Introduction

Latin America offers enormous diversity in migratory issues. In particular, the area was identified as a migrant-sending region until very recently. In the South American case Chaves-González et al., argue that, with the exception of Chile, these South American countries were long used to being countries of origin and not destination. Brazil, Chile, Colombia, Ecuador and Peru initially faced the influx in Venezuelan migrants and refugees with outdated or limited migration and integration policies (Chaves-González et al. 2021, p.2). Brumat and Vera note that “A restrictive policy shift within South America’s policy liberalization in the last two decades offers a unique opportunity to study the determinants of migration policy change (MPCh) and to understand the apparent contradictions in migration policy in the Global South.” (Brumat and Vera 2024, p. 2). In terms of Venezuelan immigration, this phenomenon constitutes one of the most significant diasporas in the last decade globally, characterised by a dramatic situation. Two decades ago, the Venezuelan case was not the object of study within the global migratory outlook (Dekocker, Valbuena and Fernández 2021). Among the countries in South America, Colombia has historically had a profile of a migrant-sending country. Since 2015, this trend has taken an unexpected turn, from being a predominant country of origin, it has also become an important destination and transit country, with a significant component of returning and mixed families (Venezuelan children or couples). Colombia has been, is, and will most likely continue to be the largest recipient of this population in the world.

Following a decade of crisis, the large-scale migration of Venezuelans to Colombia has left millions of stories in its wake. According to the Regional Inter-Agency Coordination Platform for Refugees and Migrants (R4V), there are 7,722,579 Venezuelan refugees and migrants around the world, with roughly 6.54 million in Latin America and the Caribbean. According to population by country, Colombia has 2.88 million, Peru has 1.54 million, Brazil has 510,500, Ecuador has 474,900, and Chile has 444,400 people. Likewise, according to R4V, there are 2,372,061 people in Colombia with regular status, 416,625 people are in the process of obtaining the Temporary Protection Permit (PPT), 1,890,185 people with a PPT authorization, and 503,682 people with irregular status (as of October 31, 2023) (R4V 2024).

The context of this exodus is primarily the political climate during Hugo Chávez’s presidency, characterized by hyperinflation, currency devaluation, falling oil prices, and food and medicine scarcity (John 2019). Since the beginning of the influx of Venezuelan people to Colombia, the situation has been highly politicized on both sides. The two countries have high rates of human rights violations. In Colombia, the host country, there have been consistent, systematic violations of the right to health by the Colombian government and health-promoting organizations (Serrano Frattali 2022). According to the Pan American Health Organization (PAHO), while migrants face the same health threats as anyone else, these are aggravated by inadequate living conditions and lack of access to basic services such as water, sanitation, and nutrition. Migrants are also more likely to face poor and crowded working conditions within the informal economy (PAHO 2020). In the framework of the right of access to health for migrants there is a clear distinction between regularized and irregular migrants and their access to health care under Colombia’s General System of Social Security in Health (SGSSS). The Venezuelan migrants in an irregular situation and affiliated to the SGSSS have as a general rule access to health services. By way of contextualization, a major part of migrants that regularize their migratory status are not affiliated with the healthcare system.

The right to health has been debated, and an effective solution is yet to be found in Colombia. In 2008, when Constitutional Court Decision T-760 established health as a fundamental autonomous right in Colombia, the Court’s decision addressed systemic access issues, a lack of oversight, and self-regulation in the health care system. Following the passage of Statutory Law 1751 of 2015, which regulates fundamental rights to health and prescribes other provisions, the fundamental right to health has been enshrined as autonomous and inalienable both individually and collectively.

In the context of the Venezuelan migration crisis, understanding the Venezuelan migration phenomenon in Colombia requires analysing the realities in situ through academic works that explore the characteristics of the social realities. The ordeal of Venezuelan migrants generally begins at the border with Cúcuta. From there, they begin to walk an arduous path of almost 200 km that takes several days, usually towards the Metropolitan Area of Bucaramanga (AMB). The metropolitan area includes the city of Bucaramanga, and the contiguous towns Floridablanca, Girón and Piedecuesta, which is the focus of this study. This geographical area is key to gaining a deeper understanding of the Venezuelan migratory phenomenon as approximately 73% of the Venezuelan migrant population that enters Colombia enters through the entries that are in Norte de Santander, and the main road to reach the country’s interior passes through Bucaramanga. There is another alternative road through Boyacá, but it is much less travelled. For this process, AMB is an essential area because, first, a high percentage (the majority) of the Venezuelan population passes through here, going to other cities in Colombia or to other southern countries; further, we find that this area is the main connection point with the migration routes to the interior of the country and to other countries. Second, because of its geographical location, the (AMB) is still relatively close to the Colombian–Venezuelan border. Therefore, there is a fairly large Venezuelan population settled in Bucaramanga. Third, another reason that increases this study’s importance related to this geographic scenario is the high level of spatial interrelationship; Bucaramanga often presents the so-called extended border as the Venezuelan population goes back to Venezuela and then returns to Bucaramanga.

The following sections will analyze the methodological aspects applied in this work to address the research question: What are the obstacles to exercising the right to health of the Venezuelan migrant population in the AMB? Through semi-structured and in-depth interviews and fieldwork carried out in 2022 and 2023, it was possible to learn first-hand about different perspectives related to this question. Subsequently, several contextual elements of the Santander region and the AMB will be examined, particularly in relation to the General Social Security System in Health (SGSSS for its acronym in Spanish). Then, the practices and design of public policies related to migration and the right to health of the migrant population at the national and local levels will be analysed. The experiences and narratives of Venezuelan migrants in the AMB are presented next, wherein migrants’ narratives will be described and analysed in contrast to the institutional discourse; finally, we present the conclusions of the study.

Methodology and Methodological Design

Throughout this section, the fundamental aspects of the analysis from the data collected during this academic work will be presented. For this study, a methodological design based on a qualitative methodology was applied. The research methods used are participant observation and semi-structured and in-depth interviews conducted between June 2022 and June 2023. Semi-structured interviews present a greater degree of flexibility than structured ones because they start with planned questions, which can be adjusted in the course of the interviews. Their advantage is the ability to adapt to the subjects with possibilities to motivate the interlocutor, clarify terms, identify ambiguities, and reduce formalisms. For this qualitative study, a total of 50 semi- structured and in-depth interviews were conducted: 35 interviews with the Venezuelan migrant population, 5 interviews with non-governmental organizations (NGOs), 5 interviews with Colombian State institutions, and 5 interviews with healthcare professionals. Data analysis was used to identify what kind of messages are behind the perspectives of the interviewees, and their views were decisive in shedding light on parts of the narrative that have been hardly examined to date.

The research continues by analyzing the state regulation on the human right to health. Moreover, we make a jurisprudential analysis of the decision of the Constitutional Court of Colombia regarding the protection of the right to health of Venezuelan migrants. Likewise, different sources were reviewed, such as data issued by NGOs and Colombian institutions, particularly those related to public health policies in the AMB.

National and Local Social Context: Basic Characteristics

In terms of the national landscape, since the start of the Venezuelan migration to Colombia in 2010, there have been 110,297 foreigners in Colombia, with Venezuelans accounting for 33.9% of the total foreign population. This year, there were already 37,461 Venezuelans in Colombia. Only 108 foreigners of various nationalities were naturalized that year, with Ecuador, the Bolivarian Republic of Venezuela, Spain, and Cuba having the highest totals. The year 2015 is the moment in the massive influx of Venezuelan migrants. Migración Colombia (the national migratory authority in charge of monitoring and controlling nationals and foreigners on Colombian territory) released its first official figures in 2015, registering 31,471 Venezuelan residents. Between January and August 2015, 183,292 Venezuelan citizens entered Colombia, whereas 11,020 received their foreign identification cards. In September 2019, there were 1,488,373 residents, of whom 750,918 were regular migrants, meaning they had visas, foreign identification cards, or special permits that allowed them to stay within the time limit set by law, and 737,455 were irregular migrants, meaning they entered Colombia without authorization, or whose permission to stay exceeded the time limit set by law. Thus, migration accelerated in 2018, with a 166% increase over the previous year.

In the healthcare field, we can identify various legal and policy frameworks to guarantee this right (Laws 100 of 1993, 715 of 2001, and 1751 of 2015). For example, according to Law 100 of 1993, the system of integral Social Security was created, and other provisions were issued, indicating that all Colombians will participate in the essential health service allowed by the SGSSS. As can be seen in the article’s language, only Colombians are mentioned, which represents ab initio a system of exclusion. There are two types of members in the SGSSS. There are those affiliated with the system through the contributory regime, comprising people connected through an employment contract, public servants, pensioners, retirees, and self-employed workers with the capacity to pay. Then, there are those affiliated with the system through the subsidised regime, which includes people who cannot afford to pay the total amount of the contribution and who must be subsidised by the SGSSS, i.e. the poor and vulnerable population, including mothers during pregnancy, childbirth, postpartum, and breastfeeding, community mothers, women heads of households, children under 1 year, minors in an irregular situation, people over 65 years, people with disabilities, farmers, and indigenous communities. One aspect to highlight is that in Colombia, all people, regardless of whether they have valid identification documents and do not have the ability to pay, have the right to receive emergency medical care. Angeleri noted “Describing international migration, including irregular migration, as an unexpected circumstance or as caused by unexpected circumstances is inaccurate.” (Angeleri, 2018, pp468-469). Through expansive jurisprudence, the Colombian Constitutional Court has emphasized the approach to the meaning of right to health (Judgement T-705 of 2017, T-025 of 2019, T-197 of 2019, T-403 of 2019, T-246 of 2020, and T-246 of 2020). In terms of public policy, there is always a discourse on the economic element that explores the challenges faced by the Territorial Institutions and the service providing institutions (IPSs for its acronym in Spanish) in the AMB to implement this increasingly broader vision of the concept of emergency care for the migrant population and Colombian returnees.

In terms of geographic location, the AMB is in the Department of Santander, a region that borders the departments of Norte de Santander, Boyacá, and Arauca. The AMB is made up of four municipalities: Bucaramanga (capital of the Department of Santander), Girón, Piedecuesta, and Floridablanca and has a population of 2,306,455, whereas the AMB has a population of 1,284,495 and 116,043 Venezuelan refugees and migrants in the department of Santander (GIFMM, 2023). In this area, as in all of Colombia, the actors of the SGSSS, the health promoting agencies (EPS Entidad Promotora de Salud - Health insurance agency), public and private IPSs (IPS Institución Prestadora de Servicios de Salud - Health care provider), hospitals and clinics, users’ associations, the community, the benefit plan administration companies (EAPBs for its acronym in Spanish), the Ministry of Health and Social Protection, and the National Health Superintendence converge. At all territorial levels, the SGSSS integrates management institutions and entities for the promotion and provision of health services, as well as the set of health actions and control of risk factors in their respective jurisdiction and area of competence.

At this local level, we can indicate that one of the challenges faced in conducting this research was the limited health education for Venezuelan migrants and refugees in the region. Similarly, the number of institutional documents on the subject are few and the reports have little to no publicity.

In a study carried out by the Interagency Group on Mixed Migration Flows (Grupo Interagencial sobre Flujos Migratorios Mixtos) GIFMM, which was derived from an exercise promoted between the Health Cluster and GIFMM, many gaps and holes in the legalization and affiliation to the Identification System of Potential Beneficiaries of Social Programmes (SISBEN) and with the healthcare system of the refugee and migrant population from Venezuela were identified, based on figures from the participating organizations and experts in each of the topics.

The knowledge of the Venezuelan migrant population’s true affiliation figures with the SGSSS is essential to an understanding of the right of access to health care services for migrants. Because there are few institutional reports, in the framework of this research, filing legal actions to obtain the required information was needed. Similarly, it is essential to know the real figures derived from the activities carried out by the agencies. In another petition, we were able to identify that the Secretary of Health and Environment and Integrate, with the support of national and international cooperation organizations, have channelled the affiliation of migrants, especially Venezuelan nationals, to the SGSSS.

Another contextual element to highlight is the worsened health conditions of many migrants upon entering the AMB. In the interview that was carried out in the study, the former Secretary of Health of Bucaramanga Juan José Rey indicated:

Yes, it must be said, that if something has changed, it was the condition of the migration population; the epidemiological profile of the migrant population is very different from the problems that they have been having in the system for a while. Here it is as if someone saw the diseases of a population in the 70s, which is dramatic, meaning problems of infectious diseases, problems related to malnutrition, problems of sexually transmitted infections, and people with no control. For example, with issues of diseases such as hypertension and diabetes, we see the migrant population and their diagnosis is as if we were going back 50 years in healthcare, which also tells us that the system, even though far from perfect when it comes to controlling many diseases, has improved. (Interview 48, 2023).

Another finding is the severe malnutrition suffered by many Venezuelan migrants in the AMB. One of the interviewees responded as follows to the question ‘What comparisons do you make with the Venezuelan healthcare system in recent years?’

That is difficult because there is no healthcare there right now, it has been… well, since the story of socialism began. There is no way to buy food, food is scarce, so what happens? Children are the ones who suffer, adults can put up with it, but babies don’t; they can’t take it, they ask and cry and shout. The family that has no resources to support them because we don’t think about that, but to have several children, we don’t think about the future. (Interview 37, 2023).

Healthcare Policies and Practices

From a political standpoint, enabling access to health care for the migrant population is a significant challenge. In general, the IOM states that the migration phenomenon “must be recognized as a social determinant of health; mobility not only impacts upon an individual’s physical vulnerability, but also on mental and social well-being.” (IOM n.d.). Similarly, international migration has impacted public health. Health goes beyond medical treatment; it encompasses practices of care linked to the social and economic conditions in which migrants find themselves. Another risk factor identified is women’s and adolescents’ vulnerability to various criminal behaviors, such as rape, trafficking, sexual assault, and other forms of abuse and discrimination.

Notably, the area of health care often lacks a public policy and human rights approach; instead, it is focused primarily on profit. As stated previously, Constitutional Court Decision T-760 did not consider health to be a fundamental autonomous right until 2008. Seven years later, the Colombian Congress approved Statutory Law 1751 of 2015. Similarly, this legislation established that this right includes access to health care services in a timely, effective, and quality manner to maintain, improve, and promote health. Health and human rights serve as important guiding principles. In Colombia, the right to health has been unclear. However, direct and indirect legislative recognition, normative gaps, and serious violations of the right to health have prompted the Colombian Constitutional Court to intervene several times to protect this fundamental right both for Colombians and regular and irregular Venezuelan migrants.

The Unique Affiliates Database contains data that illustrate the situation in terms of health affiliation (February 28, 2024). Venezuelan migrants with active affiliation documents such as the Special Stay Permit (PE) and Temporary Protection Permit (PT) number as follows: 4,108 in the contributing regime and 3,907 in the subsidized regime, thus totaling 8,015. Similarly, with PT, there are 291,988 in the contributing regime and 1,117,835 in the subsidized regime, thus totaling 1,409,823. As a result, the General System of Social Security in Health currently covers 1,417,838 Venezuelan migrants (296,096 in the contributory regime and 1,121,742 in the subsidized regime). In the case of the AMB, Bucaramanga has 26,283 affiliates (6,635 in the contributory regime and 19,648 in the subsidized regime). Floridablanca has a total of 7,344 Social Security system affiliates (1,777 in the contributory regime and 5,567 in the subsidized regime). In Girón, there are 4,736 affiliates (854 in the contributory regime and 3,882 in the subsidized regime), whereas Piedecuesta has 4,952 (897 in the contributory regime and 4,055 in the subsidized regime).

Colombia’s health care system is based on insurance. In other words, the (SGSSS) serves as the system’s gateway. However, it is important to note that the population not affiliated with the social security system in health has the right to emergency care. This is due in part to the development of the Constitutional Court, which grants unaffiliated migrants the right to emergency care. As a general rule, territorial entities bear the financial burden: municipalities at the first level and departments at the second and third levels of complexity. Affiliation with the SGSSS is only possible for migrants who possess a valid document while on Colombian territory.

Colombia has a healthcare system based on insurance, which means that the gateway to the entire system involves being affiliated with the SGSSS. Even so, it is important to clarify that the provision of emergency services is provided for all non-affiliated individuals within the framework of human rights, and the financial cost is assumed by the territorial entities: the municipalities at the first level and the departments at the second and third levels of complexity. For the migrant population, affiliation with the SGSSS is only possible if they have valid documentation in Colombian territory.

In its study entitled “Indicadores de Gobernanza de la Migración a Nivel Local Perfil 2022, Municipio de Bucaramanga” the IOM indicates that regarding municipal participation in the formulation of national migration policies, local authorities do not provide written evidence or mention the participation of local administrations in the preparation of the CONPES 3950 Document “Strategy for the attention to migration from Venezuela” or the draft of the Migration Law, which is currently undergoing approval in Congress. This finding in the report emphasizes the absence of participation by local authorities who are intimately familiar with migration realities in public migration management. The lack of participation means not being able to influence decisions.

In Colombia, the fundamental right to health and life with dignity is violated. The essential right to health has been the focus of social, political, and legal debates, but a solution to the health care system’s crisis remains elusive. Health care in Colombia is frequently characterized by deficiencies in this service area. In this regard, Colombian society recognizes the so-called “death walk,” which is sometimes a systematic and calculated practice by entities obligated to provide health care that intentionally delays patient care, resulting in fatalities during those delays. To enforce the right to health, numerous legal actions are observed in the Colombian health care system. Angeleri argued “the dysfunctions of this social insurance health system, which is dominated by private actors, have led to the filing of hundreds of thousands of ‘tutela’ claims by people seeking concrete access to required health care services and essential drugs as dimensions of the scope of key human rights.” (Angeleri 2022, p.6). According to Ramírez and Otálvaro, decisions and practices in the Colombian health care system are more focused on economic profitability than on achieving a high quality of life, with health being a crucial factor. Although these factors are politically significant, they are not central to a public health decision-making strategy that prioritizes system profitability. Thus, power relations use humans (including the community and health care professionals) to advance a group or individual’s economic interests, as evidenced by barriers to service access and control over public health expenditure (Ramírez and Otálvaro, 2015).

This health care issue exacerbates migrants’ health rights in Colombia, where normative gaps are subject to a narrow interpretation based on profit logic. In other words, these gaps are being used to deny health care services to migrants. A concrete example of this situation is when pregnant Venezuelan migrant women in irregular situations were denied prenatal care and childbirth assistance by health authorities, claiming that it was not an emergency. Years later, the Constitutional Court addressed some aspects of the right to health during pregnancy. Although pregnancy has not been recognized as an emergency under constitutional law, the Court cautioned that in some cases, urgent care may include the provision of specific health care services related to women’s pregnancies, such as prenatal check-ups and childbirth assistance. Law 2244 of 2022 established all pregnant women’s rights to admission to the health care system—in other words, to receive care without administrative barriers and the ability to undergo recommended prenatal checks based on current scientific evidence by levels of care to ensure the mother’s health in accordance with her health condition. Another example of how pregnant Venezuelan migrants’ health rights are treated can be found in one of our findings from the fieldwork conducted for this research by a departmental health authority, which asserted that a vaginal birth did not constitute an emergency. As a result, it is considered ineligible for insurance payment because the inter-institutional agreements between public health care providers, in general, and the respective Departmental Health Secretariat only covered true emergencies.

At the national level, the governments in office have been addressing the issue with a common denominator: a short-term, non-structural, and contextual approach. We found some measures such as granting the Permiso Especial de Permanencia (PEP) Special Stay Permit, (Resolution 5797 of 25 July 2017), which empowers the holder to carry out any legal activity or occupation in the country for a period of 90 days, which is extendable up to a maximum of two years.

As a guideline, Colombia’s Ministry of Foreign Affairs issued Decree 216 of 2021 (1 March 2021), which adopted the Temporary Protection Statute for Venezuelan Migrants under the Temporary Protection Regime and enacted other migration-related provisions. The Estatuto Temporal de Protección para Migrantes Venezolanos (ETPV) - Temporary Protection Statute for Venezuelan Migrants applies to Venezuelan migrants who want to stay in Colombia temporarily and meet one of the following four conditions: (1) being in Colombian territory on a regular basis as the holder of a Permiso de Ingreso y Permanencia (PIP) -Permanence permit-, Permiso Temporal de Permanencia (PTP) - Temporary Permanence Permit- or valid PEP, regardless of their issuance phase, including the Permiso Especial de Permanencia para el Fomento de la Formalización (PEPFF); (2) as holders of a SC-2 Safe Conduct, they will be on Colombian territory on a regular basis while processing a refugee status recognition request; (3) being in Colombia irregularly as of January 31, 2021; and (4) during the first two (2) years of this Statute’s validity, entering Colombian territory on a regular basis through the appropriate legally authorized migration control post, in accordance with the requirements established in migratory regulations. Under this decree, the Temporary Statute consists of the The Registro Único de Migrantes Venezolanos (RUMV) -Unique Registry for Venezuelan Migrants- and the PPT. Decree 216 did not establish implicit competencies for local authorities; however, they have been coordinating actions with Migration Colombia and other entities for the socialization, sensitization, and dissemination of information on the various stages of ETPV implementation.

In this regard, the IOM stated that this Statute guaranteed the right of migrants from the Bolivarian Republic of Venezuela who were in Colombia as of January 2021 to legalize their migratory status and exercise any legal activity or occupation in the country for 10 years. The decree does not establish implied competencies for local authorities; however, they have been coordinating actions with Migration Colombia and other entities for the socialisation, sensitisation, and dissemination of information on the different implementation phases of the ETPV. The (RUMV), which is part of the ETPV, allows this population to be identified by the authorities, thereby encouraging legalization, promoting affiliation with the healthcare system, and increasing employment opportunities.

Until the end of 2021, there was no official response for the migrant population who entered Colombia undocumented after 31 January 2021 (the deadline to qualify for the ETPV). The Statute’s approval took place at a time when the border crossings between Colombia and Venezuela were officially closed. This leaves the migrant population that arrived in 2021 in statutory limbo and those that continue to arrive in Colombia through unauthorised passages without stamping their passport, if they have one.

Another policy implemented by the Colombian government was in 2022, when Gustavo Petro’s government confirmed the elimination of the “Oficina para la Atención e Integración Socioeconómica de la Población Migrante” -Office for the Care and Socioeconomic Integration of the Migrant Population- also known as Borders Management (created in February 2018). This measure was justified within the context of the Colombian government’s restructuring process to save public funds. Similarly, the Colombian government claimed that the functions of this entity were inherent in the Ministry of Foreign Affairs. The monitoring of migration matters at the national level reveals that the issue has not been on the governmental agenda, and the few public policy decisions have raised more questions than answers. According to María Clara Robayo, a researcher at the Venezuela Observatory at the University of Rosario, Petro’s government “strategically decided to set aside the migration issue to be able to approach Venezuela” (Sánchez, December 12, 2023).

In the context of local politics in the AMB, in local government plans, there is the Municipal Development Plan titled Bucaramanga, City of Opportunities 2020–2023 (2020). The city has 22 healthcare Centers where the migrant population can receive care. The Bucaramanga Progresa Regional Health Plan 2020–2023, in theory, determines some actions aimed at promoting the general health of the migrant population and ensuring treatment, including treatment for tuberculosis, HIV, congenital and gestational syphilis, among others. In practice, these actions have not been fully implemented.

Along these lines, another aspect to highlight that considers the political agenda of the authorities is that in the city of Bucaramanga (17 May 2022), the first Integrate Center of Colombia for the integration of the migrant and host population was opened. Its services include affiliation with healthcare and SISBEN, Visible Point (Migration Colombia), general legal guidance, and psychosocial and legal guidance for gender-based violence and the LGTBIQ + population. This Center was the first of nine Centers that opened throughout Colombia.

It is important to highlight that IOM and Bucaramanga Health Institute ISABU signed a cooperation agreement that has had a significant impact on non-legalized migrant population and Colombian returnees and receiving communities, which was the provision of healthcare services. With the implementation of this agreement, (which began in June 2020), the provision of healthcare services is offered in all life cycles, among which are external consultations for Medicine and Promotion and Prevention, such as, for example, First Time Consultation for General Medicine and Medical Consultation for Admission to Prenatal Control.

In relation to the government plans of the municipalities of Piedecuesta, Floridablanca, and Girón, the three municipalities converge in addressing the migratory phenomenon with only a generalised description, which constitutes an absence of an institutional response at the local level to the Venezuelan migratory phenomenon. We observe how a clear differentiation is not made between maternal health, child health, chronic diseases, communicable diseases, sexual health, diseases transmitted by vectors, and zoonotic diseases.

One aspect to highlight is the creation of the so-called Boards. First, the Coordination Board of Migration Affairs of the Bucaramanga Mayor’s Office (Decree 052 of 2020) aims to coordinate actions to protect and promote the rights of the migrant and host population. This Board meets bimonthly and is consultative in nature, chaired by the Secretary of Social Development and comprises the highest authorities of the Ministries of the Interior, Education, and Health. Representatives of the Ombudsman’s Office, the Attorneyship, Migration Colombia, the National Family Welfare Institute, the Governor’s Office of Santander, academic institutions, NGOs; the United Nations agencies present in the region also attend as permanent guests without voting rights. Second, the Colombian national government established the first Departmental Migration Board (Santander Migration Management Board) in Bucaramanga (26 October 2018) that evaluates the strategies and measures taken to serve the Venezuelan migrant population arriving in this department. This Board prioritises caring for the Venezuelan migrant population in matters of health, labour inclusion, protection of minors, and security. Third, the ‘Technical Committee on the Health and Migration of the Health and Environment Secretary of the Municipality of Bucaramanga was created for the integration of the migrant and returning population to the Social Security Health System SGSSS’ (Resolution 032 of 2022), and as part of the committee, the implementation of the Health Sector Response Plan to the migration phenomenon was institutionalised. The response plan is based on three components: the affiliation with the SGSSS, the development of education, information and communication actions in health, and epidemiological surveillance. The plan is composed of 57 activities.

In the same work IOM does about migration governance indicators at the Local Level in Bucaramanga, as indicated previously, various topics were addressed. The implementation of local initiatives and strategies to serve the migrant population is carried out, depending on the topic, from the corresponding thematic departments. For example, the Department of Social Development leads strategies to assist the population in vulnerable situations; the Department of the Interior is responsible for promoting access to justice, combating human trafficking and mediating in conflicts involving refugees, migrants and the host community. The Department of Health promotes the affiliation of the population to the SGSSS in Health, and the Department of Education carries out plans to ensure migrant children and adolescents remain in schools. In the same way, another aspect indicated in the same work is found in the case of an agreement between the Department of Social Development of Bucaramanga and the UNHCR, a support space for Venezuelan migrants that was inaugurated in June 2021 located in the Quebradaseca Interchange. In this space, the population has access to different services offered by UNHCR, Samaritan’s Purse, IOM- OIM, UNICEF, Woman and Future Foundation, Profamily, Red Cross and Corporación Opción Legal. Services include legal guidance, support for family reunification, health promotion and prevention, a safe space for early childhood, sociocultural integration, and psychosocial care.

One of the most important findings of this study is related to the role of NGOs, which are clearly organized with local institutions in the area. Beyond the institutional framework, NGOs and international cooperation organizations that are implementing humanitarian aid programs end up replacing the role that corresponds to the government at all levels. Because of their active and dynamic roles, these organizations play a crucial role in the social lives of Venezuelan migrant workers in the AMB, and for them, they represent the state. The Venezuelan migrant population sees NGO workers more than public officials as they are asked for help, for example, requesting legal assistance for the protection of the right to health. In these situations, it can be seen how NGOs sometimes make up for the lack of political will of national and local governments and, in other cases, for the lack of operational capacity.

In conclusion, public policies are not congruent in all the municipalities of the AMB. As a general rule in government plans, no serious migration strategies are presented. Further, there is a lack of political will in various agencies, and in others, we witness the performance of formal and non-substantive activities, with the goal of justifying (pretending) their commitment and compliance with duties; however, in practice, these activities rarely have a great impact. The role of control agencies in this regard is often non-existent. The important work by the Superintendency of Health should be noted though, which in many cases due to its inspection, surveillance, and control functions has had an impact in forcing the system’s actors to comply with the following focal issues: financing, insurance, provision of services, user care, special actions and measures, information, and targeting of health subsidies. Almost a decade after the beginning of the migration phenomenon in the region, there are no institutional, much less regulatory, frameworks in all the AMB municipalities in terms of migration. Although it is true that some efforts have been made by the Colombian government and some institutions to provide healthcare to the migrant population from Venezuela, it is clear that these efforts have not been sufficient in meeting the healthcare needs of this population in the AMB. A clear example is that a large proportion of migrants who had an undocumented status have been prevented from accessing and using social and healthcare services. Similarly, there is a clear violation of the Venezuelan migrant population’s right to participate in the decisions that affect them and that are adopted by the agents of the SGSSS, e.g. participation in the development of policies; decisions that may mean a limitation or restriction; and the evaluation of the results of healthcare policies. In other words, participation by the Venezuelan migrant population in constructing policies that guarantee their human rights to health is extremely rare.

Experiences and Narratives of Venezuelan Migrants in the AMB

Through semi-structured interviews and fieldwork, migrant individuals’ firsthand perspectives on the effective protection of the right to health, their views on the AMB’s Health System, and the barriers they have faced in accessing its services were recorded. It is important to highlight the wide range of migrant realities reflected in this sample, as both men and women of various ages (ranging from 18 to 70 years) were interviewed, with varying lengths of stay in Colombia; some have been in the AMB for more than six years, while others have only been here for a month.

In terms of migratory status, 58% of the 35 people interviewed have a regular immigration status. In contrast, 42% lack valid documentation that identifies them in the country and grants them full access to health care. The reasons for not having these documents are varied and reveal obstacles such as registration issues, scams, or charges for processing with relevant entities, lack of knowledge about the process (especially among newly arrived migrants in the country), and the lengthy process of obtaining the PPT, with the latter being the most mentioned by the interviewees: “I arrived in Colombia 6 years ago through Maicao, migration, and the trail. Right now, I am waiting for the PPT. I requested it two years ago, and now it is showing as In Process on the website” (Interviewee 7, 2023).

Other challenges may arise when possessing a passport because even if the migrant individual has a PPT, they will still require the passport, along with other documents, to process the Type R visa. This practice represents an administrative barrier for people who have had to leave their country due to extreme rights violations, as in the case of one of the interviewees:

Well, what happens is that here, the only thing they ask for to nationalise you or give you a PPT, so to speak, is that you have your passport stamped right now, but what the Colombian government does not understand is that to get your passport in Venezuela, you have to wait six months; in my condition, I fled here because they were going to kill my daughter, so I couldn’t wait six months. They do not understand that here. Without a PPT, you have no benefits, not healthcare, not even education… because I once went here to the Ministry of Education with my daughter, they ordered me to enrol her, but the high schools denied because she was an undocumented Venezuelan. (Interview 43, 2023).

Although the PPT is necessary for the migrant population to effectively enroll in the SGSSS, these recurrent legal and bureaucratic barriers in the legalization process translate in practice into limited access to healthcare services since, without a valid identification document, migrants can only access emergency services and limited services provided by NGOs such as the Red Cross. This is exemplified by one of the interviewees:

I don’t have any immigration status now. To get healthcare, I have to make an appointment with the Red Cross so that they can treat me. When I was pregnant, I asked for the safe-conduct, and it was accepted on 18 February 2017, which was when my child, who is Colombian, was born. But then, I kept renewing the safe-conduct until the issue of RUMV for PPT came up. I already left the SISBEN there, the safe-conduct there, and I’m waiting for the PPT to arrive. (Interview 7, 2023).

However, migrants also identify facilitators to legalize their migratory status in the country, among which they mention the goal and support received by public institutions such as the mayor’s office and the hospitals themselves, as well as the advice of some NGOs, as one of the interviewees commented when asked about her migration status:

Well, when I arrived it was easy because it was being done at the Red Cross and I did my paperwork, and I got my permit. Then, a month later, I got a call from immigration, and I went to immigration to get fingerprints, a photograph and all that. After about three months, I already had my PEP. (Interview 33, 2023).

Affiliation with the SGSSS

The lack of legal documentation is a primary obstacle migrants face in the process of affiliation with a EPSs or SISBEN.

However, in the corpus of interviews, other obstacles were identified, such as lack of knowledge of the process and the requirements for affiliation (which delays their intention to affiliate), lack of time or procrastination due to other priorities, and wait times in the SISBEN process. The latter is the case of one of the interviewees who stated:

I’ve been here for three years and I’m waiting for the SISBEN. I got it in December but I’m not affiliated with any insurance yet because I went to the Foundation where the hospitals sent me; they weren’t able to take care of me because of this prostate case I am currently suffering from. (Interview 17, 2023).

In addition, with regard to the process of affiliation with the SGSSS, the GIFMM coordinator also identifies one of the barriers as access to adequate information and guidance, which prioritises effective access to healthcare services beyond the bureaucratic process of the PPT.

Well, there are also good practices, but also many lessons learned from the process. For example, some good practices include organized support between Migration Colombia and the cooperation organizations, but also to the territorial entities, regarding the legalization process. A clear example is that the person leaves with their PPT, with their temporary protection permit, for one day, or from Migration Colombia, but doesn’t know what it’s for. It is seen as just another document, but they don’t know that they have to continue with a series of procedures, so one of the barriers is also information and guidance. For Migration Colombia, it’s important that they leave with their PPT and that’s it, but we have to see it a little further, and for the mayor’s office of the respective municipality, it should be much more important that the person is insured (Interview 28, Cristian Cano, 2023).

Although the majority perception is that the affiliation process is difficult, some interviewees mentioned that it was simple and smooth, which allowed them to affiliate quickly. Some recurring facilitators highlighted by these people were affiliations through an employer, having dual nationality and the support received by some public institutions and NGOs, specifically the services of the Integrate Centre and the mass affiliation days:

It was easy through Legal Option, which organized a workshop here in the community and affiliated us with Coosalud. The agency was here in the community, I didn’t have to go anywhere. (Interview 6, 2022).

Health and Accessibility

The experiences of the people interviewed in the healthcare services of the AMB can be classified into two major groups. The first is made up of those who are affiliated with a healthcare system (contributory or subsidised) and who, as a result, have the opportunity to access comprehensive care: emergency services, exams, appointments with specialists, medications and ongoing treatment. In general, these people have a positive perception of the healthcare services received, regardless of the regime in which they are enrolled, as reflected in the response of one of the interviewees to the question ‘What is your experience with accessibility to health services?’

Well, it was timely, I mean, I feel that healthcare in general is working quite well. I come from a country where if you don’t have private insurance, you are not treated in a decent health centre. If you don’t pay for private insurance in Venezuela you have to go to a hospital and bring the supplies that they’re going to give you, meaning you, as a patient, have to bring the medicine, bring the injection, bring everything. I’m comparing it with Venezuela. In Colombia, the times I went through the family doctor, the general practitioner, this part is very preventive. Here, you have to visit the doctor and you can do check-ups, but it is like prevention. There was a maximum wait time that I had to call several times, but there was no need to file a petition, although one authorisation took a month. That was the longest it took me. (Interview 39, 2023)

Like the interviewee mentioned above, it is not uncommon to identify in the narratives of these interviewees that waiting times are an obstacle both in the emergency room and in procedures for scheduling appointments, authorisation of procedures and tests. This is demonstrated by an interviewee who suffered severe back pain that required care from a traumatologist:

The procedures were completed over the phone, but it was first necessary to go to the Famisanar office to authorise the exam or consultation. You could go there, and if you’re lucky, you will wait a little or spend half the morning there. Then, getting the appointment is complicated. It may have taken at least two months to get the first appointment, and then, it could have taken at least one more month to get the second one. There are always long waiting times.

However, several interviewees recognise that this is a problem of the Colombian Healthcare System in general and not a particular obstacle of the Venezuelan migrant population. As one interviewee mentioned, these waiting times implies taking leaves from work (risking the same job) are

…normal, like everything else, sometimes it takes a little while, and you have to do a lot of running around. Sometimes, it’s complicated in that sense, but that’s what you have to go through, the normal procedure. (Interview 46, 2023).

The second group is made up of those interviewed who stated that they were not affiliated with any healthcare system. A common factor of their narratives was negative perceptions of the services, in some cases because they have not been able to access them when they had health problems, and for others because they have the idea that they will not be cared for because of their migration status.

For those who don’t have a permit, it’s terrifying because if they want to, they don’t take care of you. So, you must have the papers for work, health, everything. If you don’t have that permit here, you’re like nobody. (Interview 33, 2023).

When asked about healthcare experiences, one of the interviewees in this group exemplifies this barrier from his own experiences:

[At the healthcare institutions], they tell me that they can’t treat me because I’m Venezuelan, and I must have some document that validates me because the EPS is essential here in Colombia. They don’t even admit me, that is, I practically have to self-medicate on my own and try to see what’s not good for my health. (Interview 22, 2023).

This barrier is exacerbated when, in addition to being denied service, they experience unsuccessful redirections to other institutions or erroneous information is provided. An example of this is the ordeal through Bucaramanga that one of the interviewees experienced, ultimately, not being able to receive care:

I’ve been in a lot of pain. This week, I went where they told me, at 27 with 48, and I still don’t appear in the SISBEN. Then, I went to the University Hospital, and they told me that they couldn’t treat me there because I had to go to Hospital del Norte; so, I went there and they told me that the insurance I have doesn’t cover it yet. (Interview 17, 2023).

On the other hand, most of the interviewees without any affiliation with the SGSSS are aware of the option to be treated by the Red Cross services for illness. Those who visited this institution report having been cared for and had positive opinions about the care received. However, the services provided by the Red Cross are limited, especially in terms of specialists and conditions requiring continuity of care or prolonged treatment.

[At the Red Cross] they give you the date and where you have to go. I think they are affiliated with some laboratory clinics where I went for tests, but I don’t have the papers yet to go to a specialist or follow a treatment plan. (Interview 17, 2023).

This aspect was continuously presented in the fieldwork and was corroborated in some interviews. In the interviews conducted, some stories coincided in indicating the theme of surveillance. As a guideline in Colombia surveillance systems, private security systems are very common in the vast majority of public and private institutions, including healthcare institutions, public and private schools, shopping malls, warehouses, and even residential buildings also have it. It is a whole surveillance system that works constantly. The guards in healthcare institutions for some interviewees constituted a concrete barrier to proper care, especially in emergencies. This perspective aligns with that found in the fieldwork.

Regarding accessibility, the director of the Foundation Entre dos Tierras said:

Relative, that is relative, we as migrants have access to the HUS or Hospital del Norte. If we do not have consistency in healthcare and, unfortunately, the visible face of these two centres, very important health centres in the city, are the guards, the watchmen, they are the ones who have laser beams in their eyes; they know if they let you in or not, just as it happens to a Colombian that the first barrier in healthcare is the guard. Therefore, waiting times are relative, maybe the guard is in a good mood that day, he sees a pretty woman and lets her in, or he simply understood that there was an emergency and let her in, but we’ve had cases where people have died due to a guard’s negligence and that is where it should be reported; however, it cannot be reported anywhere, because there’s no way to do it. (Interview Foundation Entre dos Tierras, 2023).

In an interview with Gibran Mouarbes Giraldo, an insurance professional in the project with the German cooperation for the migrant population’s health insurance, about the affiliation process, said:

Yes, the affiliation, let’s say that the SGSSS in Colombia is an insurance model, in quotation marks, it’s not safe, it’s not insured, and it does not insure, but it’s based precisely on access. The main barriers that we identified are the security guard who tells them that they aren’t getting care there, the secretary who takes the wrong information, the office assistant at the EPS who doesn’t bill them or doesn’t make them sign an authorisation, etc. (Interview 46, 2023).

Cristian Cano from GIFMM Santander shares the following on the process of affiliation with the SGSSS:

…institutional barriers, it seems like in some places, the guard does the Triage; yes, the guard tells the person if they should or should not continue and, in fact, that also has other connotations of xenophobia and its relationship with the user, etc. (Interview 28, 2023).

Support of NGOs and Public Institutions

Within the narratives of the people interviewed, different organizations can be identified that have facilitated protection of the Venezuelan population’s rights. According to those interviewed, state organizations such as the Women’s Integral Centre, and NGOs such as Legal Option and Foundation Dos Tierras provided them with support and advice in filing legal actions such as protections or rights of petition. The following is an example of each of these fundamental legal figures in Colombia for the protection of rights:

I filed a writ for the protection of constitutional rights against Hospital del Norte because I was pregnant 2 years ago. They told me that my daughter was stillborn, but they didn’t let me touch her, they didn’t let my husband come to the institution, they didn’t even let me take pictures. They didn’t even give me the body to bury it because they say that I did not have a funeral service, they did not give me the body. For this reason, I decided to file a writ for the protection of constitutional rights against them, which I am still waiting for. I did it with the lawyer from the Women’s Integral Centre, they were the ones who advised me at that time. I had no knowledge, I had no EPS, I had nothing, so they advised me. (Interview 6, 2023).

I didn’t get [the PPT]; I look at the website and it had not arrived, and they had not yet approved it. Some people from the NGO came here and the boy did me a favour, looked for me, did it again, and sent me back to immigration so that they could take my information again and do it again. And that’s when he told me: ‘Wait three months and if you don’t hear anything by then I’ll send a right to petition for that’. And he did. After 3 months, he sent the right to petition again and that’s when it came because it didn’t come before that. (Interview 36, 2023).

Another facilitating role played by NGOs is that of offering healthcare services to Venezuelan migrants, such as medical care, access to medicine, and general exams. As mentioned in the previous sections, the Red Cross is widely recognised by the migrant population in this regard. Examples were also found of other organizations that facilitate healthcare services such as the Foundation Against Hunger, UNHCR, and the Jesuit Refugee Service.

Perception of Healthcare

The answers provided by the Venezuelan migrants interviewed about what they understand by ‘access to healthcare services’ reveal several themes and perspectives. Many of the interviewees emphasised that access to healthcare services should be considered a basic human right that should be provided to all people, regardless of their migration status or nationality. An example of this is one interviewee’s response: ‘For all human beings anywhere in the world, it’s a right to be taken care of’ (Interview 17, 2023). Some mentioned that access to healthcare services means being able to receive emergency medical care without barriers, delays, or discrimination, but access to healthcare services also includes preventive measures, regular check-ups, and basic medical services.

In terms of affordability and flexibility, several interviewees mentioned that healthcare services should be more flexible and affordable for migrants, especially with the lack of legal documentation, and they expressed the desire to receive equal treatment and that discrimination should not influence access to these services. In the words of one of the interviewees: ‘[Healthcare services] should be a little more flexible since we’re coming disoriented, we don’t have legal documentation, and because we don’t have documentation, we practically die for a hospital’ (Interview 21, 2023).

In terms of medical care quality, some mentioned that, while healthcare services may be offered free of charge, it is necessary to improve the quality of service to ensure timely and effective treatment. One of the interviewees touched on this point with a frustrating experience she had in the emergency department:

If a person goes to a doctor, they go due to an emergency, because they’re sick, not to be put in a room for 12 h to wait; then, the person has to leave because it’s better to leave than to keep waiting to receive care. (Interview 38, 2023)

When asked, ‘What do you think about the healthcare received?’ opinions are mixed and vary based on individual experiences. Some have had a positive experience and are grateful for the care and reception provided by the Colombian health system, rating it as ‘very good’ and ‘excellent’ and giving a high score to the quality of care. Others mention that they received adequate care without major complaints, but they had to wait in some cases. In general, they are satisfied with the service received. However, some did have negative experiences with healthcare and described it as ‘lousy’ or ‘bad’. There are also examples of people who have experienced discrimination and xenophobia:

The truth is that in some cases, not all, but in some cases, it’s been very bad because there are people who want to yell at us, people who even humiliate us; there is xenophobia for being a migrant. It happened to me with my daughter. Because I’m a migrant, I have to wait, I mean, you have to go to one side, and they skipped to the Colombians and left me waiting. (Interview 6, 2023).

The variety of answers provided demonstrates that it is essential not to generalize when it comes to healthcare received by migrants. However, it is clear that there are still barriers to guaranteeing this right and it is necessary to continue taking actions that respond to these realities.

Conclusions

Although analysing migration in the geographic setting studied should be of great academic interest, it should be noted that there are very few studies on the right to healthcare in this geographic area, and the few studies that are available tend to present very generalized and imprecise data. Similarly, there are very few reports prepared by public and private institutions and the various actors of the SGSSS; those that exist are generalized and imprecise, and most of the time they are not disseminated.

The findings from this study revealed a quasi-generalized perception that, in the context of the crisis in the Colombian healthcare system, the resources allocated to migrants’ healthcare undermine equity. The expenditure of resources by healthcare providers to care for the Venezuelan migrant population is highlighted since it is perceived as a tension between caring for Colombian nationals versus caring for foreigners, which underlies the idea that the State has few resources, and that these should be allocated primarily to caring for Colombians instead of foreigners.

We have seen that the right to healthcare for immigrants with an irregular migration status is by general rule limited only to emergency care. For the institutional political discourse, emergency care is presented as unrestricted respect by the Colombian State for its national and international human rights obligations, but the reality is that there is a huge contradiction and non- compliance with these legal obligations by the Colombian State, and in particular, it constitutes a discriminatory practice that limits equal access to healthcare services. The fact that the right to health in Colombia (like many other rights) is based on a principle of fiscal responsibility and entities’ profit motives leads to the commodification of the right to health, causing it to revolve around economic elements rather than human rights. It is clear that demands for social health security are increasing, far outpacing the effective GDP growth rate, posing a conflict between financial needs and the Colombian state’s capacity and/or willingness to allocate social public spending toward addressing basic health needs. In this sense, proper health care attention within the logic of fiscal rules represents a fiscal risk in Colombia, implying limitations on the right to health. This dramatic reality applied in a migration scenario further aggravates access to healthcare for this vulnerable population in the AMB, since, as has been demonstrated, it has led most authorities in this area to perceive and present it more as an economic challenge than a protection challenge. In addition, there is no active participation of the migrant population in health plans.

There is no homogeneous institutional coherence in the 4 AMB municipalities in terms of migration management, as it can be observed that healthcare actors and local authorities have different degrees of political will in this area.

In the interviewees’ narratives, they indicated a general notion of positive health, but there is another very diverse narrative when it comes to specific situations that require continual treatment, as in the cases of maternity, and catastrophic or high-cost diseases. In these cases, not having documentation may be tantamount to the death of the person, unlike being insured, which often increases the possibility of successful treatments.

In the case of catastrophic diseases, such as cancer, diseases with enormous suffering, migrants indicated an enormous dissatisfaction with the institutions providing services, as they are constantly denied proper care at specific times. In our analysis, we can see that the EPSs’ strategies for non-compliance include a combination of compliance and non- compliance, and it can be observed that they do comply with due attention at certain times. However, at times they fail to comply, often causing irreversible damage to patients. The lack of adequate care in a catastrophic disease can be extremely serious since timely treatment is required. Diseases that entail a high treatment cost where life survival depends to a large extent on timely treatment is very difficult, and it is even more difficult for subsidized regimes. Similarly, the exaggerated bureaucratic procedure requires a series of steps for proper care, and an error or an untimely procedure can mean the appointment, exam, or the determined procedure gets cancelled. The SGSSS analysis shows that the establishment of multiple steps has the purpose of impeding timely care for users.

Undoubtedly, the greatest obstacle to applying the right to health of the Venezuelan migrant population in the AMB is documentation. This legal barrier makes it much more difficult to access healthcare services and, in many cases, it is impossible to access these services. In other words, the non-legalized Venezuelan migrant population in Colombia can only have access to emergency services since not having documentation is an obstacle that prevents other rights. It is also essential to understand that insurance does not mean the provision of healthcare services; there is obviously a relationship between these two elements, but insurance does not always translate into receiving healthcare services.

Similarly, in our specific study, it was possible to identify how even for those who have legalized their status, access to subsidized health services, such as SISBEN, is a very complex and time-consuming process. Similarly, on several occasions, for migrants who are in the contributory system with the capacity to pay, the EPSs impose a series of non-existent requirements to not include them. The constant bureaucratic barriers in the healthcare system create a serious risk to proper care.

Another important finding is that a barrier or obstacle to accessing healthcare services is often discretional, the ‘curved’ clinical system, and the level of xenophobia and stigmatization in the agencies and/or among officials, which determine the effectiveness and scope of public policies in the AMB. At the same time, these barriers can diminish or disappear depending on the will of the official, clinical arrangements, and other interests.

It was possible to identify that the AMB’s local authorities, the Governor’s Office of Santander, NGOs, international cooperation agencies, and some control bodies such as the municipal ombudsman’s offices worked together multiple times to respond to the challenges related to healthcare. This coordination for joint work is linked to the so-called Migration Boards, Unified Command Points, and Health Boards, the Coordination Board for Migratory Affairs of the Mayor’s Office of Bucaramanga, and the Migratory Management Board in Santander, spaces created for a response. While it is true that there is essential harmonious work for healthcare, which translates into the institutional incorporation of these good practices by local authorities, this is far from confirming that local governments present a serious commitment and a real political will through public policies to guarantee the right to health of the Venezuelan migrant population in the AMB. In fact, NGOs have stepped in to replace the State in the territory.

Healthcare problems have often been the motivation for leaving Venezuela and continue to be a serious problem to be solved for many Venezuelan migrants in the AMB. The protection of the health and well-being of the Venezuelan migrant population in the AMB lacks a clear political will, which has often hindered comprehensive healthcare at all stages of life.