovations and structural upgrades to meet local and international standards. The overall damage to the health sector is estimated at around $1.4 billion, with reconstruction costs projected at $14.2 billion over the next decade.
The loss of ambulances, medical equipment, and trained personnel further strains the healthcare system. Vaccination rates have plummeted, and specialized services like sexual and reproductive health are critically under-resourced, with only 13% availability nationwide.
International Response and Reconstruction Efforts
The international community, including the WHO, United Nations agencies, and donor countries, has mobilized to support Ukraine’s healthcare system. Germany pledged €20 million for reconstructing the Okhmatdyt children’s hospital, symbolizing international solidarity. WHO and partners emphasize the importance of renovating underground shelters and building resilient health infrastructure capable of withstanding ongoing multi-hazard threats.
Ukraine’s government plans to expand underground medical facilities, including a 12,000-square-meter hospital in the Kharkiv region with a capacity for 2,000 patients. Kharkiv’s mayor envisions an “underground town” with schools, medical institutions, and amenities integrated into a secure subterranean complex.
The Broader Human Rights and Strategic Implications
The targeting of healthcare is part of a broader pattern of violations against civilians in Ukraine, contributing to a humanitarian catastrophe. The deliberate destruction of hospitals is a war crime under international law, yet accountability remains elusive. As Pavlo Kovtoniuk warns, impunity risks normalizing these attacks as a military strategy.
Ukraine’s underground hospitals symbolize resilience and innovation but also a tragic regression in the respect for humanitarian principles established after World War II. The need to bury hospitals underground recalls past conflicts where indiscriminate attacks forced similar adaptations, underscoring the failure of modern warfare to protect the most vulnerable.
The systematic targeting of medical facilities in Ukraine represents a profound violation of international humanitarian law and human rights. The construction of underground hospitals is a courageous and necessary response to ensure the survival of healthcare services amid relentless assaults. However, these adaptations highlight the urgent need for stronger international mechanisms to enforce the laws of war, hold perpetrators accountable, and protect medical personnel and infrastructure in conflict zones worldwide.
For think tanks focused on human rights and conflict resilience, Ukraine’s underground hospitals offer a critical case study in the evolving nature of warfare, the erosion of legal protections, and the innovative strategies required to safeguard life and dignity in the most challenging circumstances.
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