Environmental and Social Systems Assessment (ESSA) Colombia: Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (P180534) October de 2023 World Bank Acronym AEE Aparatos Eléctricos y Electrónicos APS Atención Primaria de Salud AR Área de Resultados BM Banco Mundial CC Cambio Climático CIIU Código Industrial Internacional Uniforme CONPES Consejo Nacional de Política Económica y Social COTSA Consejos Territoriales de Salud Ambiental DANE Departamento Administrativo Nacional de Estadística DNP Departamento Nacional de Planeación EAPB Entidades Administradoras de Planes de Beneficios EPS Entidades de Promoción de la Salud EPSI Entidades de Promoción de la Salud Indígena ESSA Evaluación de los Sistemas Sociales y Ambientales ESE Empresas Sociales del Estado FMAM Fondo para el Medio Ambiente Mundial GoCo Gobierno de Colombia IEC Información, Educación y Comunicación IPS Instituciones Prestadoras de Servicios de Salud MADS Ministerio de Ambiente y Desarrollo Sostenible MIE Ministerio de Igualdad y Equidad MSPS Ministerio de Salud y Protección Social OPS Organización Panamericana de la Salud PB Principio Básico PBS Plan de Beneficios en Salud PforR Programa por Resultados PGIRHS Plan de Gestión Integral de Residuos Hospitalarios y Similares PND Plan Nacional de Desarrollo POT Planes de Ordenamiento Territorial PQRSD Peticiones, Quejas, Reclamos, Sugerencias y Denuncias RAEE Residuos de Aparatos Eléctricos y Electrónicos RES Residuos de Establecimientos de Salud RESPEL Residuos Peligrosos SGSSS Sistema General de Seguridad Social en Salud SISBEN Sistema de Identificación de Potenciales Beneficiarios de Programas Sociales SNGRD Sistema Nacional de Gestión del Riesgo de Desastres de Colombia. SISPI Sistema Indígena de Salud Propia Intercultural UNGRD Unidad de Gestión del Riesgo de Desastres 2 Contents EXECUTIVE SUMMARY ........................................................................................................ 5 BACKGROUND ........................................................................................................................ 8 1.1. Context ............................................................................................................................ 8 1.1.1 The state context........................................................................................................ 8 1.1.2 The Context of the Health Sector in Colombia ....................................................... 10 DESCRIPTION OF THE PROGRAM BY RESULTS FOR IMPROVED ACCESS TO EFFECTIVE HEALTH SERVICES FOR THE VULNERABLE AND ENHANCED HEALTH SYSTEM RESILIENCE. ......................................................................................................... 16 2.1 Program objectives ......................................................................................................... 18 2.2 Disbursement Linked Indicator (DLI)............................................................................ 19 2.3 Program Scope ............................................................................................................... 21 2.4 Geographical scope of the Program ............................................................................... 21 2.5 Description of the borrower's past experience with the World Bank in the health sector. .............................................................................................................................................. 22 DESCRIPTION OF THE SOCIAL AND ENVIRONMENTAL SYSTEMS APPLICABLE TO THE PROGRAM ..................................................................................................................... 22 3.1 Key Program implementation agencies and partners ..................................................... 22 3.1.1 The key areas and partners in social participation .................................................. 23 3.1.2 The key areas and environmental partners .............................................................. 30 3.1.3 Laws, regulations and environmental and social policies. ...................................... 32 PROGRAM CAPACITY AND PERFORMANCE ASSESSMENT ...................................... 42 4.1 Capabilities to implement the program's environmental and social management system. .............................................................................................................................................. 42 ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT (ESSA) ........................... 44 5.1 Introduction to the ESSA and general description. ........................................................ 44 5.2 ESSA methodology ........................................................................................................ 45 ENVIRONMENTAL AND SOCIAL RISK SCORES ............................................................ 46 6.1 Risks and social considerations associated with the Program. ....................................... 46 Recommendations on social aspects. ................................................................................... 52 6.2 Environmental risks and considerations associated with the Program .......................... 55 6.3 Climate Change (CC), extreme weather events and disaster risks ................................. 58 6.4 Gap análisis. ................................................................................................................... 67 PROGRAM ACTION PLAN (PAP)........................................................................................ 72 CONSULTATION PROCEEDINGS ...................................................................................... 81 ANNEX A - ESSA Consultations Report ................................................................................ 83 3 4 EXECUTIVE SUMMARY The World Bank (WB), in accordance with World Bank Policy on Program for Results Financing OPS 5.04-POL 107, carried out an Environmental and Social Systems Assessment (ESSA) of the country’s health system as applied to the Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience (henceforth the “Program”), under a PforR financing mechanism. The scope of the ESSA was to evaluate the systems promoting environmental and social sustainability, and assess their ability to: avoid, minimize or mitigate the potentially adverse impacts associated with the Program affecting natural habitats and physical cultural resources; protect patients and caregivers and worker safety; consider issues related to indigenous peoples, ethnic groups, underserved groups and migrants; and avoid social conflict. In addition, it identified the actions required to improve and strengthen national systems and mitigate potential environmental and social risks. The specific objectives of the ESSA purport to: (a) identify the potential benefits, risks, and environmental and social impacts applicable to the Program's interventions; (b) review the policy and legal framework related to managing the environmental and social impacts of the Program's interventions; (c) assess the institutional capacity for environmental and social management systems within the Program’s system; (d) evaluate the performance of the Program’s system with respect to the core principles of the PforR instrument and identify gaps, if any; and (e) submit recommendations and a Program Action Plan (PAP) to address gaps and improve performance during program implementation. The Program (PforR) will be structured around two Results Areas (RA) that are aligned with the National Development Plan (PND Spanish acronym) 2022-2026 "Colombia world power of life". The PND, sanctioned by Law 2294 of May 19, 2023. AR 1 is intended to improve effective access to health services for vulnerable people and AR 2 to improve the resilience of the health system in the face of climate change and threats to public health. The first AR supports actions to strengthen primary health care under a broad and multidisciplinary approach that includes physical and mental health. It addresses early-stage interventions with a focus on vulnerable groups, promoting screening, monitoring, and access to treatment for child malnutrition, maternal mortality, breast cancer, and HIV, with a focus on prioritized territories and vulnerable populations such as migrants. The second RA supports actions to build the resilience of the health system in the face of future pandemics and climate change. This focus area supports the strengthening of public health infrastructure and surveillance, on the one hand, and efforts to mitigate and adapt to the impact of climate change. Regarding the environmental component, the World Health Organization (WHO) indicates that the waste generated by the activities of health establishments, from contaminated needles, sharp elements, chemical, cytotoxic and radioactive residues, have a higher potential risk of produce injuries and infections than any other type of waste and its improper handling can cause serious consequences for public health and an appreciable impact on the environment. The main environmental risks and impacts of the Program, as well as the focus of the ESSA, are centered on (i) the management of Health Care Waste (HCW); (ii) The potential generation of Waste Electrical and Electronic Equipment (WEEE), motivated by the dismantling generated by the scheduled obsolescence of the electronic equipment necessary for the effective and efficient provision of quality health services; and (iii) The impacts of natural disasters and those caused by the effects of Climate Change (CC) both due to their direct effects to interfere with the dynamics of the provision of health systems, such as interrupting telecommunications services or impacting on the health of healthcare workers. The environmental risk was considered "moderate" because no constructions will be carried out, nor will areas associated with cultural heritage be intervened, and their actions and investments are carried 5 out in the footprint of health establishments without affecting biodiversity protection areas. However, possible (smaller) increases in the management of HCWs may be due to improvements in the quality of benefits, and early diagnosis and treatment of diseases such as cancer, during the initial stages (until such medical practices are commonplace in the universe of benefits). In addition, the potential generation of WEEE, because of the implementation of the Program, contributes to the risk rating. The operational phase may present certain risks and impacts associated with the management of intramural medical waste (segregation or selective collection by category, packaging, and temporary storage), and its transportation, treatment and final disposal of hazardous medical waste. If not managed well, these activities will pose a threat to the environment, public health, and safety at work. Colombia's institutional setup has the potential to develop the capacity required to face potential environmental risks and challenges. Dispersed populations present disadvantages for the final treatment of HCW and WEEE, linked to operational difficulties. The ESSA confirms that the current system to manage the environmental aspects of the Program is reasonably covered by regulations and institutional capacities, where the Ministry of Health and Social Protection (MSPS Spanish acronym) establishes the governing policies. Intramural compliance of the HCW management, under the responsibility of each establishment, and extramural management is regulated by the environmental authority of each jurisdiction. Said management has an acceptable compliance for the World Bank and has shown progress in recent years during the implementation of the previous program for results of the health system1 and the improvements implemented by the MSPS in terms of Inspection, Surveillance and Control (IVC Spanish acronym) at the territorial level, training, and censuses of health establishments. The legal framework regulates the environmental and sanitary comprehensive management of waste generated in health care and other activities. The legal framework regulates the environmental and sanitary comprehensive management of waste generated in health care and other activities. At the subnational levels, the Regional Environmental Authorities (Autonomous Regional and Sustainable Development Corporations, and Urban Environmental Authorities) are responsible for the management of HCW and WEEE in their jurisdictions, with differences between them in the possibility of management operations and the dispersal of territories. The provisions of the existing environmental legal and regulatory framework are adequate and require enabling institutional and technical capacity to comply with them. The intended destinations of WEEE as post-consumer materials within hospital management are not clearly established. From the Social point of view, ESSA concludes that the Program will contribute, especially for the most vulnerable populations, to generating benefits through the expansion of access and use of efficient and quality health services by the affiliated to the General System of Social Security in Health (SGSSS Spanish acronym), both the contributory and the subsidized regime. Among the key social problems that were identified are inequalities in health care services in remote districts or those linked to ethnic or indigenous minorities that are reflected in the differentiated affectation that can be identified when reviewing statistics on diseases such as child malnutrition and maternal and child mortality. Also, the gender analyses and the situation of migrants or returnees show certain health needs that need to be addressed, and towards which the actions proposed in the Program and its indicators are oriented. The general social risk was classified as "moderate" due to possible errors in the selection of the most vulnerable, due to reasons such as few resources for the development of strategies or territorial systems for their identification and monitoring; weakness in the application of tools unified to target and prioritize the population, restricted access for geographic and security reasons to ethnic communities, and lack of data to track people who do not yet have their immigration status defined. This will be mitigated by strengthening the intercultural approach of the health, gender and diversity, strengthening 1 Support Program for the financial sustainability of the Colombian health system (P169866) 6 information systems for monitoring the prioritized population and a solid communication strategy, stakeholder participation and attention to complaints and claims (PQRS Acronym in Spanish for Petitions, Complaints, Claims and Suggestions) of the MSPS. In the other hand, there is no land acquisition, resettlement, or loss of access to natural resources. The results of the ESSA confirm that the current systems of the Government of Colombia to manage the environmental and social aspects of the Program have solid foundations in a robust legal framework to provide equitable and inclusive access to health services under the new challenges. Additionally, the ESSA findings identified a general level of implementation and satisfactory compliance with the current regulations for the management of medical waste, although it is not possible to verify homogeneity in the management of HCW and WEEE at Departmental levels, especially in those with unfavorable socioeconomic indicators. To maximize the benefits of the Program, ESSA proposes 4 social actions and 4 environmental actions as part of the Program Action Plan: The social actions contemplated in an Action Plan on the most significant capacity gaps refer to: i) strengthening the adoption of the intercultural approach to health that has been working in a participatory manner with the country's indigenous peoples and ethnic communities; ii) the unification of the information tools for the management of information derived from the action of basic health teams, which will make it possible to prioritize and plan health care effectively within the territories; iii) technical assistance for the development of territorial capacities for public health management, seeking to strengthen the management of public health priorities, including the social and gender determinants that affect the health situation of the territory; and, iv) Information, Education and Communication (IEC) strategies for inclusive and territorially relevant health, which allow populations to dialogue with health sector entities about the benefits of this Program and freely present their concerns and proposals. The environmental actions contemplated in an Action Plan on the gaps identified are: v) Future scenarios for the management of HCW (Its purpose is to establish medium-term horizons in the face of potential stress situations in the health system, avoiding the generation of environmental and social risks in such circumstances); vi) Plan or registration program on the obsolescence of Electrical and Electronic Equipment (EEE) of health centers for post-consumer recovery and comprehensive management of WEEE; vii) Adaptation to CC of the health system (Includes the design of an Early Warning System (SAT Spanish acronym) associated with climate variability, includes the design of a tool for monitoring and prediction of Vector-Borne Diseases); analysis of information on climate-sensitive health events and support public health surveillance actions for the Territorial Health Directorates (DTS Spanish acronym); the design of a tool for the analysis of the vulnerability of the Institutions Providers of health services in the public sector to climate variability and change); and viii) Mitigation of Climate Change. This activity contributes to establishing the baseline for the generation of Greenhouse Gases (GHG) of the Health System and to preparing a guide to guide and encourage establishments in the adoption of mitigation measures. 7 BACKGROUND 1.1. Context 1.1.1 The state context 1 Colombia is a decentralized unitary Republic, with autonomy of its territorial entities, democratic, participatory, and pluralistic (National Constitution of 1991). It implements an administrative decentralization as part of the development policies carried out by the national government, through which a large part of the State administration is shared between the administrative entities of the central and territorial levels. These entities, organized hierarchically, are the departments, municipalities, and districts. Other special divisions are indigenous territorial entities and collective territories. The Departments are headed by a governor in charge of the autonomous administration of the resources granted by the State. They have autonomy in handling matters related to their jurisdiction and function as coordination entities between the nation and the municipalities. In Colombia there are 32 departmental units, and a Capital District (Bogotá), 1,102 Municipalities and 19 non-municipalized areas. The Municipalities are administratively and legally organized territorial entities, they are directed by a mayor. The Districts are territorial entities with a special administration. Due to their national importance, in Colombia the cities of Bogotá, Cartagena, Barranquilla, Santa Marta and Buenaventura carry this badge. The Indigenous Territorial Entities are indigenous local governments that occupy some departmental or municipal portion. For their part, the Collective Territories have been awarded to the Afro-Colombian population that predominates in the Pacific zone, allowing them to organize themselves in community and business associations. 2 Colombia is among the countries with upper middle income. Regarding the Human Development Index (HDI), it is among the countries with a high index of 0.752 (UNDP 2021), although it suffered a drop compared to pre-pandemic values. However, not all the indicators that are part of the HDI had the same behavior. Mainly, the drop in the HDI is explained by the decrease in life expectancy at birth, which went from 76.8 years in 2019 to 72.8 years in 2021, which implies a loss. The 2018 National Population and Housing Census indicates that 45.5 million inhabitants reside in Colombia. 3 Inequalities in Colombia are high and persistent. Income inequality in Colombia is one of the highest in the world, the highest among the Organization for Economic Co-operation and Development (OECD) countries, and the second highest among eighteen Latin American and Caribbean (LAC) countries). Inequality increased further with the shock of COVID-19, with the Gini coefficient rising from 0.517 in 2018 (before the upward trend began) to a peak of 0.544 in 2020. While the economic recovery in 2021 reversed the income inequality, the Gini coefficient remains very high (at 0.523). Furthermore, the recovery did not reach all groups: while the national poverty rate fell to 39.3 percent in 2021, from 42.5 in 2020, rural poverty increased, the poverty rate reduced only marginally for Venezuelan migrants and remained the same for Afro-Colombians and indigenous people, groups with significantly higher poverty rates before the pandemic. There are large disparities in key development outcomes, including effective access to health. Specifically, differences in access to quality Primary Health Care (PHC) services, including prenatal and maternal care, create significant inequalities in effective health coverage and have a negative impact on population health outcomes. Colombia ranks low among OECD countries in key population health indicators, such as maternal mortality, infant mortality due to malnutrition, and breast cancer survival, a direct reflection of difficulties in accessing health services effective for vulnerable population. 8 4 The Government of Colombia puts equity at the center of its reform agenda. The new Government began its term in August 2022, having proposed a political agenda focused on social reforms to face the high levels of inequality and exclusion in the country. In this sense, the National Development Plan 2022-20262 aims to lay the foundations to overcome the inequities and exclusions that have led to high levels of inequality and advance the peace process, a path of environmentally sustainable development and a transformation production that leverages the adoption of technology in agriculture, transportation infrastructure, and greater investment in science, technology, and innovation. 5 Colombia is highly vulnerable to climate change and geophysical hazards mainly due to its diverse geographic features and due to its socioeconomic context. Most of the population is concentrated in the mountainous region along the Andes, which is prone to landslides and flooding, with floods accounting for 45 percent and landslides 19 percent of total natural hazards. in the country. In addition, the loss of glaciers due to the increase in temperatures affects the availability of water and increases the occurrence of landslides and floods due to surface runoff from melting ice. On the other hand, droughts are also frequent in the country, which have increased by around 2.2 times compared to previous years, in turn affecting the country's agricultural production. The country is also affected by the El Niño Southern Oscillation, which causes abnormal weather conditions, such as more intense droughts or extreme rainfall patterns. Additionally, communities along the Caribbean and Pacific coasts are at risk from sea level rise, storm surge, and temperature extremes. The impacts of natural disasters and those motivated by the effects of Climate Change (CC) both due to their direct effects to interfere with the dynamics of the provision of health systems, such as interrupting telecommunications services or impacting on the health of health workers alter access to health as well as its quality. 6 Colombia has 2.5 million migrants settled in the Single Registry of Venezuelan Migrants (RUMV Spanish acronym) 3. The influx of Venezuelan and Colombian migrants who returned and emigrated to Venezuela in the 1970s is generating significant fiscal and economic pressures and represents a significant burden for institutions, service provision systems, and the labor market, particularly in the receiving areas. Contrary to traditional migratory processes, the current influx, which increased considerably in 2018, and then in 2022, and is characterized by a very rapid arrival of people and a relatively high proportion in conditions of socioeconomic vulnerability. In the short term, the migration phenomenon may affect the significant progress made in reducing poverty and could have a negative impact on local labor markets due to the difficulties migrants face in entering the formal labor market, the possible increase in employment informal and underemployment, the increase in the labor supply, which can decrease real wages. Demands for health, housing, education, and water and basic sanitation services have increased rapidly and are concentrated in areas characterized by pre-existing deficits in the provision of services. In addition, due to the growth of vulnerable populations, the demand for social protection services in receiving areas tends to exceed existing capacities. The short-term fiscal impact of the immigration process is challenging. According to estimates made by the Interagency Group on Mixed Migration Flows (GIFMM in its Spanish acronym) and the National Government, presented at the launch of the Colombia Chapter of the Regional Response Plan for Refugees and Migrants 2023-2024 (RMRP in its Spanish acronym), 2 Gobierno de Colombia (2023). Colombia, Potencia Mundial de la Vida. 2022-2026. https://www.dnp.gov.co/Paginas/plan-nacional-de-desarrollo-2023-2026.aspx 3 2.508.242 Migrantes con RUMV finalizado; 1.749.945 con Usuario y Contraseña RUMV; 2.382.010 con Encuesta de Caracterización Finalizada Fuente: Migración Colombia (Fecha de Consulta 30-4-23). Distribución de Venezolanos en Colombia Corte a 28 de febrero de 2022. Migración Colombia: 2.477.588 Total Venezolanos, donde 333.806 son Regulares, Personas que se benefician del Estatuto Temporal de Protección para Migrantes Venezolanos (ETPV), 1.231.675 se encuentran en “proceso de regularización”; 617.069 están “Autorizados”, 295.038 son “Irregulares”. 9 by 2023. They will need resources of USD 664.87 million to serve 1.6 million Venezuelan migrants and refugees, Colombian returnees from Venezuela, and local host communities (provided by International NGOs, National NGOs/CSOs, Others, and UN Agencies). In addition, in the medium term, investments in infrastructure would be necessary to expand the network of services in the receiving areas, particularly in education, health, and water and sanitation. 1.1.2 The Context of the Health Sector in Colombia 7 The Colombian General System of Social Security in Health (SGSSS) provides almost universal health insurance coverage and a high level of financial protection to its beneficiaries. Colombia has achieved exemplary levels of coverage with more than 98 percent of the population insured in 2022, while maintaining low out-of-pocket spending levels at around 15 percent of current health spending, one of the lowest levels in the region. However, the SGSSS currently faces important challenges that require urgent attention to guarantee effective access to health services for its most vulnerable population. The main challenges facing the health sector in Colombia include: (i) inequal effective access to health services, especially for the subsidized population; (ii) a rapid aging of the population with greater demand for services and a high burden of non-communicable diseases, especially the chronic ones; (iii) large gaps in the provision of mental health care with limited capacity to meet the needs derived from six decades of internal conflict and the pandemic; (iv) additional pressures on the sector due to a massive influx of Venezuelan migrants to Colombia; (v) inadequate availability and distribution of health professionals; (vi) performance management systems focused on cost containment rather than on quality of care; (vii) gaps in public health surveillance, zoonotic diseases, and risk communication; and (viii) limited efforts to date by the health sector to take mitigation and adaptation actions related to the impact of climate change in a highly vulnerable context. 8 Despite important progress in achieving universal health coverage and reducing out-of-pocket payments, significant gaps remain in access to effective health services, especially in remote and rural areas. Barriers in access to effective health services for vulnerable populations have remained stubbornly high over the last decade and relate to: (i) quality of care, including cultural competency and other administrative barriers; (ii) physical access to care for the most vulnerable populations living in rural and remote areas of the country (due in part to problems related to the uneven distribution of health infrastructure and human resources for health at the subnational level); and (iii) cost-related barriers. Geographic and financial barriers mainly affect people in remote and rural areas where communication is difficult and transportation costly. Departments bordering Venezuela are particularly affected by problems related to effective access to health services because: (i) they are receiving significant numbers of pendular and non-pendular migrants from Venezuela; (ii) they are generally poorer than other departments; and (iii) they tend to be unattractive to private insurers and providers. 9 Colombians regularly resort to the constitutional court to resolve problems of lack of access to care through the “tutela” mechanism. The tutela is a mechanism through which constitutional judges can compel health insurance companies or health care providers to provide services to patients within a reasonable period of time. The high volume of tutelas experienced in the health sector over the last decade (88,000 tutelas in 2021 out of a total of 450,000 tutelas) is a strong indicator of the extent to which Colombians experience barriers to effective access to health services. More than seventy percent of the tutelas filed in 2021 were accepted by the constitutional court, pointing to their relevance and urgency. The most frequent tutela requests were related to access to health services (74.3 percent), followed by access to medicines (16.4 percent). A high percentage of the complaints filed as tutelas are due to the lack of integration and continuity of services. Fragmentation of care is particularly acute in the case of non-communicable disease management, including chronic diseases. 10 In addition, significant movements of affiliates between health insurance companies (Entidad Promotora de Salud, EPS -Spanish acronym-) due to the liquidation of several EPSs and limited interoperability of electronic health records negatively affect continuity of care 10 Poor outcomes in the prevention and control of noncommunicable diseases such as cancer and cardiovascular disease, maternal and infant mortality, and infectious diseases such as HIV are common. The vulnerable population, defined as the subsidized population (which represents close to half of the entire insured population), experiences worse effective access to health services. Key population health indicators, such as maternal mortality or child mortality due to malnutrition, are not on track to achieve the Sustainable Development Goals by 2030 and rank second or worst among OECD countries. In 2020, the maternal mortality rate for Colombia was estimated at 75 per 100,000 live births, far from reaching the goal of 32 per 100,000 live births established in the National Development Plan, while infant mortality under five years of age per malnutrition remained high at 7.8 deaths. malnutrition for every 100,000 children. Fewer than one in two women with breast cancer had their cancer detected early enough that treatment could be started early enough to maximize survival from the disease. 11 Breast cancer is the leading cause of death for women in Colombia and the most prevalent type of cancer among women, and data suggest this is expected to continue unless immediate action is taken 4. Although all cancer-related mortality rates in Colombia have been increasing, between 2010 and 2017 breast cancer mortality increased the most, with an increase of 2.87 x 100,000. The situation worsens with the pandemic. Without concrete actions, the WHO estimates that by 2040 there will be a 49.1% increase in its incidence (from an estimated 15,509 new diagnoses in 2020 to an estimated 23,100 new cases in 2040) and a 66.6% increase in the mortality (ibíd). 12 There are important differences in the screening, early detection and opportunity for both diagnosis and treatment of breast cancer for women according to the health regime to which they are affiliated, with worse results for vulnerable women in the subsidized regime. In 2018, the average number of days from the clinical perception of the patient's symptoms to diagnosis was between 15 and 29 days for women in the contributory regime and double the time for women in the subsidized regime (between 30 and 59 days). Likewise, the average time between diagnosis and the start of treatment was 30 to 59 days for women in the contributory health regime and more than 90 days for those in the subsidized regime. While the numbers have improved somewhat since then, the most recent data from the High Cost Account show that the median number of days is 25 days between detection and diagnosis and 53 days between diagnosis and treatment differences with important among women affiliated with the contributory and subsidized regime persist5. 13 The Ten-Year Plan for the control of cancer in Colombia, 2012-2022, set the goal of implementing a National Cancer Early Detection Program that included breast cancer, through early diagnosis, starting from a goal of 60% with a baseline from 31% of 2008 there are still no evaluation reports on its implementation; In any case, the program included: coverage of screening mammography (70% in women between 50 and 69 years of age) and the guarantee of timely access to diagnostic confirmation and treatment in 100% of women with reported mammograms. 14 In Colombia, in accordance with the agenda of the Sustainable Development Goals (SDG) for 2030, it was set as a target goal that in 93% of births mothers attended 4 or more prenatal check-ups during their gestation, compared to the total number of births alive (Departamento Nacional de Planeación, 2018). According to the WHO antenatal care model, the recommended 4 WHO. Globocan - Cancer Today. 2020. 5 Fondo Colombiano de Enfermedades de Alto Costo, Cuenta de Alto Costo (CAC). Situación del cáncer en la población adulta atendida en el SGSSS de Colombia, 2021; Bogotá, D. C. 2022. 11 number of antenatal visits for a mother is eight (WHO, 2016). The percentage of births in Colombia with mothers who received less than four prenatal consultations in 2022pr was 15.7%, a figure that is almost three percentage points below that reported in 2021. Births of mothers who receive less than eight consultations prenatal services in 2022pr also recorded a reduction compared to 2021, going from 72.4% in 2021 to 68.7% in 2022pr. In contrast, the percentage of live births in which the mother receives eight or more prenatal consultations increases, from 27.2% in 2021 to 31.3% in 2022pr. In 2022pr, Vichada, Vaupés, Guainía, Chocó and Amazonas are the departments with the highest percentage of live births, children of mothers who do not receive prenatal consultations. In the entire series, the highest percentage of births of this type, by department of residence of the mother, occurred in Vichada in 2020, when close to half (47.9%) of all live births reported to mothers who reside in that department, do not receive prenatal consultations. Vichada in 2022pr remains with the highest percentage of mothers who do not receive prenatal check-ups with 37.1%. In 2022pr, 25 of the 32 departments and the district of Bogotá, show a decrease in the percentage of births to mothers who did not receive prenatal consultations, compared to 2021. Caldas stands out as the department with the lowest percentage of births to mothers who do not receive controls throughout the series. In 2022pr and compared to 2021, the percentage of births to mothers who did not receive prenatal check-ups decreased in all five-year age groups of the mother. In the case of mothers who receive between 1 and 3 prenatal check-ups, all five-year age groups report lower percentages compared to the previous year, except mothers between 10 and 14 years of age. In 2022pr, mothers between the ages of 10 and 14 continue to report the highest percentages of not receiving prenatal check-ups or receiving between 1 and 3. In 2022pr, live births recognized by their parents as indigenous report the highest percentage of births in those in which the mother does not receive prenatal check-ups, this despite the reduction of 5.9 percentage points observed in this percentage between 2021 and 2022, going from 25.9% to 20.0%, respectively. Live births recognized by their parents as Palenqueros from San Basilio and Raizales from the San Andrés archipelago are the only ones to report increases compared to the previous year in the percentage of births to mothers who did not receive prenatal check-ups.6 Graph N° 01 Percentage of live births in which the mother did not receive prenatal consultations during the gestation period and ethnicity. Whole, national. Years 2018-2022pr Source: National Administrative Department of Statistics (DANE for Spanish acronym) – Vital Statistics. pr: Preliminary figures Technical Bulletin Cumulative year 2022pr, IV quarter 2022pr and running year 2023pr 6 DANE Estadísticas Vitales (EEVV) Año acumulado 2022pr, IV trimestre 2022pr y año corrido 2023pr 12 15 For moderate and severe acute malnutrition in children under 5 years of age for epidemiological week 16 of 2023 (April 16 to 22), 7,027 accumulated cases7 have been reported annually in Colombia. In this epidemiological week, 482 cases were reported, with the highest number of cases in Bogotá, Antioquia and La Guajira. The accumulated national prevalence of the last 52 epidemiological weeks (17 of 2022 to 16 of 2023) is 0.55 cases per 100 children under 5 years of age. The territorial entities with the highest prevalence are Vichada (1.86); La Guajira (1.86); Chocó (1.60) and Casanare (1.08). 72.4% of the cases were classified as moderate acute malnutrition and 27.6% as severe acute malnutrition; 9.7% of the cases in older than 6 months were reported with an arm circumference of less than 11.5 cm. The highest proportion of cases of acute malnutrition was reported in children under 1 year of age (32.9%); followed by the 1-year group (27.9%). According to the area of residence, the highest percentage is reported in residents in municipal capitals at 68.3%. For epidemiological week 16 of 2023, compared to the historical average, significant differences were observed in the notification of cases in Antioquia, La Guajira, Chocó, Bolívar, Risaralda, Atlántico, Cartagena, Caldas, and Buenaventura. No statistically significant variations were observed in the remaining territorial entities. In municipalities with more than 100,000 inhabitants for epidemiological week 16 of 2023, compared to the historical average, significant differences were observed in the notification of cases in Medellín, Riohacha, Tunja, Arauca, Bucaramanga, Quibdó, Armenia and Manizales. No statistically significant variations were observed in the remaining cities. The information is notified weekly by the territorial entities (ET) to the National Institute of Health (INS) through the Public Health Surveillance System (Sivigila). With these figures constantly increasing, surely increased in 2020 due to the Covid 19 pandemic, it is not surprising that the FAO report of May 2022 included Colombia among the 20 countries that it calls hunger hotspots in the global context. As of Law 1804 of 2016, a State policy for the Comprehensive Development of Early Childhood is established for the first time, including an important effort for the attention directed to children between 0 and 5 years of age, considering it is established that the Adequate nutrition is a preponderant factor for its integral development. In the National Development Plan 2022-2026, chapter 3, "Human Right to Food" proposes to stop a mortality rate due to malnutrition in children under 5 years of age (for every 100,000 children under 5 years of age) of 8.0 in 2021 to 3.37 at the end of the four-year period. 16 According to data from the Observatory of Human Talent in Health (OHTH) of the MSPS, the estimated number of health professionals for 2020 was 406,833. There are 374,741 assistants, 962 professional technicians, and 30,604 registered technologists. The estimated density of medical and nursing professionals is 39.57 per 10,000 population nationwide and there are approximately 24.06 physicians per 10,000 population8 (still below OECD rates of more than 3 physicians per 1,000 population). The departments where a higher density is observed are Bogotá, D.C. (45.80), Archipelago of San Andrés, Providencia, and Santa Catalina (33.65), Atlántico (30.21), Valle del Cauca (27.8), Risaralda (27.41) and Antioquia (25.17); On the other hand, Chocó (8.64) and Vaupés (5.40) are the departments with the lowest density. Nationwide, for every 10,000 inhabitants, there are 1.93 nutrition and dietetics professionals. 17 Neoplasms are the third cause of death in Colombia. Between 2005 and 2019, malignant tumors of the digestive organs and peritoneum, except for the stomach and colon, were the leading cause of mortality in men and women (14.96% of deaths). Prostate cancer is the second leading cause of mortality in men. Mortality from breast cancer has had an increasing trend from 2012 to 2019. For the first year the mortality rate from this cause was 10.55 per 100,000 women, while in 2019 it was 7 Casos acumulados de SE 17 de 2022 a SE 16 de 2023 Fuente: Boletín Epidemiológico Semanal Semana epidemiológica 16 del 16 al 22 de abril de 2023. INS-MSPS 8 Análisis de Situación de Salud -ASIS- 2021 Dirección de Epidemiología y Demografía, Ministerio de Salud y Protección Social 13 14.28 per 100,000 women. The departments of Atlántico and Valle were the ones with the highest mortality from this cause in 2019, although the differences were not statistically significant. The trend of mortality from cervical cancer in the country has fluctuated from 2012 to 2019. For 2012, the mortality rate was 6.45 x 100,000 women and for 2019, 7.2 x 100,000 women. The departments with the highest rate for 2019 were Arauca and Guaviare (map 44), both with a higher rate than the national one, being statistically significant9. 18 Mortality from communicable diseases has followed a downward trend. Acute respiratory diseases are the leading cause of death within the group, between 2005 and 2019 they produced 52.8% (113,896) of deaths. For its part, HIV (AIDS) was attributed 16.91% (36,453) of deaths from communicable diseases and constitutes the second most frequent cause of death. The frequency of mortality due to sub-causes in this group is similar between the sexes10. 19 Mortality from conditions of the perinatal period has remained decreasing and constant. Between 2005 and 2019, 44.1% (29,051) of deaths from these causes were attributed to respiratory disorders specific to the perinatal period. The subgroup of the rest of certain conditions originating in the perinatal period (residual subgroup that includes the following diagnostic codes: P00-P96, P08, P29, P35, P37-P96) caused 22.7% (14,953) of deaths, followed by of bacterial sepsis of the newborn, with 16.9% (11,142). The behavior between the sexes is similar11. 20 In Colombia, the maternal mortality ratio has tended to decrease over time. Between 2008 and 2011 the indicator fluctuated between 60.5 and 69.1 and subsequently between 2011 and 2019 there were 18.4 fewer deaths per 100,000 live births. Throughout the period the reduction was 27.7%, which translates into 19.4 fewer deaths per 100,000 live births 12 . Since 2018, Colombia has reinforced its strategies to reduce maternal mortality by issuing Conpes 3918 dated March 15, 2018, aimed at strategies for the implementation of the SDGs; it is proposed to reach 51.0 cases of maternal mortality that same year and systematically reduce to 32.0 maternal deaths per 100,000 live births in 2030; however, in 2020, 587 maternal deaths were reported, of which 403 were classified as early maternal deaths, 150 late maternal deaths, and 34 maternal deaths due to coincidental causes; there is an increase of 34.3% in the number of cases of maternal mortality when compared to the year 2019. In the National Development Plan 2022-2026, objective 3 of Health and Well-being exposes a maternal mortality ratio at 42 days (by per 100,000 live births) of 83.2 in 2021 and it is proposed to reach the goal of 32 at the end of the four-year period. Additionally, the Colombian State has perfected an important planning instrument that is part of the 2022-2031 Ten-Year Public Health Plan: the Acceleration Plan for the reduction of maternal mortality, whose objective is: "Reduce maternal mortality through of the implementation of sectoral and intersectoral strategic and operational actions, adopting a gender and intercultural approach, in the prioritized territorial entities that meet the targeting criteria”. 21 The figures reveal that Vichada, Vaupés, Guainía and Amazonas, where a significant proportion of the country's indigenous peoples reside, present a higher percentage of live births to mothers who did not receive prenatal consultations. However, it must be taken into account that the main instrument to contain maternal deaths is the Acceleration Plan for the reduction of maternal mortality and this does not prioritize municipalities in the mostly rural departments such as Arauca, Casanare, Vichada, Meta, Guanía, Guaviare, Caquetá, Vaupés, Putumayo and Amazonas in which the supply of health services has historically been deficient, and that, according to the national 9 Análisis de Situación de Salud (ASIS) Colombia, 2021 10 Análisis de Situación de Salud (ASIS) Colombia, 2021 11 Análisis de Situación de Salud (ASIS) Colombia, 2021 12 Análisis de Situación de Salud (ASIS) Colombia, 2021 14 epidemiological situation, five of these departments Guainía, Vichada, Amazonas, Vaupés and Putumayo presented the mortality ratios highest maternal with more than 100 cases per 100,000 live births in 2020. 22 Indigenous peoples present less favorable indicators in terms of morbidity and mortality than the rest of the population. The infant mortality rate, in all ethnic groups, presents a higher rate than in the national total and then in the rest of the population. The highest rate of infant mortality (by ethnicity) is shown by the Rom peoples, while the palenquero and indigenous groups occupy the second and third place respectively, with rates that are equivalent to more than three times the national rate. On the other hand, in the case of maternal mortality, the indicator for the indigenous and black and Afro-Colombian groups is equivalent to more than three times the indicator for the national total and around four times in relation to the rest of the population. 23 The access of children belonging to ethnic groups to comprehensive care is conditioned by the limited availability of services with a differential ethnic focus. Households with ethnicity face a deprivation in early childhood care, which includes simultaneous access to health, adequate nutrition, and initial education 1.45 times more than the general population. In the framework of comprehensive care in 2017, only 26% of children from 0 to 5 years old belonging to ethnic groups had access to comprehensive prioritized early childhood care. 24 Among the population victims of conflict, 3,732,110 people during the year 2020 accessed the provision of health services. In this same year, women represented 61% of the care provided in health institutions. Although the report "Analysis of the Health Situation" of the Ministry of Health (2021) does not reveal figures on the population of minor victims, it is important to highlight that for the year 2017, the single registry of victims of the conflict (Unidad para las Víctimas, 2017) found that 13.8% of the total victims were minors from ethnic communities. 25 Colombia has made progress in terms of coverage and social protection, but still faces challenges in terms of access and quality of health care. 26 Venezuelan migration puts pressure on the health system and challenges effective access for this population. Around 2.5 million Venezuelan migrants are regularizing their registration (see below). Venezuelan migrants often arrive in Colombia with nutritional deficiencies, incomplete vaccination schedules and, in general, with weakened immune systems, which has had a significant negative impact on the public health indicators of the migrant population and the receiving population, including infectious diseases. Affiliation of migrants to the SGSSS remains a challenge, especially for migrants living in rural and remote areas (as of August 2022, 924,391 migrants, or the equivalent of 37 percent of all migrants with Temporary Protection Status were insured, more than 75 percent of which are in the subsidized regime). Access: 27 The National Political Constitution of Colombia consecrates life as a fundamental right of Colombians, and in turn health, as a fundamental right guaranteed by the State. Article 49 of the Constitution determines that health services will be organized in a decentralized manner, by levels of care and with the participation of the community. Based on Law 100 of 1993, the General Social Security Health System (SGSSS) is created, from which the Health Benefits Plan (PBS) is generated, where individual services are organized according to the logic of an insurance market, whose objective is to provide health care to the population of the national territory. In this scheme, the Health Promotion Entities (EPS) are the insurers that link the population to the health system, 15 to guarantee the provision of the PBS through the Service Provider Institutions (IPS). Law 1751 of 2015, called the Statutory Health Law, consecrates health as an autonomous fundamental right, guarantees its provision, regulates it and establishes its protection mechanisms. Public spending on health is of the order of 5.3% of GDP, and in 2017, per capita public spending on health was $336 per inhabitant. By 2018, 94.44% of the country's population was affiliated with the SGSSS. 28 The Health Promotion Entities (EPS) are the insurers that associate the population with the health system, are responsible for registering taxpayers and collecting their contributions. Its basic function is to organize and guarantee, directly or indirectly, the provision of the mandatory health plan for members (Law 100, 1993). After affiliation with an EPS, any person must enroll in one of the IPSs, according to their choice, for outpatient care from the network of providers made up of the EPS. 29 The Health Benefits Plan (formerly Mandatory Health Plan) contains a set of health services that all EPSs, without exception, must provide to all people who are affiliated with the Social Security Health System by the Contributive Regime or Subsidized (Ministry of Social Protection, 2004). 30 Through the General System of Social Security in Health (SGSSS) the conditions of access to a Plan of Health Benefits are created for all the inhabitants of the national territory. This plan must allow the comprehensive protection of families from maternity and general illness, in the phases of promotion and promotion of health and for the prevention, diagnosis, treatment and rehabilitation of all pathologies, according to the intensity of use. and levels of attention and complexity. that are defined (Law 100, 1993). 31 The Contributive Regime is a set of rules that govern the linking of individuals and families with the SGSSS, through the payment of an individual and family contribution, or a previous economic contribution financed directly by the affiliate or in concurrence between the latter and their employer. (Law 100, 1993). The Subsidized Regime corresponds to a set of rules that govern the connection of individuals with the SGSSS, through the payment of a subsidized contribution, totally or partially, with fiscal or solidarity resources (Law 100, 1993). DESCRIPTION OF THE PROGRAM BY RESULTS FOR IMPROVED ACCESS TO EFFECTIVE HEALTH SERVICES FOR THE VULNERABLE AND ENHANCED HEALTH SYSTEM RESILIENCE. 32 The Program that will be supported by this PforR is part of the part of the National Development Plan - PND 2022-2026 "Colombia world power of life". The PND, sanctioned by Law 2294 of May 19, is an important instrument of public policy for the country. It is a long-term government plan that establishes the objectives, goals, and strategies to promote the economic, social, and environmental development of Colombia over a period of four years. The PND focuses on five transformative lines of action: (i) Territorial planning focused on water, (ii) Human Security and Social Justice, (iii) Human Right to Food, (iv) Productive transformation, internationalization, and climate action, and (v) regional convergence. The health sector is approached through different transformative lines, with a strong emphasis on the determinants of health, such as water and nutrition. Most of the health goals and interventions are incorporated into Chapter 3, Human security, and social justice. Article 150 establishes that the Administrator of the Resources of the General System of Social Security in Health (ADRES Spanish acronym), on behalf of the EPS and other Entities Obliged to Compensate, will make the direct transfer of the resources of the Units of Payment by Capitation (UPC Spanish acronym) of the contributory and subsidized regimes, 16 destined to the provision of health services, to the institutions and entities that provide said services and that test technologies included in the benefit plan, as well as to the providers. 33 The PND 2022-2026 specifically addresses the link between public health and climate change. In the General Part of the National Development Plan, Chapter 2. Human security and social justice, Catalyst C Expansion of capacities: more and better opportunities for the population to achieve their life projects, Health, environment and climate change, section B Health, environment and climate change: “Public health will contribute to the adaptation and mitigation of climate change through research, inspection, surveillance and control. Participation and social mobilization with a climate justice approach will be stimulated. Likewise, the country will adopt international standards for the protection of life and health and the intersectoral action plan of the Comprehensive Environmental Health Policy (PISA Spanish acronym) will be issued and implemented. To mitigate the risks that affect the health of the populations, it is necessary to: (i) establish technical health criteria in the licensing processes of productive and infrastructure projects, and (ii) define the environmental limits for the protection of the health of the populations. people and communities”. 34 The Ministry of Health will define the recognition percentages for Health Promotion Entities . It also establishes the recognition and liquidation of the nation's debts with the health sector related to technologies not covered by the UPC and the debts generated by the care of COVID-19. The Nation will finance the health of the unaffiliated migrant population. The promotion of the manufacture, semi-processing, sale, import of medicines, vaccines, devices, and other health technologies is encouraged. The Ministry of Health will work on updating its mental health policy and the implementation of special policies to support people deprived of liberty. In general terms, the proposed PND changes its focus and methodology, highlighting positive aspects such as interculturality and a perspective based on the determinants of health, including environmental protection. 35 The proposed PforR addresses effective access to health services, and the resilience of the health system in the face of Climate Change and future pandemics. It considers key aspects of the health system such as acute malnutrition of boys and girls, maternal and child mortality, early detection of breast cancer and improving the survival of women. Also, the proposed Program continues to support the sustainability and resilience of the health system through a focus on improving preparedness and response to future pandemics and adaptation and mitigation of the consequences of climate change. To do this, it is based on the lessons learned from the COVID-19 pandemic and the need to strengthen essential public health functions and specifically pandemic preparedness and response. In addition, it supports the commitments of the Colombian government to advance its adaptation and mitigation response to climate change, an important effort to improve the resilience of the health system. Finally, the proposed Program will guarantee that migrants affiliated with the SGSS have access to effective health services and obtain the care they need. 36 The proposed PforR will be structured around two result areas (RAs). (1) Improved access to effective health services for vulnerable populations and (2) Enhanced health system resilience to climate change and public health threats. The RAs complement one another to address key challenges in the health sector identified in the NDP: (i) inequality in access to effective health services, especially for the vulnerable population; (ii) fragmented health care models and (iii) health system vulnerabilities to face future public health threats and climate change related shocks. The Program promotes a holistic approach to health, recognizing that both access to effective health services and strong health system resilience are essential to improving the health of the population, especially for the vulnerable population. The Program focuses on vulnerable 17 populations; that is, populations covered under the subsidized regime of the SGSSS and targeted in the NDP (women, children under five, and migrants). 37 Results Area 1 (RA1): This results area aims to improve access to effective health services for the vulnerable population, defined as populations covered under the subsidized regime of the SGSSS and targeted in the NDP: women, children under five, and migrants. Furthermore, all related Result area’s DLIs and intermediate indicators are disaggregated by migration status of the vulnerable population. This results area would specifically support the following interventions to be implemented by the MSPS; (i) the implementation of a unified and integrated monitoring and follow-up system for children with acute malnutrition complemented with advanced malnutrition screening and community surveillance in priority departments; (ii) the implementation of an integrated care model with advanced use of telemedicine to reduce lethality of extreme morbidity cases in pregnant women; (iii) the implementation of an integrated care network for better targeting of women at risk of developing breast cancer to achieve higher levels of screening and improve early detection of the disease and the timeliness in initiation of treatment; (iv) the implementation of integrated strategies to achieve effective access to antiretroviral treatment and comprehensive care for regular migrants with HIV enrolled in the SGSSS subsidiary regime; and (v) the roll out of multidisciplinary PHC in territorial entities with focus on mental health interventions monitoring, and access to effective GBV survivor related services. 38 Results area 2 (RA2): This result area aims to enhance the ability of the health sector to adapt and mitigate consequences of climate change, and better prepare and respond to future public health threats. This results area related to the human security and social justice transformative line of the NDP. This results area would specifically support the following interventions to be implemented by the MSPS: (i) New infrastructure standards for health care providers including energy efficiency standards and adaptation and mitigation measures to climate change and developing a plan to support the transition of the health sector to low-carbon emissions; (ii) the development of a comprehensive climate change management plan for the health sector; and (iii) the implementation of new requirements to strengthen public health surveillance capacities at the subnational level through the development and implementation of integrated public health risk communication strategies incorporating a One Health approach, and climate change considerations. . 2.1 Program objectives 39 Program Development Objectives (PDO): The Program Development Objective is to improve access to effective health services for the vulnerable population and enhance the resilience of the health system to climate change and public health threats. The higher objective of the Program is to enhance access to effective health services with a focus on prevention and primary health care. PDO level result indicators 40 Two PDO indicators have been selected to measure progress in achieving the two RAs of the Program: (a)Improved timeliness in the initiation of treatment for breast cancer. The indicator is calculated as the time elapsed (measured in number of days) between the first histopathologic diagnostic report and the first treatment (chemotherapy, radiotherapy, or surgery). The indicator will be further disaggregated for vulnerable women in the subsidized regime. (b) Percentage of territorial entities that develop a Climate Change Adaptation Plan for Environmental Health. The indicator will be measured as the development and implementation of a risk communication plan 18 with a One Health and climate change approach in all sub-national territorial entities of the country, a total of 37 departments and districts. 2.2 Disbursement Linked Indicator (DLI) RA1: Improve effective access to health services for vulnerable populations. 41 DLI 1. Children under 5 years old with acute malnutrition identified, reported, and receiving treatment for acute malnutrition in prioritized departments. Supports the goal of improving access to effective health services for the vulnerable through the promotion of the screening, monitoring and access to treatment of infant malnutrition in prioritized territories that concentrate over 70% of the cases. Infant mortality due to acute malnutrition reached its highest level in the past five years—308 children younger than 5 died- with 21,400 children diagnosed for acute malnutrition. Acute malnutrition is concentrated in the poorest departments in the country. Yet, adequate, and timely diagnosis and treatment of acute malnutrition significantly reduces mortality rates and increases the survival of children who suffer from it. Activities under this indicator will not only support the provision of timely care to all children under 5 years of age with acute malnutrition to minimize their risk of mortality but will also strengthen the capacity in territories to report and provide adequate follow up and treatment. Malnutrition is climate sensitive in Colombia and this DLI intends to help the country reduce the vulnerability of populations to malnutrition, and therefore reduce the risks climate change can pose for malnutrition in the country. 42 DLI 2 Implementation of the integrated strategy to reduce maternal mortality in prioritized departments. supports the goal of improving access to effective health services for the vulnerable through the strengthen access to comprehensive health care for pregnant women and newborns in 19 prioritized territories with the highest maternal mortality rates. Maternal mortality in Colombia is high for the country income level, not on target to achieve the SDG and concentrated among the most vulnerable in poor territories such as Chocó, Arauca, La Guajira, Nariño, Magdalena, Norte de Santander, Bolívar, and Cauca. The MSPS is committed to accelerate the reduction of maternal mortality through the development and implementation of a system to monitor the cohort of pregnant women, ensure the early identification of potential risks and establish an integrated network of care to effectively address obstetric emergencies and reduce its fatalities. Activities supported under this indicator include capacity building and training for health professionals, the adoption of a gender and interculturally sensitive protocol of care, and the use of telemedicine to support effective management of emergencies and care in cases of extreme maternal morbidity. 43 DLI 3 Vulnerable women diagnosed with breast cancer with early-stage diagnosis (IIA). Supports the goal of improving access to effective health services for the vulnerable through actions to improve the early detection of breast cancer, one of the key indicators negatively impacted by the pandemic. Breast cancer related mortality has been increasing in Colombia and the situation worsened with the pandemic. Without implementing effective interventions, WHO estimates that by 2040, there will be an increase of 49.1 percent in breast cancer incidence (from an estimated 15,509 new diagnoses in 2020 to 23,100 estimated new cases in 2040) and an increase of 66.6 percent in mortality. The MSPS is committed to expand the routine population screening to promote early detection of breast cancer and to improve breast cancer treatment and outcomes. To this end, DLR 3.1 supports the continuation of the PDI and DLR 2.1 indicators under the Improving Quality of Health care Services and Efficiency in Colombia Program (P169866). Only 22% of women aged 50-69 have a mammogram every two years, far below the goal of 70% for 2030 with important differences based on whether they are affiliated to the contributory or the subsidized health regime (34.51 and 7.17% respectively). Activities under this indicator include identification 19 of women at risk of developing breast cancer through much higher levels of screening and implementing early detection networks at sub-national level. 44 DLI 4 Migrants with HIV have access to effective treatment. Supports the goal of improving access to effective health services for the vulnerable by focusing on access to treatment for migrants living with HIV. Providing access to effective health services for migrants has been a priority for the government. Seventy one percent of Venezuelan migrants with temporary protection permit are affiliated to the health system but access to effective care for the migrant population is limited due to financial, geographical, and administrative barriers. The HIV prevalence among them is estimated double of the prevalence in the native population (0.9% and 0.5%, respectively) but few migrants living with HIV know their status and receive adequate treatment. Activities under this indicator include increased access to effective HIV prevention and ARV drugs and care for regular migrants under the SGSSS subsidiary regime. This DLI will receive additional support from the Global Fund for AIDS, Malaria and Tuberculosis (GFATM), that it is expected to provide an additional US$ 5 million in grant financing; this indicator will serve as a reference point for monitoring progress of the ONUSIDA 95-95-95 targets. AR2 Enhancing health system resilience in Colombia. 45 DLI 5 New infrastructure standards for health care providers including energy efficiency standards and adaptation measures to climate change. This DLI supports the goal of enhancing health system resilience through the approval of a new framework for infrastructure works and mandatory enabling standards for health care providers to comply with, including energy efficiency and climate-focused adaptation standards. It complements previous efforts from the resolution 3100 focused on habilitation and quality of care (financed by the active PforR), seeking to update the resolution 4445 from 1996, focusing on infrastructure of the healthcare facilities. The MSPS will elaborate the administrative act requiring health care providers to comply with: (i) requirements for location of facilities, (ii) general requirements and characteristics of infrastructure, (iii) conditions for service delivery facilities, (iv) conditions of health services, (v) mandatory areas or stations for health services including emergency services, (vi) food production, (vii) environmental sustainability, and (viii) surveillance and control. Among these codes, several of them build on adaptation and mitigation features in the face of climate change such as: (i) environmental sustainability and infrastructure, (ii) surveillance and control, (iii) emergency services, (iv) energy efficiency, and (v) requirements for building infrastructure that aim at ensuring that healthcare facilities are in optimal condition for standing natural (i.e., earthquakes) and climate-related hazards (i.e., floods). Environmental sustainability and energy efficiency include: (i) the use of equipment and materials that are energy efficient (> 20 percent more efficient than standard practice), (ii) natural ventilation and lighting, to reduce cooling and illumination needs for buildings, and air conditioning use and costs, (iii) lighting standards (I.e. sensor-controlled lighting) and equipment specifications to reduce consumption and GHG emissions, (iv) efficient heating equipment to reduce consumption and GHG emissions, and improve production and distribution of hot water, and (v) collection and use of rainwater for irrigation of green areas. 46 DLI 6 Development of a Comprehensive Climate Change Management Plan for the Health Sector. This DLI intends to strengthen the regulatory framework necessary to implement Colombia’s climate change adaptation and mitigation strategies to promote an efficient health system response to climate change. To this end, the Program will finance the development of a Comprehensive Climate Change Management Plan for the Health Sector (PIGCCS), that includes three disbursements results; (i) the creation of the sectoral committee for climate change management, with functions and responsibilities in the formulation and implementation of the 20 PIGCCS; (ii) the elaboration of the Roadmap for the Adoption of the PIGCCS; and (iii) the publication of the action plan for implementation of the PIGCCS. 2.3 Program Scope 47 The proposed PforR would support three components of the Government PND 2022-2026. The objectives of the PND for the health sector are mainly organized into three components: (i) towards guaranteeing access to a universal system based on a predictive and preventive health model; (ii) the mental, physical and social well-being of people, including environmental health and climate change mitigation and adaptation interventions; and (iii) healthy eating practices appropriate to life course, populations, and territories. 48 The Program is structured to respond to these streams of challenges in two Results Areas: (1) improve access to effective health services, and (2) enhance the resilience of the health system to climate change and public health threats. The first RA aims to improve access to effective health services for the vulnerable population, defined as populations covered under the subsidized regime of the SGSSS and targeted in the NDP: women, children under five, and migrants. Furthermore, all related Result area’s DLIs and intermediate indicators are disaggregated by migration status of the vulnerable population. The second focus area aims to enhance the ability of the health sector to adapt and mitigate consequences of climate change, and better prepare and respond to future public health threats. 2.4 Geographical scope of the Program 49 The Program is national in scope. Assistance will be provided to the Government of Colombia for the entire country, although some activities will focus on priority departments identified by the government for accelerated action related to maternal mortality, infant mortality due to acute malnutrition, and early detection of breast cancer. 50 The limit for the PforR within the Program: The PforR will support specific lines of action within the Health Chapter, under the Well-being and Human Dignity Pillar in the government program: National Development Plan (PND) 2023-2026. The Health Chapter, as established by the PND, aims to tend "towards a guaranteeing, universal system, based on a model of preventive and predictive care." The PforR is very well aligned with this vision and focuses on the provision of access to effective health services through a continuous care model, prioritizing vulnerable and marginalized populations, while strengthening the system against possible impacts and interruptions. 51 Exclusions: I. There is no land acquisition planned in the Program. II. Project activities that generate or promote involuntary resettlements and livelihood restrictions are excluded. III. In the Program there are no works, constructions, facilities, or occupation of new habitats outside the current footprint of the health system. IV. The reconstruction or rehabilitation of infrastructure located in areas prone to natural hazards is not permitted in the Program. V. The PforR will support specific lines of action within the Health Chapter, under the Pillar of Well-being and Human Dignity in the government program: National Development Plan (PND) 21 2023-2026, but they are outside the scope of the PforR: a) "Science and Technology for Health and Health Innovation Policies"; b) "Food promotion and traditional cuisines"; c) "Road Safety"; d) "Safe water supply." 2.5 Description of the borrower's past experience with the World Bank in the health sector. 52 The proposed PforR builds on the successful experience with, and lessons learned from the first health sector PforR for Colombia (P169866). The first PforR was declared effective on November 30, 2020. With over 76 percent disbursed in two years of implementation, it has been instrumental in mobilizing the MSPS to advance the implementation of the health sector priorities of the 2018-2022 PND, namely enhancing quality of care and health system sustainability, and providing better access to care to migrants through affiliation to the social security system. Key results include the affiliation of 225,000 migrants to the SGSSS and the realization of a savings plan through more efficient price regulation for medicines and medical technologies. In addition, the Program supported valuable institutional strengthening through substantive capacity building and technical assistance related to the Program results framework and Program Action Plan. 53 The proposed Program is aligned with the long-term strategic orientations of the health sector included in the first PforR, with an ongoing focus on quality of care, health sector sustainability and resilience, and better access to care for Venezuelan migrants and host populations. By focusing on access to effective health services for the vulnerable population, the proposed Program continues to focus on quality of care as a key driver for improved health system performance. The proposed Program will also increase efforts to improve early detection of breast cancer, one of the leading causes of death for women in Colombia, supported in the previous Program. This specific indicator is the only one not on track to be achieved due to, among other reasons, the disruption to health services that occurred during the pandemic and will be restructured and replaced by key milestones. The indicator is included in the proposed PforR, due to the importance of accelerating the improvement in early detection of breast cancer and improving survival. In addition, the proposed Program continues to support sustainability and resilience through a focus on improving preparedness for and response to future pandemics and adaptation to and mitigation of the consequences of climate change. DESCRIPTION OF THE SOCIAL AND ENVIRONMENTAL SYSTEMS APPLICABLE TO THE PROGRAM 3.1 Key Program implementation agencies and partners 54 The implementation of the Program will be executed and supervised at national level using the regulations and capabilities of the existing substantive areas, corresponding to the Ministry of Health and Social Protection and the DNP which will provide general supervision of the Program, facilitate strategic decision making, and ensure coordination between agencies during the execution of the Program. 55 The Ministry of Health and Social Protection (MSPS) within the framework of its powers, formulates, adopts, directs, coordinates, executes and assesses public policy in the field of health, public health, and social promotion in health, and participates in the formulation of pension policies, periodic economic benefits and professional risks. Furthermore, it directs, guides, 22 coordinates and assesses the Social Security System for Health (SGSSS) and the General Professional Risks System, under its powers, additionally formulates, establishes and defines the guidelines related to the Social Protection information systems. 56 The MSPS is comprised of two deputy ministries: the Deputy Ministry of Social Protection and the Office of Deputy Ministry of Public Health and Service Provision, and by the Office of the Minister with specific functions in Formulation, implementation and monitoring of policies with specific offices equipped with specific working groups (Assistance and Reparations Group for Victims of Armed Conflict; Ethnic Affairs Group; Disability Management Group; Integral Social Promotion Management Group; Health Disaster Risk Management Group; Planning Group; Group for Sectoral Studies and Evaluation of Public Policy and Promotion of Social Participation in Health, among others). 57 The MSPS and the NGO "Health Care Without Harm" (HCWH) signed a memorandum of understanding to estimate the climate footprint of the Colombian national health system at facility level. The project will have three main axes: the identification of a sample of hospitals and health centers representative of the Colombian health system, the training of the teams of said establishments in the use of the Climate Impact Monitoring tool developed by HCWH, and the technical support so that the establishments that make up the sample can determine the size and composition of their climate footprint. With the analysis of the data obtained from this exercise, an estimate of the greenhouse gas emissions of the Colombian health sector at the national level will be made. Finally, based on these findings, a series of specific recommendations will be prepared, which will serve as input for the process of elaboration of the Comprehensive Sectoral Climate Change Management Plan (CSCCMP) for the Colombian health sector. 3.1.1 The key areas and partners in social participation 58 The key areas and partners in Social Participation in the Colombian Health System are engaged in the Policies, Plans and Programs that are based on an important regulatory framework, in the 2023-2026 PND and in the CONPES documents. The MSPS through Resolution 2063 of 2017 adopts the Social Participation in Health Policy (PPSS) for the purpose of fulfilling the responsibility of strengthening the citizenry in health processes, developing actions that allow the State to guarantee the right to social participation in health policy generating conditions for the active and effective participation of citizens. Additionally, the "Office of Territorial Management Emergencies and Disasters", through the "Management and promotion of social participation in health" Group under the Office of the Minister tracks, monitors and assesses the implementation of the PPSS, articulates with society through various mechanisms of social participation in health, such as the Territorial Councils for Social Security in Health (CTSSS); the Community Attention Department (SAC); the User Attention System (SIAU); Community Participation Committees (COPACO); Users Association; Hospital Ethics Committee; and Citizens' Health Inspectorships. The Office of Social Promotion (attached to the Minister's Office), through the Ethnic Affairs Group, interacts with these minorities as described below. 59 Law 10 of 1990 gives the community the opportunity to participate in health organization councils and, Decree 1416 of 1990, incorporates the head of the Directorate of Departmental and Municipal Health in structuring the National Councils of Social Security in Health (COPACOS). Article No. 175 of Law 100 of 1993 states that “The territorial entities at the sectional, district and local levels may create a Territorial Council for Social Security in Health that advises the Health Directorates of the respective jurisdiction, on the formulation of health plans, strategies, programs and projects and in the guidance of the Territorial Social Security in Health Systems, which carry out the policies defined by the National Council of Social Security in Health. Decree 1216 of 1989 that creates the Community Participation Committees in Health (COPACOS). Law 1751 (Statutory 23 Health Law) in chapter II "Guarantee and mechanisms of protection of the fundamental right to health", Article 12. Participation in the decisions of the health system. It sets forth that "The fundamental right to health includes the right of individuals to participate in decisions taken by health system agents that affect or are of interest to them". 60 The Integral Territorial Action Model (MAITE) seeks to strengthen local authorities and engage the community in joint work to develop plans that improve the health of the population. To this end, the health needs of each territory shall be identified to direct the assistance provided by the Ministry of Health. The MAITE has just been designed to replace the Comprehensive Healthcare Model (MIAS) and is the new operational approach of the Comprehensive Healthcare Policy (PAIS). It will be carried out through eight lines of action: Insurance, Public Health, Provision of services, Human Talent in Health, Financing, Differential approach, Intersectoral articulation and Governance. MAITE is the management instrument used to improve the health conditions of the population through coordinated actions between the agents of the health system, agents of other systems and the communities, under the leadership of the department or district, which identifies priorities and establishes actions that are operationalized through inter-institutional and community agreements, with the support and facilitation of the Ministry of Health. It stipulates that there must be opportunities for all populations, according to life course, ethnicity, disability status, gender or sexual identity or victim of armed conflict, and according to their geographical (territorial milieu where they live: urban, rural or dispersed rural), cultural, historical and social conditions, have at their disposal health services, procedures, actions and interventions, under conditions of acceptability, accessibility and quality. Similarly, the differential approach of the MAITE proposes the integration of a pre-existing Program of Psychosocial Care and Comprehensive Assistance to Victims (originating in Law 1448 of 2011, Article 137), which will be the procedures and interventions for comprehensive healthcare and psychosocial care, aimed at overcoming health and psychosocial effects related to the victimizing event. It also stipulates a comprehensive pathway of care for victims of gender violence, a protocol and model of comprehensive healthcare for victims of sexual violence. It additionally proposes a health sector response plan for the migration phenomenon containing two strategies: first, the enrolment of the population of returnees and regular migrants, and second, the development of care packages for groups and events prioritized in the Plan. National Entities 61 The Office of Social Promotion, among the agencies attached to the Office of the Minister of Health and Social Protection, coordinates the formulation and implementation of programs and projects targeting vulnerable populations (displaced populations, the disabled, older adults, early childhood, victims of armed conflict and intrafamily abuse, people with mental disorders and ethnic groups). This agency participates in the design of health models specific to ethnic groups and in the coordination of the public health plan with them and provides guidance on the pathway for access to the right to health to populations in a situation of displacement. Through the Assistance and Reparations Group for Victims of Armed Conflict it implements The Psychosocial Care and Integral Health for Victims Program (PAPSIVI). A process, which started ten years ago, set out to address the psychosocial impacts and damage to the physical and mental health of the victims caused by or in relation to the armed conflict, in the individual, family and community spheres in order to mitigate their emotional suffering, contribute to physical and mental recovery and the reconstruction of the social fabric in their communities. 62 The Office of Deputy Ministry of Public Health and Service Provision is comprised of the Directorates of Epidemiology and Demography; of Medications and Health Technologies; Healthcare Human Talent Development; Service Provision and Primary Care, and Promotion and 24 Prevention. Reporting to this last, the Office of Deputy Director of Environmental Health is responsible for determining Environmental Health public policies and monitoring compliance with regulations at sub-national levels. 63 The Office of Deputy Minister of Social Protection is the main relevant actor in the implementation of the Program through its articulation with IPS and EPS entities. It is part of the Directorates for Regulation of the Operation of Health Insurance, Occupational Risks and Pensions; of Regulation of Benefits, Costs and Rates of Health Insurance of Sector Financing. 64 The Ministry of Equality and Equity (MIE for Spanish acronym) proposed by Law 2281 of 2023. It is a main body of the central sector of the Executive Branch at the national level, rector of the administrative Sector of Equality and Equity and its affiliated or related entities. The advisory, coordination and articulation bodies indicated by law or regulation. The purpose of the ministry, within the framework of constitutional mandates, the law and its powers, is to design, formulate, adopt, direct, coordinate, articulate, implement, strengthen and evaluate policies, plans, programs, strategies, projects and measures to contribute to the elimination of economic, political and social inequalities; promote the enjoyment of the right to equality; compliance with the principles of non- discrimination and non-regression; the defense of subjects of special constitutional protection, vulnerable populations and historically discriminated or marginalized groups, incorporating and adopting rights, gender, differential, ethnic-racial and intersectional approaches. 65 The National Planning Department (DNP) is responsible for the preparation, socialization, assessment, and monitoring of the National Development Plan (PND) and coordinates the inclusion of relevant comments by the National Planning Council, the National Council for Economic and Social Policy (CONPES) and other civil society actors. The DNP acts as the Executive Secretariat of CONPES. The PND is the formal and legal instrument through which the government's objectives are outlined and at the same time allows for the evaluation of the government's performance. The DNP manages the "Social Registry" in which the sources of information of the entities that have nominal data on malnutrition and beneficiaries in social programs will be integrated, which serves as an analysis instrument for the National Follow-up and Monitoring System for the Overcoming Malnutrition led and administered by the Ministry of Equality and Equity in coordination with the MSPS among other state agencies13. The legal framework of the PND is governed by Law 152 of 1994, which contains, among others, the general planning principles, the definition of the national planning authorities and instances, and the procedure for the preparation, approval, execution and assessment of the National Development Plan. 66 National Council for Economic and Social Policy (CONPES): It is the highest national planning authority and serves as an advisory body to the Colombian Government (GoCo for sapanish acronym) in all aspects related to the economic and social development of the country. It coordinates and guides the agencies responsible for economic and social management in the Government, through the study and approval of documents on the development of general policies that are submitted in session. The most relevant CONPES documents in the framework of the project are: CONPES 3918 of 2018 To achieve the Sustainable Development Goals; CONPES 147 of 2012 on Preventing teenage pregnancy; CONPES 155 of 2012 on National pharmaceutical policy; CONPES 161 of 2013 on Gender Equality for women; CONPES 3550 of 2008 on Guidelines for the formulation of the comprehensive environmental health policy; CONPES 3874 of 2016 National policy for the integral management of solid waste; CONPES 3950 of 2018 Strategy for the attention of migration from Venezuela. 13 Texto conciliado del proyecto de ley número 274 de 2023 cámara – 338 de 202 senado “por el cual se expide el Plan Nacional de Desarrollo 2022- 2026 “Colombia potencia mundial de la vida” Artículo 215°. Sistema Nacional de Seguimiento y Monitoreo para la Superación de la Malnutrición. 25 67 The Institute for Health Technology Assessment (IETS) is the National Health Technology Assessment Agency of Colombia. Created by Law 1,438 of 2011, it is a decentralized entity of the health sector, which generates evidence with scientific rigor to support decision-making, which contributes to the improvement of health and the sustainability of the system with legitimacy, innovation, quality, equity. and efficiency. Subnational Entities 68 The Departments must direct, coordinate and monitor the health sector and the Social Security System for Health in the territory of their jurisdiction, taking into account national provisions on the subject. To this end, they have management duties over the health sector in the departmental sphere; provision of health services; Public Health; and Insuring the Population through the SGSSS. The Municipalities are in charge of directing and coordinating the health sector and the SGSSS within the scope of their jurisdiction, for which they carry out the management duties of the sector at the municipal level; Insuring the Population through the SGSSS; Public Health. The Districts shall have the same powers in Health as the municipalities and departments, except for those that correspond to the intermediation function between the municipalities and the Nation14. 69 The Departmental and District Health Directorates carry out the inspection, oversight and control of the content, quality and reporting of the information that comprises the Quality Information System. The Offices of Director of Municipal Health carry out an ongoing active search of the Health Services Providers that operate in their respective jurisdictions, for the purpose of informing the Departmental Entities in line with the Special Registry of Health Care Providers, thus guaranteeing the ongoing compliance of the conditions of licensure. The Departmental, District and Local Health Directorates, perform the inspection, oversight and control of the internal management of waste generated in healthcare activities. International organizations 70 The Pan American Health Organization (PAHO) is the international organization specialized in public health in the Americas. PAHO are committed to ensuring that each person has access to the quality healthcare they need, and without falling into poverty. Through its work, it promotes and supports everyone's right to health, fosters cooperation between countries and works collaboratively with ministries of Health and other government agencies, civil society organizations, international agencies, universities, social security agencies, community groups and other partners. PAHO ensures that health is included in all policies and that all sectors do their part to ensure that people live longer and better years of life, because health is our most valuable resource. 71 The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). It provides technical assistance services, mainly to the Member States of the Americas, but also to the Coordination Mechanisms of the Countries, to develop National Strategic Plans; prepare epidemiological updates; prepares investment cases, risk analysis, technical guides, gap analysis, performance frameworks, micro and macro stratification, and costing; to formulate evidence-based interventions; facilitate technical review panels, policy dialogue, and consensus building among stakeholders. 14 Artículos 43, 44 y 45 de la Ley 715 de 2001. 26 Stakeholders from ethnic groups and indigenous Peoples 72 Colombia is a multiethnic and multilingual country in that 14.4% of people belong to an ethnic group that differs from the majority of society and there are four recognized ethnic groups: the indigenous population (3.4%), the Raizal Archipelago population of the San Andrés, Providencia and Santa Catalina Archipelago (0.08%), the black or Afro-Colombian population (10.5%), - of which the Palenqueros of San Basilio are a part from the municipality of Mahates in the department of Bolívar- (0.02 %), and the Rom or gypsy population (0.01)15. 73 The Office of Social Promotion of the MSPS deals with relations with indigenous peoples, black Afro-Colombian communities, Raizales and Palenqueros, and the Rom (Gypsy) People. hey are populations whose social, cultural, and economic conditions and practices distinguish them from the rest of society and who have maintained their identity throughout history, as collective subjects that affirm their individual origin, history, and cultural characteristics (self- recognition), which are expressed in their worldviews, customs and traditions. According to the 2005 census of the National Administrative Department of Statistics (DANE), 14.4% of the people in Colombia belong to an ethnic group. There is participation in consensus-building meetings where standards of care are established that respect their ethnic and cultural identity, forms of social organization and linguistic characteristics, without the need to create a special health system for each ethnic group. 74 The Permanent Coordination Workgroup with indigenous peoples and organizations is a space for articulation between the GoCo agencies and the delegates of the indigenous organizations and the representatives of the Indigenous Peoples. Decree 1848 of 2017 establishes the Licensure System of Indigenous Health Insurance Enterprises (EPSI), applicable during the period of transition to the Personal and Intercultural Indigenous Health System (SISPI) and other provisions are set forth. This decree comprises a set of requirements and procedures that determine the administrative, scientific, technical, cultural and financial conditions, to guarantee access to health services with a differential approach to its enrollees, considering the socio-cultural and geographical characteristics of indigenous peoples, to operate in the subsidized Health regime. 75 The National Social Protection Workgroup of black, Afro-Colombian, Raizales and Palenquero communities, guaranteed the inclusion of the differential approach in health plans, programs and projects, as well as the prioritization of actions in disease prevention and health promotion for this population. In this context, the agreement was made, among other things, to cover 100% of the Afro population in the General Health System according to national and territorial powers, to launch a National Social Protection Workgroup for these communities with the participation of other entities from the health sector, such as the Colombian Institute of Family Welfare (ICBF), National Apprenticeship Service (SENA), MADS, Social Action, Supersalud, Supersubsidio Familiar, National Institute of Health, INVIMA, Office of the Attorney General and Advocate's Office, among others. 76 The Health Workgroup for the Rom people. Under the aegis of Decree 2957 of 2010, work on public health actions for the gypsy ethnic group needs to cover all members of the respective Kumpañia, and these last need as well to establish intercultural, qualitative and quantitative indicators of the public health situation of the population, and tracking and monitoring mechanisms, in order to verify the effect of these health actions, the impact of resources and the adoption of measures targeted at preserving or recovering the health of its members. Within the framework of the PND, guidelines are developed (pending) with directives and guidelines for socio-cultural adaptation and inclusion of the intercultural approach for the Rom people. 15 Censo del DANE 2005 27 Venezuelan migrant and refugee stakeholders 77 Decree 216 of March 1, 2021 16 created a regularization process for Venezuelan migrants and allows the request for a 10-year temporary status, through the creation of the "Temporary Protection Status for Venezuelan Migrants" (ETMV for Spanish acronym). Said process covers Venezuelan migrants who are in Colombia in a regular situation, those who are in an irregular situation and were in the country before January 31, 2021, and those who legally enter the country through an official port of entry in the first two years of the validity of the statute. Other requirements include having no criminal record and no active orders of deportation, removal, or economic sanctions. 78 Migration Colombia designed a Comprehensive Plan specially designed for Venezuelan Migrants, with measures aimed at facilitating the obtaining of the Permit for Temporary Protection (PPT). The issuance of the PPT is in charge of the Colombia Migration Special Administrative Unit. The Virtual Pre-Registration in the Single Registry of Venezuelan Migrants (RUMV for Spanish acronym - Registro Único de Migrantes Venezolanos-) and the socioeconomic characterization survey will be available for completion as of May 29, 2022, solely and exclusively for the following population: (i) Venezuelan migrants who entered Colombian territory on a regular basis from May 29, 2021 to May 28, 2023 through the respective legally authorized Immigration Control Post, (Term until November 24, 2023); (ii) Boys, girls and adolescents linked to an Administrative Process for the Restoration of Rights (PARD for Spanish acronym - Proceso Administrativo de Restablecimiento de Derechos-) and adolescents and youth linked to the Criminal Responsibility System for Adolescents (SRPA for Spanish acronym - Sistema de Responsabilidad Penal para Adolescentes-), as well as those who are enrolled in an educational institution in the levels of initial, preschool, basic and secondary education. Deadline: May 30, 2031. In the registration process, the “Permit for Temporary Protection” (PPT) is requested. The PPT is a mechanism for migratory regularization and identification document, which authorizes Venezuelan migrants to remain in Colombia under conditions of special migratory regularity for its term of validity. 79 Some Venezuelan migrants reside with a Special Permanence Permit (PEP) created by the Ministry of Foreign Affairs, which allows them to access health, education, work and childcare, but since Decree 216 of 2021 came into force they must access the PPT. The migrant population from Venezuela also includes victims of the Colombian internal armed conflict who left the country and who, as a consequence of the economic, political and social situation that Venezuela is going through, have returned to Colombia. The needs arising from migrants in transit to third countries must also be considered. The increase in the number of migrants from Venezuela has generated care needs for this population in terms of health (among others) accelerating in such a short time pressures on the institutions, services, and related social aspects. 80 El Grupo Interagencial sobre Flujos Migratorios Mixtos (GIFMM). The Interagency Group on Mixed Migration Flows (GIFMM). Coordinates the response to the needs of refugees, migrants, returnees, and host populations, both nationally and through local presence in 14 departments in a complementary manner to the response of the Colombian Government. It is made up of more than 200 organizations (including UN Agencies, civil society, religious organizations, and NGOs, among others) that coordinate their efforts under the Response Plan for Refugees and Migrants from Venezuela (RMRP) in 17 countries of Latin America and the Caribbean. The RMRP (2023- 2024) contains a comprehensive response in 31 of the 32 Colombian departments, which will be implemented through GIFMM partners, with priority in border areas. The funds will be used to 16 https://dapre.presidencia.gov.co/normativa/normativa/DECRETO%20216%20DEL%201%20DE%20MARZO%20DE%2020 21.pdf 28 respond to humanitarian needs and facilitate the economic integration of refugees and migrants, returned Colombians and host communities, complementing, and supporting the efforts of the National Government. Gender violence stakeholders 81 The National Violence Observatory is an inter-sector space provided by the Ministry of Health and Social Protection, in order to promote the generation, collection, analysis and dissemination of information on gender violence and how to approach it in a comprehensive manner in the national territory. 82 Integrated Information System on Gender Violence (SIVIGE for Spanish acronym) was built through the exchange and technical work carried out in the National Intersectoral and Inter- Institutional Coordination Mechanism for the comprehensive approach to gender violence 17 . Alongside the MSPS, the Ministry of Justice and Law, the National Administrative Department of Statistics, the Presidential Counselor's Office for Women's Equality, and the National Institute of Legal Medicine and Forensic Sciences work on the formulation and implementation of the SIVIGE 18 . The goal of SIVIGE is to provide, integrate, harmonize and disseminate statistical information on gender violence, based on quality standards, the principles of official statistics and international standards, to support the design, implementation and assessment of public policies and the targeting of actions that allow approaching gender violence in a comprehensive manner to ensure the effective enjoyment of rights. 83 The Presidential Council for Women's Equity. He will lead the recently created National System for Registration, Attention, Follow-up, and Monitoring of Gender-Based Violence (VBG) 19. It will have a strategy for the integration of care routes in GBV, and a mechanism to centralize information. In addition, it will strengthen and guarantee the interoperability of the different information, follow-up and monitoring systems, created by Laws 1257 of 2008, 1719 of 2014, 1761 of 2015 and 2126 of 2021, as well as the hotlines for GBV victims, with an intersectional and territorial gender approach. Mechanism for Petitions, Complaints, Claims, Requests and Whistleblowing (PQRSD) 84 A Mechanism for Petitions, Complaints, Claims, Requests and Whistleblowing (PQRSD in Spanish) is institutionalized in the GoCo for all its ministries and divisions. Especially in the MSPS, the “Citizen Services” division implements a section where a petition, complaint, claim, suggestion or whistleblowing can be formulated respectfully through the MSPS PQRSD web form (https://www.minsalud. gov.co/atencion/Paginas/Solicitudes-sugerencia-quejas-o-reclamos.aspx). Any of these shall be processed by the Citizen Services Group, in accordance with the guidelines established in Resolution 3687 of August 17, 2016. Depending on the type of petition, the deadlines established for resolution are established between 10 and 30 days, although most should be settled within 15 days. Furthermore, users are instructed on the said page to refer to another division of the GoCo if the request does not fall under the purview of the MSPS. Citizens also have the Petitions, Complaints, Claims and Denunciations mechanism of the National Health Superintendence (Supersalud), an entity whose mission is to protect the rights of users of the General Social Security Health System, through the activities of inspection, surveillance, control and the exercise of the jurisdictional and conciliation function. Supersalud has a mechanism that has several channels for 17 Consagrado en las bases del Plan Nacional de Desarrollo Ley 1753 del 2015 18 De acuerdo con el artículo 31 de la Ley 1719 de 2014 y el artículo 12 de la Ley 1761 de 2015 19 Texto conciliado del proyecto de ley número 274 de 2023 cámara – 338 de 202 senado “por el cual se expide el Plan Nacional de Desarrollo 2022- 2026 “Colombia potencia mundial de la vida” Artículo 341 29 filing petitions such as face-to-face assistance in offices, a telephone line, WhatsApp, and other services that are indicated on the entity's website20. All PQRSD through the entity must be resolved in an estimated time of 15 days. 3.1.2 The key areas and environmental partners 85 The key areas and environmental partners in the Colombian Health System refer to the management of Waste from Health Establishments, the generation of WEEE, and the effect of the impacts of Climate Change on the health sector. The management of Health Establishment Waste that has two instances, one within the health establishments (intramural) determined under MSPS policies, and another outside the Provider Entities (extramural) under the supervision of the MADS. Decree 351 of 2014 (compiled in Decree 780 of 2016 - Single Regulatory Decree of the Health Sector-) is for purposes of regulating from an environmental and health standpoint the integral management of waste generated in healthcare and other activities. 86 The Office of Deputy Ministry of Public Health and Service Provision of the MSPS through the Office of Deputy Director of Environmental Health is responsible for determining Environmental Health public policies and monitoring compliance with regulations at sub-national levels. It is also the governing body for the Integral Management of Hospital Waste and similar. The internal management of waste or hazardous waste, sharps, that with biological or infectious risk, is established in the Manual for the Integrated Management of Waste Generated in Health Services and other Activities (Decree 351 of 2014, compiled in Decree 780 of 2016), and includes the action carried out by the generator, which involves the coverage, planning and implementation of all activities related to minimization, generation, segregation, internal movement, internal storage and/or waste treatment within its facilities. 87 The Subdirectorate of Environmental Health within the framework of the Ten-Year Public Health Plan (PDSP), the Comprehensive Health Care Policy (PAIS for Spanish acronym) and the Comprehensive Environmental Health Policy (PISA for Spanish acronym), is responsible for monitoring progress in territorial management of environmental health applicable to the Territorial Health Directorates (Departments and Districts), through actions aimed at the capture, notification and evaluation of information related to public health management processes; which includes transversal aspects of environmental health management applicable to all territories, inquiring about the existing particularities in order to recognize them and contextualize the technical assistance processes that must be given from the national level for capacity building. In this context, the Environmental Health Management Monitoring process was designed at the territorial level, regulated by Resolutions 3496 of 2019 and 367 of 2023, which allows knowledge of the particularities of the different territories and proposes in a standardized manner the aspects that are transversally common for the monitoring and evaluation of the territorial management of environmental health, harmonized with the public health management processes established in Resolution 518 of 2015. 88 The Subdirectorate of Environmental Health is also responsible for the Formulation of the Comprehensive Climate Change Management Plan (PIGCCS for Spanish acronym) of the Health Sector. In addition, it guides the EPS through the preparation of Guidelines for (a) the Formulation of Territorial Plans for Adaptation to Climate Change from the Environmental Health Component (PTACCSA for Spanish acronym), and (b) the Climate Change Mitigation Guide for the health sector. 20 https://www.supersalud.gov.co/pqrd.html 30 89 The Ministry of Environment and Sustainable Development (MADS) is the body governing environmental and renewable natural resource management. It directs the National Environmental System, formulates public policy in regard to Electric and Electronic Device Waste (WEEE), and through the Chemical Substances, Hazardous Waste and Ozone Technical Unit Group is responsible for the Policy for Comprehensive Management of Solid Waste. It regulates the prevention and management of hazardous waste or waste generated within the framework of comprehensive management and establishes the requirements and procedure for the Registry of Generators of Waste or Hazardous Waste. In addition, the MADS, through the Directorate of Climate Change and Risk Management (i), develops the technical and operational bases necessary to advance in the management of climate change in the different sectors and territories of the country, in association with public and private actors. of the local, national and international order; (ii) provides the technical elements for the elaboration of public policies, plans, projects, and climate change programs, with a low-carbon approach that will strengthen the development of the country; (iii) establishes guidelines to prevent ecological risk in coordination with the entities that make up the National System for Disaster Prevention and Response; and (iv) guides the assessment of vulnerability impacts of biodiversity and its ecosystem services due to the effects of climate change, among others. 90 The National Institute of Health (INS) is the scientific-technical authority and has the purpose of reducing and/or mitigating the negative impacts that may be generated on the environment and health, through compliance with legal requirements and current environmental regulations. It promotes awareness, environmental training, and communication in ongoing fashion, focusing its efforts on the proper management of solid waste, discharges and atmospheric emissions. It has developed the Integrated Waste Management Manual and establishes the assessment mechanisms through the monitoring and tracking programs. 91 The Institute of Hydrology, Meteorology and Environmental Studies (IDEAM) provides technical and scientific support to the National Environmental System, it generates knowledge, produces reliable, consistent, and timely information on the state and dynamics of natural resources and the environment. It is responsible for the Registry of Generators of Waste or Hazardous Waste, aimed at improving the knowledge of the issues associated with this type of waste, planning its management, and establishing priorities for the definition of actions. 92 The National Institute for Food and Drug Surveillance (INVIMA) is the National Regulatory Agency and is a scientific-technical surveillance and control entity, which works through the application of the sanitary norms associated with the consumption and use of food, medicines, medical devices and other products under sanitary surveillance for the protection of individuals and the collective health of Colombians. 93 The Regional Environmental Authorities (Regional Autonomous Corporations, Corporations for Sustainable Development, and Urban Environmental Authorities) are responsible for the implementation of extramural hazardous waste policies (collection, storage, transport, treatment, use and/or final disposal of HCW) in accordance with the legal provisions and policies of the MADS. 94 The Regional Autonomous Corporations and those for Sustainable Development corporate entities of a public nature, created by law, integrated by the territorial entities which, because of their characteristics constitute the same ecosystem geographically or form a geopolitical, biogeographic or hydrogeographic unit, endowed with administrative and financial autonomy, their own assets and legal status, responsible by the law for managing, within the area of their 31 jurisdiction, the environment and renewable natural resources and to advance their sustainable development. They are the top environmental authority at the regional level and are responsible for the sustainable and rational use of renewable natural resources and the environment in their respective jurisdiction, the promotion of scientific research and technological innovation, manage the regional land planning process to mitigate and deactivate pressures from inappropriate exploitation of the territory, and to foster, with the cooperation of national and international entities, the generation of appropriate technologies for the use and conservation of resources and the environment of their area of influence. 95 The Urban Environmental Authorities are present in municipalities, districts, or metropolitan areas whose urban population is equal to or greater than one million inhabitants. They carry out the duties of the Regional Autonomous Corporations in their jurisdiction. 3.1.3 Laws, regulations and environmental and social policies. 96 Relevant laws, regulations and policies at the national level for the proposed Program were analyzed. The analysis covered whether there are any significant gaps that would prevent accomplishing the environmental and social goals included in the core principles of the ESSA. Table N ° 1 provides a detailed analysis of the legal and regulatory framework applicable to the Program. 97 The provisions of the existing legal and regulatory environmental framework are adequate, the compilation of the rules in an updated decree facilitates their understanding and implementation. While the provisions of the Biomedical, Chemical and WEEE Waste Management Standards are being implemented by Departmental, District and Municipal authorities, efforts are required to improve the monitoring of the management of the different types of waste, both intra and extramural, by national authorities (MSPS and MADS). 98 The own regulatory framework in Environmental Health is comprised by Law 09 of 197921, by which initial sanitary measures are dictated; Law 715 of 2001, which establishes organic regulations regarding resources and powers to organize the provision of education and health services, among others; Law 1335 of 201122 or Anti-tobacco law; Resolution 1229 of 2013, which establishes the sanitary inspection, surveillance and control model for products for human use and consumption, Decree 780 of 2016 or the sole regulatory Decree of the Health Sector; Resolution 518 of 2015 that established provisions in relation to Public Health Management and guidelines for the execution, monitoring and evaluation of the Public Health Plan of Collective Health Interventions (PIC); among other regulatory instruments. 99 In terms of Environmental Health, the MSPS coordinates joint actions at the inter- institutional and intersectoral level23 in management spaces such as: the Territorial Council of Environmental Health (COTSA) and its technical tables, in the Territorial Council of Zoonoses, in the Institutional Technical Committee for Environmental Education (CIDEA), in territorial environmental councils; in territorial Councils for Risk Management, in the Regional Air Quality Tables, in Regional Climate Change Nodes, in territorial Planning Councils, and in sectional and local Committees on occupational safety and health, among others. 21 https://www.minsalud.gov.co/Normatividad_Nuevo/LEY%200009%20DE%201979.pdf 22 https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=36878 23 https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/SA/abece-operacion-sectorial- sa.pdf 32 100 The existing legislative framework is adequate to guarantee social sustainability and the interest of the marginalized and vulnerable population, including the population belonging to indigenous peoples, ethnic groups, and migrants. 101 The United Nations Framework Convention on Climate Change was ratified by Colombia through Law 164 of 1994, and Law 1844 of 2017 approves the "Paris Agreement", adopted on December 12, 2015, in Paris, France. The Paris Agreement establishes obligations associated with GHG mitigation with respect to the long-term goal included in article 2 and associated with Nationally Determined Contributions (NDCs). 102 The Nationally Determined Contribution (NDC) of Colombia for 2020 24 includes in the country's climate commitments for the year 2030, for the health sector two adaptation goals (i) that 100% of the territorial entities of the health sector at the departmental, district and municipal level of categories 1, 2 and 3, formulate adaptation actions that allow preventing climate-sensitive diseases such as dengue, malaria and zika, among others, by the year 2030. 40% of these entities must implement these actions by that date; (ii) By 2030, 40% of the Institutions Providing Health Services in the public sector will implement adaptation actions in the face of possible events associated with climate variability and change. 103 In the Update of the Nationally Determined Contribution of Colombia (NDC), Annex A3. Reported support needs for the Adaptation priorities for the health sector identifies four types of activities necessary for the Health Sector: (i) Design and implementation of an Early Warning System (SAT for Spanish acronym) associated with climate variability; (ii) Design of a statistical tool that allows analysis of information on climate-sensitive health events and supports public health surveillance actions for the Territorial Health Directorates (DTS for Spanish acronym); (iii) Tool for monitoring and prediction of Vector-borne Diseases; (iv) Tool for vulnerability analysis of public sector health service provider institutions to climate variability and change25. 104 The Institute of Hydrology, Meteorology and Environmental Studies (IDEAM for Spanish acronym) has developed the procedure for the generation of regional and local climate change scenarios based on global models. 105 Regulations for Petitions, Complaints, Claims, Requests and Whistleblowing (PQRSD for Spanish acronym) Article 74 of the Political Constitution of Colombia guarantees that "All persons have the right to access public documents except in cases established by law." Law 1755 of 2015 regulates the Fundamental Right of Petition and replaces a title of the Code of Administrative Procedure and Administrative Law, for the purpose of providing all people with the right they have to submit petitions, complaints, claims, suggestions, etc., in a respectful manner to the authorities for reasons of general or specific interest and to obtain a prompt response. 106 In the case of the issuance of administrative acts (Laws, Decrees, Resolutions) there is a public consultation mechanism that consists in the web publication of the project and comments, criticisms, and suggestions that, after being considered, are incorporated into the administrative process of the Ministry for their enactment. The mechanism is established under Law 1437 of 2011, especially in article 8 thereof on “Duty of information to the Public”. 24 Actualización de la Contribución Determinada a Nivel Nacional de Colombia (NDC), Diciembre 10 2020 y Portafolio de metas de adaptación al cambio climático – Contribución Determinada a Nivel Nacional de Colombia (NDC) Enero 1, 2020 Pag 10 a 15 25 Actualización de la Contribución Determinada a Nivel Nacional de Colombia (NDC) Anexo 3 33 Table N ° 1: Environmental and social laws, regulations and policies that are relevant to the proposed Program. Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions Political Constitution of 1991 Establishes collective and environmental rights (Chapter III. Articles 78 to Relevant conceptual framework 82) Law 09 of 1979 By which initial sanitary measures are issued. Pertinent Law 99 of 1993 Ensure the adoption and execution of the respective policies, plans, Relevant conceptual framework programs and projects, in order to guarantee the fulfilment of the duties and rights of the State and of private citizens in regard to the environment and the natural heritage of the Nation. Law 715 of 2001 Established the powers of the Nation and territorial entities in the health Relevant to the General Program, it establishes the sector, as well as the resources to be allocated to the territorial entities in responsibilities at the level of the territorial accordance with the General Share Interest System. authorities for decentralization of the implementation Article 43. Powers of health departments. of environmental health policies Article 44. Powers of municipalities. Municipalities responsible for leading and coordinating the health sector and the General Social Security System for Health within the scope of their jurisdiction. Article 45. District powers in respect to health. Childhood and Adolescence Code. Its purpose is to guarantee the full Relevant to the Program, it establishes the routes and Law 1098 of 2006 development of children and adolescents. institutional powers for the comprehensive protection of the rights of children and adolescents. Article 9 Awareness and prevention measures. Regulated by National Decree 4796 of 2011. All authorities in charge of formulating and implementing public policies must recognize the social and biological Law 1257 of 200826 differences and inequalities in relationships between people according to Pertinent sex, age, ethnicity, and the role they play in the family and in the social group. Gives specifications for the National Government and for Departments and Municipalities. Law 1335 of 2011 Anti-tobacco law Pertinent. Its objective is the strengthening of the Social Security System for Health Pertinent for the Program because health insurance Law 1438 of 2011 (SGSSS) and creates the Institute for Health Technology Assessment and quality coincide with the objectives of the SGSSS 26 https://www.unidadvictimas.gov.co/sites/default/files/documentosbiblioteca/ley-1257-de-2008.pdf Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions (IETS), which generates evidence with scientific rigor to support decision- (generate conditions that protect the health of making, which contributes to improving the health and the sustainability Colombians, with the well-being of the user being the of the system with legitimacy, innovation, quality, equity and efficiency. central axis and articulating nucleus of health policies). Establishes the guidelines for the adoption of a public policy for the Law 1672 of 2013 comprehensive management of electrical and electronic equipment waste Pertinent. (WEEE). Article 31 Unified system of information on sexual violence. In accordance with the provisions of article 90 numeral 9 of Law 1257 of 2008 and article 3, literal k) of National Decree 164 of 2010, the National Administrative Department of Statistics, in coordination with the High Presidential Council for the Equity of Women and the National Institute of Legal Medicine and Law 1719 of 201427 Forensic Sciences, will advise the incorporation into the Unified Registry Pertinent. System of Cases of Violence against Women contemplated in said regulations, of a single information component, which allows knowing the dimension of sexual violence against women. that this law deals with, monitor its risk factors, and provide elements of analysis to evaluate the measures adopted in terms of prevention, care and protection. Law 1751 of 2015 Its purpose is to guarantee the fundamental right to health, regulate it and Pertinent to the Program establish its protection mechanisms. It classifies femicide as an autonomous crime, to guarantee the investigation and punishment of violence against women for reasons of gender and discrimination. Its Article 9°. Legal Technical Assistance. The State, through the Ombudsman's Office, will guarantee guidance, advice and legal representation to women victims of gender violence and especially femicide Law 1761 of 201528 Pertinent. violence free of charge, immediately, specialized and priority from the perspective of gender and Human Rights of women, in order to guarantee their access to the administration of justice, to an effective judicial remedy and to the granting of protection and care measures enshrined in Law 1257 of 2008 and in other administrative and jurisdictional instances. 27 http://www.secretariasenado.gov.co/senado/basedoc/ley_1719_2014.html 28 http://wp.presidencia.gov.co/sitios/normativa/leyes/Documents/LEY%201761%20DEL%2006%20DE%20JULIO%20DE%202015.pdf 35 Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions Legal nature and guiding principles of family police stations. Its purpose is to dictate provisions that provide tools to Family Police Stations to manage their institutional design and to facilitate, expand and guarantee access to Law 2126 of 202129 justice through specialized and interdisciplinary care, in order to prevent, Pertinent. protect, restore, repair and guarantee the rights of those who are at risk, are or have been victims of gender-based violence in the family context and victims of other violence in the family context. Decree 1609 of 2002. Regulates the handling and overland transporting of hazardous goods Pertinent, relevant to WEEE transportation. Operate and develop the public health surveillance and control system within the framework of the Social Security System for Health. Coordinate Decree Law 4109 of 2011 Pertinent. the surveillance of risks and threats to public health and protect communities against them. Sets forth prohibitions on environmental matters, referring to Hazardous Relevant to the management and final disposal of Law 1252 of 2008. Waste (RESPEL) Hazardous Waste Resolution 0371 of 2009 Establishing guidelines for the Management Plans for the Return of Post- Relevant for the management and final disposal of Consumer Products such as Drugs or Expired Medications waste generated by expired drugs. Resolution 18005/2010. adopts the Regulation for the management of radioactive waste. Relevant conceptual framework for the management Ministry of Mines and Energy of radioactive health-care waste establishments. Creates the National Intersectoral Technical Commission for Environmental Health (CONASA) whose purpose is to coordinate and Creation and maintenance of relevant technical guide the design, formulation, monitoring and verification of the spaces for decision-making, management and implementation of the Comprehensive Environmental Health Policy Decree 2972 of 2010 intersectoral coordination in addressing social and (PISA). It establishes as part of its functions: "Promote the creation of the environmental determinants that affect the quality of Territorial Councils on Environmental Health (COTSA) by the member life and health of the population. Ministries and guide their regulation", and "Support the creation of the Unified Environmental Health Information System (SUISA)". 29 https://www.funcionpublica.gov.co/eva/gestornormativo/norma.php?i=168066#:~:text=se%20determinar%C3%A1%20as%C3%AD%3A- ,1.,cualquier%20forma%20de%20violencia%20sexual. 36 Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions Establishes the inspection, surveillance and sanitary control model for Resolution 1229 of 201330 Relevant Conceptual products for human use and consumption. Establishes the Ten-Year Public Health Plan 2012-2021 It is based on eight priority dimensions: 1) Environmental health, 2) Sexuality and sexual and reproductive rights, 3) Coexistence and mental health 4) Food and nutritional security, 5) Healthy life and non- communicable conditions 6) Healthy life and communicable diseases, 7) Pertinent. Resolution 1841 of 2013 Public health in emergencies and disasters, and 8) Health in the workplace; and two transversal dimensions: 1) Differential management of vulnerable populations and, 2) Strengthening of the health authority for health management; each dimension in turn develops a cross-sectoral and sectoral component that incorporates a set of actions (common and specific strategies). Decree 351 of 2014. Update the standard for waste generated in healthcare and other activities Relevant conceptual framework Decree 1076 of 2015 Single regulatory decree of the Environment and Sustainable Development Relevant conceptual framework that compiles and sector. organizes the legislation for the HCW management and final disposal of extramural. Establishes provisions in relation to Public Health Management and Resolution 518 of 2015 established guidelines for the execution, monitoring and evaluation of the Pertinent. Public Health Plan of Collective Health Interventions (PIC). Establishes the process of Integral Planning for Health, and provides the regulatory grounds for carrying out a Territorial Health Situation Analysis and the Characterization of the population enrolled in the Benefits Plan Administration Entities (EAPB). Relevant because the EAPBs are responsible for In addition, its purpose is to establish provisions on the comprehensive Resolution 1536 of 2015 compliance with the Policy in accordance with its planning process for health in charge of territorial entities at the users and their organizational forms. departmental, district, and municipal levels, as well as national government institutions; Likewise, establish the obligations that, in order to contribute to this purpose, must be fulfilled by the Health Promotion Entities (EPS), the other Benefit Plan Administration Entities and the Occupational Risk 30 https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/resolucion-1229-de-2013.pdf 37 Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions Administrators, which will be mandatory, within the scope of their powers, so they must welcome and integrate the inputs that allow their execution. Establishes the obligation of health care waste generators that amount to Resolution 5262 of December approximately 47,000 to register in the Registry of Hazardous Waste Relevant. 16, 2021 Generators, in accordance with the aforementioned standard, regardless of the moving average of generation. They modify articles 6 and 8 of Resolution 3496 of 2019 that establishes Resolution 367 of 2023 the process for strengthening environmental health management at the Relevant territorial level. Decree 780 of 2016 Single Regulatory Decree of the Health Sector (Compiles Decree Relevant conceptual framework that compiles and 351/2014). organizes the legislation for the HCW management, treatment, and final disposal of extramural. Decree 284 of 2018. Comprehensive management of Electric and Electronic Device Waste Relevant conceptual framework for the management (WEEE). of WEEE. Resolution 851 of 2022 Single Regulatory Decree of the Environment and Sustainable Development Pertinent, relevant to the management of WEEE Sector on the management of waste electrical and electronic equipment (WEEE) Law 1806 of 2016 Establishes the State policy for the Integral Development of Early Relevant conceptual framework that connects Childhood from Zero to Forever within the framework of the Integral Healthcare from the beginning of life. Protection Doctrine. Create a special regime to put into operation the Indigenous Territories regarding the administration of the indigenous peoples' own systems, in Conceptual framework relevant to health policies for Decree 1953 of 2014 accordance with the provisions established herein, until such time as the law indigenous peoples. that is the subject of article 329 of the Political Constitution is enacted. (SISPI). Establecer el proceso para el fortalecimiento de la gestión de la salud ambiental a nivel territorial, a través del diagnóstico, la formulación, la Resolución 3496 de 2019 Pertinent. implementación, la autoevaluación, la evaluación y el seguimiento de los planes sectoriales de fortalecimiento de capacidades. 38 Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions Creates the National Commission of Indigenous Territories and the Conceptual framework for coordination with Decree 1397 of 1996 Permanent Coordinating Workgroup with the peoples and organizations indigenous Peoples. HEALTH AND SAFETY AT WORK Law 1562 of 2012 "Under which the Occupational Risk System is modified and other Relevant conceptual framework for the operators of provisions on Occupational Health are issued" the HCW management system. “Whereby enacting the Single Regulatory Decree of the Labor Sector” - Conceptual framework relevant to the Occupational Decree 1072 of 2015 Chapter 6. Defines the mandatory guidelines to implement the Occupational Health and Safety Management System. Health and Safety Management System. “Whereby article 2.2.4.6.37 of Decree 1072 of 2015, Single Regulatory Conceptual framework relevant to the Occupational Decree 52 of 2017 Decree of the Labor Sector, on the transition for the implementation of the Health and Safety Management System. Occupational Health and Safety Management System is modified” “Whereby the Minimum Standards of the Occupational Health and Safety Conceptual framework relevant to the Occupational Resolution 0312 of 2019 Management System SG-SST are defined” Health and Safety Management System. Colombian Technical Standard NTC OHSAS 18001 Occupational Risk Assessment Institute of Hygiene and Safety of Spain- INSHT. Good practices relevant to the Occupational Health Good practices GTC 45 of 2012. and Safety Management System. NTC 4114 Industrial Safety - Performing Planned Inspections. NTC 3701 CLIMATIC CHANGE Its purpose is to establish the guidelines for the management of climate Relevant because it defines the (1) Comprehensive change in the decisions of public and private persons, the concurrence of the Sectoral Climate Change Management Plans Nation, Departments, Municipalities, Districts, Metropolitan Areas and (PIGCCS) as the instruments through which each Law 1931 of 2018 Environmental Authorities mainly in the actions of adaptation to change Ministry identifies, evaluates, and guides the climate change, as well as mitigation of greenhouse gases, with the aim of incorporation of greenhouse gas mitigation and adaptation measures to climate change in the policies 39 Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions reducing the vulnerability of the country's population and ecosystems to its and regulations of the respective sector. (2) effects and promoting the transition towards a competitive, sustainable Comprehensive Territorial Climate Change economy and low-carbon development. Management Plans (PIGCCT) as the instruments through which territorial entities and regional environmental authorities identify, evaluate, prioritize, and define adaptation and mitigation measures and actions for greenhouse gas emissions greenhouse, to be implemented in the territory for which they have been formulated. Establishes the National Climate Change System (SISCLlMA), in order to coordinate, articulate, formulate, monitor, and evaluate policies, regulations, strategies, plans, programs, projects, actions, and measures Decree 298 of 2016 regarding adaptation to climate change and mitigation of greenhouse gases, Pertinent. whose intersectoral and transversal nature implies the necessary participation and co-responsibility of national, departmental, municipal or district public entities, as well as private entities and non-profit entities. Define as hospital establishments and similar, all institutions providing Resolution 4445/1996 health services, public, private or mixed, in the phases of promotion, Pertinent. prevention, diagnosis, treatment and physical or mental rehabilitation. Determines the achievable minimums within which the criteria of the infrastructure standard are found. Defines the procedures and conditions Resolution 3100/2019 for the registration of health service providers and authorization of health Pertinent. services, and the Manual for Registration of Health Service Providers and Authorization is adopted. CONPES CONPES 147 of 2012 Pregnancy prevention in adolescence Reproductive Health Diagnosis and Management Plan CONPES 155 of 2012 National pharmaceutical policy Drug acquisition diagnosis and management plan CONPES 161 of 2013 Gender equality for women Gender Equality Diagnosis and Management Plan 40 Policy / Applicable Law / Objective and provisions Relevance to the program and key Regulation conclusions Guidelines for the formulation of the comprehensive environmental health Management of hazardous waste inside health CONPES 3550 of 2008 policy establishments National policy for the integral management of solid waste Management of hazardous waste outside health CONPES 3874 of 2016 establishments, and their final disposal. For the achievement of sustainable development goals Diagnosis and Management Plan on background in the CONPES 3918 of 2018 prevention of cervical cancer Strategy for the attention of migration from Venezuela Integration into the health systems of migrants arriving CONPES 3950 of 2018 in Colombia from Venezuela. PARTICIPATION Its purpose is to promote, protect and guarantee modalities of the right to Law 1757 of 2015 participate in political, administrative, economic, social and cultural life, Relevant for citizen participation mechanisms and also to control political power. For the purpose of adopting the policy of social participation in health Pertinent Resolution 2063 OF 2017 (PPSS), and applying to the members of the health system, within the framework of its powers and duties. Law of Transparency and the Right of Access to National Public Pertinent. Law 1712 of 2014 Information. The MSPS makes available to citizens, the health sector and interested Relevant. Resolution 1519 of 2020 parties, the new section on Transparency and Access to Relevant National Public Information MECHANISM FOR PETITIONS, COMPLAINTS, CLAIMS, REQUESTS AND WHISTLEBLOWING (PQRSD) Regulates the processing of requests, complaints, claims, whistleblowing, Articulation of users with the Ministry of Health and congratulations and requests for access to information made to the Social Protection and other GoCo bodies for access to Resolution 3687 of 2016 Ministry of Health and Social Protection information, requests, complaints, claims, whistleblowing, congratulations. 41 PROGRAM CAPACITY AND PERFORMANCE ASSESSMENT 4.1 Capabilities to implement the program's environmental and social management system. 107 The capability of the institutions to effectively implement the program's environmental and social management system is considered adequate considering the regulations (extensive regulatory framework) developed through a process of consensus-building and discussion in the agreements that make up the PND and that are latter reflected in the CONPES documents, Laws, and Decrees. 108 The “Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience” is based on: contribute to establishing and strengthening a focus on access to effective health services for the most vulnerable, based on the quality approach and focusing support towards reducing the high levels of maternal mortality and malnutrition. It will redouble efforts to improve early detection of breast cancer, one of the leading causes of death for women in Colombia. In addition, the proposed Program continues to support the sustainability and resilience of the most vulnerable, through an approach that contributes to improving the preparation and response to future pandemics and adapting to and mitigating the consequences of climate change. 109 With respect to Venezuelan migrants, the Program will help ensure that migrants affiliated with the subsidized health system have access to effective health services and obtain the care they need. Thus, the Program will also contribute to the effective care of Venezuelan migrants and their host populations, as well as to advance their process of socioeconomic inclusion within the country. 110 70 The organizational and administrative structure of the MSPS described in the previous section demonstrates that the institutional capability (personnel, budget, availability of implementation resources, training, etc.) is adequate considering the current evidence to carry out responsibilities defined under the Program's system. A division of responsibilities exists under the same approach that, when embodied in consensus-building processes, strengthens the system, even if the processes may be longer than expected. 111 Under the mandate of the National Constitution of 1991, Colombia is a decentralized unitary Republic, with autonomy of its territorial, democratic, participatory, and pluralistic entities . Under this mechanism of administrative decentralization, a large part of the State administration is performed in shared fashion between the administrative entities at the central and territorial levels (departments, municipalities, and districts). This national status makes the implementation of the Program automatic without the need to generate specific implementation arrangements for the program, providing immediate effectiveness and efficiency in inter-institutional articulation. 112 The Departmental, District and Local health secretariats are responsible in their territories for (i) directing, coordinating, evaluating and controlling the General System of Social Security in Health; (ii) plan and execute projects and guarantee the effective exercise of the right to health of the entire population; (iii) design and strengthen the primary health care strategy; (iv) coordinate inspection, surveillance, and control actions; (v) coordinate health actions in the face of emergencies and disasters. 113 The approach to environmental issues involving the MSPS and MADS is fully integrated and is reflected in the operational sequences at the subnational levels. 114 The processes of drafting regulations undergo steps of public consultation before their final authorization. Some standards are "compiled" into unique standards to update and promote implementation. 115 The Climate Change policy is governed by the Ministry of Environment. At the MSPS level, the Environmental Health Sub-directorate is in charge of preparing the Comprehensive Sectoral Climate Change Management Plan (PIGCCS) for the Colombian health sector, and the adaptation and mitigation guides that guide the regional, departmental secretariats and district. In addition, through a ministerial agreement with the NGO " Health Care Without Harm" it will estimate the climate footprint of the Colombian national health system at the level of a sample of establishments, it will contribute to generating capacities in the use of the climate impact monitoring tool developed by Health Care Without Harm and will provide technical support to determine the dimension and composition of its climate footprint. Subsequently, it will make an estimate of greenhouse gas emissions from the Colombian health sector at the national level. 116 To address and reduce inequities, the GoCo has established consultation mechanisms such as “Workgroups” and “Pathways” for the socio-cultural adaptation and inclusion of the intercultural approach for ethnic groups, indigenous peoples, and vulnerable populations. These are spaces where they build consensus and establish standards of care that respect their ethnic and cultural identity, forms of social organization and their own linguistic characteristics. 117 As in all areas of government, the MSPS has a system of procedures for Petitions, Complaints, Claims, Suggestions and Whistleblowing. Citizens also have the Petitions, Complaints, Claims and Denunciations mechanism of the National Health Superintendence (Supersalud), an entity whose mission is to protect the rights of users of the General Social Security Health System, through the activities of inspection, surveillance, control and the exercise of the jurisdictional and conciliation function. This mechanism is especially relevant because it addresses cases in which the population faces harm due to access barriers to guarantee their fundamental right to health. Supersalud has a mechanism that has several channels for filing petitions such as face-to-face assistance in offices, a telephone line, WhatsApp, and other services that are indicated on the entity's website. All PQRSD through the entity must be resolved in an estimated time of 15 days. 43 ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT (ESSA) 5.1 Introduction to the ESSA and general description. 118 ESSA is a Program document prepared by Bank staff for a thorough assessment of: 1) the systems that the GoCo implements to manage the benefits, risks and environmental and social impacts that are associated with the program to support the financial sustainability of the Colombian health system; and 2) the institutional capability of the government to plan, monitor and report on environmental and social management measures under the Program. 119 Its findings have the goal of ensuring that programs supported by PforR financing are implemented in a manner that maximizes potential environmental and social benefits and avoids, minimizes or mitigates adverse environmental and social impacts and risks. These findings contribute to the preparation of the Program Action Plan (PAP) that the government is expected to use to close the significant gaps in existing environmental and social management systems in line with the sustainability principles of the PfoR. 120 From an environmental point of view, the ESSA assesses the system, capability and performance of the government through the review of national and sectoral laws relevant to the Program, regulations, protocols on public health issues, but specifically Health Care Waste (HCW) management services (handling, transport and final disposal) and WEEE management. It also assesses occupational health and safety (OHS) aspects in health centers and their associated service system (HCW collection and disposal transportation). In addition, it evaluates the aspects related to the effects of Climate Change on the Health System, either due to its effects on the health of the population itself, as well as on the infrastructure and the capacity of the system to continue operating in the face of adverse climatic effects. like geophysicists. 121 From the Social standpoint, the ESSA assesses that equal access to the Health System is guaranteed for all residents, including vulnerable groups, with a focus on gender and indigenous peoples as well as ethnic minorities. It is intended to ensure that there are no prejudices or discrimination against individuals or communities included in the scope of the Program, particularly considering indigenous peoples, minority groups and the less favored or vulnerable, especially in cases where there may be adverse impacts or where the development benefits have to be shared. 44 Applicability of the ESSA Core Principles Core Principle 1: Applicable Core Principle 4: Not Applicable The procedures and processes for environmental and social Land acquisition and loss of access to natural resources are management are designed to (a) promote environmental and managed in a manner that avoids or minimizes displacement, social sustainability in the design of the Program; (b) avoid, and helps the persons affected to improve, or at least restore, minimize or mitigate adverse impacts; and (c) promote their livelihoods and living standards. informed decision-making related to the environmental and Core Principle 5: Applicable social effects of a Program. Due attention is paid to cultural appropriateness and equitable Core Principle 2: Not Applicable access to the benefits of the program, paying special attention The procedures and processes for environmental and social to the rights and interests of indigenous peoples and the needs management are designed to avoid, minimize or mitigate the or concerns of vulnerable groups. adverse impacts on natural habitats and physical cultural Core Principle 6: Applicable resources that stem from the Program. Avoid exacerbating social conflicts, especially in fragile Core Principle 3: Applicable states, post-conflict areas or areas subject to territorial Protect public and worker safety against the potential risks disputes. associated with exposure to toxic chemicals, hazardous waste and other hazardous materials within the framework of the Program. Among the six core principles that guide the analysis of the ESSA (Bank Policy and the Bank Directive for Program for Results Financing -PforR-), from an environmental and social standpoint, four are considered relevant to the Program. 5.2 ESSA methodology 122 Initially, information was collected from secondary data sources that were validated and supplemented through consultations and interviews with the key stakeholders. Officials and technicians from different divisions of the MSPS were also interviewed to gather evidence, functional knowledge, and concerns. 123 Existing regulatory and policy frameworks were analyzed: environmental and social, worker health and safety. Legal and regulatory requirements were assessed, including those related to environmental conservation, pollution prevention, occupational health and safety and public safety, social inclusion and the transparency and accountability mechanism, and the social and environmental aspects related to the Program. 124 The operational procedures, existing institutional capability, and the viability of the effective implementation of the Program activities were reviewed. Existing gaps are identified for remediation. 125 As part of the ESSA's preparation, discussions and consultations were held with key stakeholders at the MSPS. Específicamente se puso especial énfasis en las direcciones vinculadas con los límites del Programa. The consultations began in February 2023, the interviews were carried out during a World Bank mission in Bogotá between February 08 and 10, 2023, and then a new mission in Bogotá was carried out between April 27 and May 05. 2023 and allowed to deepen the social aspects of ESSA. Within the orbit of the MSPS, the Subdirectorate of Environmental Health31; the Department of Epidemiology and Demography32; technical teams from MSPS and Primary Health 31 Sobre Estrategia de transición con bajas emisiones de carbono para el sector sanitario con objetivos cuantificables. 32 Sobre Sistema integrado de vigilancia de la salud pública y cambio climático a nivel subnacional 45 Care Centers (CAPS for Spanish acronym)33; the Directorate of Assurance and Sub-directorate of Noncommunicable Diseases of the Directorate of Promotion and Prevention, Office of Social Promotion and Directorate of Medicines34; Directorate of Promotion and Prevention35. Other State entities participating in these spaces were the National Planning Department - DNP Presidential Agency for International Cooperation of Colombia, APC-Colombia. ENVIRONMENTAL AND SOCIAL RISK SCORES 6.1 Risks and social considerations associated with the Program. 126 This section provides an overview of the social risks associated with this Program, which are based on three of the ESSA Core Principles (CP), CP 1, CP 5 and CP 6. CP 1 covers general aspects of environmental and social management, aims to promote environmental and social sustainability in the design of the Program, avoid, minimize or mitigate adverse impacts and promote informed decision making related to the environmental and social impacts of the Program. For CP 5 on Indigenous Peoples and vulnerable groups, the objective is to give due consideration to cultural suitability and equal access to the benefits of the Program, paying special attention to the rights and interests of indigenous peoples and the needs or concerns of vulnerable groups. CP 6 considers social conflicts, especially in fragile states, post-conflict areas, and has the goal of avoiding the exacerbation of social conflicts in fragile states, post-conflict areas or areas subject to territorial disputes. Core Principle 4, land acquisition, is not relevant because the Program does not provide for any land acquisition, given that the Program is not compatible with any construction, so there will be no need for expropriations or resettlements as a result of the project, nor any limitation to access or use of land. 127 Core Principle 1.- Summary of findings: The Program is expected to have positive impacts on population health, including the most vulnerable sectors, as well as women and children, and the adult population, including dispersed rural populations. The positive impacts are achieved through the expansion of access and use of efficient quality health services, by those enrolled in the SGSSS, from both the contributory and subsidized regime. 128 The ESSA results confirm that the GoCo's current system for managing the social aspects of the Program to improve access to effective health services for vulnerable people and greater resilience of the health system, has several strengths. Which are based on a current high enrolment coverage (94.4% in 2018) to the Social Security System for Health (SGSSS), a solid legal framework to improve equitable and inclusive access to EPS and IPS services, a decentralized management system, with autonomy of its territorial, democratic, participatory and pluralistic entities established at the constitutional level. There are also long-standing institutional 33 On administrative act that includes climate change adaptation and mitigation standards for service providers, CAPS in operation, implementation of carbon emission reduction measures in public hospitals. 34 On Venezuelan migrants with HIV with access to effective antiretroviral treatment, regulations allowing access to effective antiretroviral treatment for HIV, domestic production of drugs for neglected diseases, and beneficiaries with access to treatment for neglected diseases. 35 On Households served with effective services through multidisciplinary teams and CAPS, basic health teams operating continuously in the national territory, including territories with high migrant population, beneficiaries screened for depression through multidisciplinary teams of extramural care and vulnerable beneficiaries with access to effective health services. 46 mechanisms based on the National Development Plan (PND) and the documents of the National Council for Economic and Social Policy (CONPES) so that a variety of stakeholders have partition spaces regarding the Health System, including procedures for Petitions, Complaints, Claims, Suggestions and Whistleblowing at the national and local level. 129 According to the Ministry of Health (2021), for the year 2021 the percentage of affiliates to the subsidized regime at the national level was 47.7%; a percentage similar to that of affiliates to the contributory regime of 46.2%. However, the regional perspective reveals that for the departments of Guaviare, Sucre, Meta, Caquetá, Casanare, Caldas, Boyacá, Córdoba, Arauca, Huila, Bolívar, Choco, Amazonas, Norte de Santander, Tolima, Putumayo, Vaupés, more than 60 % of affiliates belonged to the subsidized regime, which could suggest a possible gap in the quality of health care. 130 The Program requires greater involvement of the health secretariats at the departmental and municipal levels. Although national health plans establish goals that departments and municipalities could adopt, a World Bank evaluation of the Quality of Care in the Health Sector in Colombia (2019) reveals that, in practice, there is fragmentation between the goals set at the different levels. Consequently, the Program must confirm the level of the capacities of the territorial entities to plan and manage the public health network and if this is one of the factors that affects the unequal performance that is observed in relation to the indicators associated with maternal mortality and malnutrition that have been previously described. 131 The data on the performance of the PQRSD in the health sector shows that, although the Ministry of Health has an effective mechanism for citizen care, in recent years, the use of the guardianship action before the National Health Superintendency is growing. This finding suggests that the guarantee of the right to health requires mechanisms that transcend instances of citizen participation and PQR. Actions at the regional or local level, through teams that go to homes, constitute an opportunity to strengthen dialogue, participation, and trust in health sector institutions, which additionally require efforts to disseminate sufficient information so that people and groups know, understand, access the benefits of this Program, and can present freely and at any time, their concerns or suggestions about health services. 132 Core Principle 5.- Summary of findings: The Program has a low probability of any negative social impact. The key social problem identified is related to inequalities in health care services in districts that are remote or connected with ethnic or indigenous minorities. The gaps in the provision of health services to ethnic minorities and indigenous peoples have been identified and assessed by the GoCo in the document “Bases of the National Development Plan 2022-2026” and in the specific CONPES, establishing the steps to be followed and the key actors involved. 133 The National Accessibility Plan for People with Disabilities, prepared by the MIE, contemplates, among other aspects, accessibility in the institutions that provide health services and information for people with disabilities in accessible means, modes, and formats on the offer of services, health care and user rights. 134 Population-based primary health care with a focus on multidisciplinary territorial teams and primary health care centers ensure high coverage from the early stages of the care continuum. This is the focus of all the actions supported by the Program in this Focus Area. The Program is providing explicit support to the multidisciplinary strategy of primary health care. In this PforR, the World Bank will support the actions of the MSPS to form a multidisciplinary team for primary health care. The Program includes a DLI on the number of multidisciplinary teams operating in the 47 field. In addition, support in this area focuses on the number of vulnerable households being monitored by these multidisciplinary teams as an intermediate indicator. 135 A key social problem identified is related to inequalities in health care services in districts remote from or linked to ethnic or indigenous minorities. The gaps in the provision of health services to ethnic minorities and indigenous peoples have been identified and assessed by the GoCo in the document "Bases of the National Development Plan 2022-2026" and in the specific CONPES, establishing the steps to follow and the actors’ keys involved36. During 2022 and 2023, the Ministry of Health has made progress in agreeing on the guidelines of the Indigenous and Intercultural Health System (SISPI) for indigenous peoples; health guidelines specific to the Black, Afro-Clombian, Raizales and Palenqueras communities and for the Rom communities. It is required that the processes of territorial dissemination, protocolization and adoption of these instruments take place, to plan culturally relevant health actions and that address maternal and child health indicators that profoundly and differentially affect Colombian ethnic groups. 136 The Program further supports the State's culturally appropriate indigenous health agenda by improving the quality of health care in all districts and also by trying to bridge the gap in health care provision among the poorest and most backward districts. of the state. The Program supports distribution equity, affordability, to overcome cultural, ethnic, migrant, returned Colombian, victims caused by or related to the armed conflict, or gender restrictions for access or participation. Consider how to alleviate cultural, financial, or physical barriers that make it difficult for socially marginalized or disadvantaged groups to participate (for example, sparse populations, the poor, the disabled, children, the elderly, indigenous peoples, or ethnic minorities, among others). 137 Regarding maternal mortality: the prioritization of urban and peri-urban areas in the Program can contribute to reducing the gaps of inequity in health care, especially for pregnant mothers. The general population of rural Colombia is highly vulnerable, but they may be even more vulnerable if they belong to an ethnic group, particularly due to the tensions that can arise between cultural practices of health care based on the use of plants and rituals associated with nature, with the practices of western medicine. Another aspect to consider is found in the tools for obtaining information on maternal mortality in the national territory that are the input for the formulation of strategies, plans or programs; The Public Health Surveillance System (Sivigila) created the Web- Based Maternal Mortality Epidemiological Surveillance Information System in 2012, however, internet connectivity in rural areas is still quite deficient despite the fact that It rose as a result of the situation caused by Covid 19. According to DANE, the proportion of households with an Internet connection in 2021 in the national total was 60.5%, in capitals 70.0% and in populated centers and dispersed rural areas 28.8%; Even though these figures reveal only household access, it must be taken into account that connectivity depends on the infrastructure available in the territories, so the State institutions that exist in rural areas do not have Internet access either. 138 Recent trends in maternal mortality in Colombia are worrisome. There has been an increase in the rate mainly due to COVID-19, but also due to other specific factors such as hypertension, obstetric sepsis, and abortion. Most of the cases are concentrated in poor territories such as Chocó, Arauca, La Guajira, Nariño, Magdalena, Norte de Santander, Bolívar and Cauca. Furthermore, maternal mortality is closely related to income, as the rate in the bottom quintile is more than 5 times higher than in the top income quintile, at 180 per 100,000 and 35 per 100,000, respectively. In turn, this inequality is correlated with unequal access to prenatal care: while 91.5% of pregnant women in the top income quintile have at least one prenatal checkup, the percentage drops to 77% among pregnant women from the bottom quintile. This has led the Government to develop the Plan to Accelerate the Reduction of Maternal Mortality that the World Bank supports with the proposed 36 Ver párrafos 8 y 9 de este documento 48 Program. Thus, the activities supported are the development and implementation of the Maternal Mortality Care Network Strategy and the implementation of an information system for monitoring cohorts of pregnant women. Specifically, the Program includes a DLI on the implementation of the Maternal Mortality Care Network Strategy, which includes the identification of the Maternal Mortality care network at the territory level and the training of health workers in the territory. In addition, intermediate indicators include the number of women in the cohort of pregnant women who are being monitored in the aforementioned system and the rate of use of telemedicine to consult referral hospitals in the care network for cases of extreme maternal morbidity. 139 Migrant pregnant women are also considered a vulnerable population. According to Infographics from the National Migration and Health Observatory, based on data from Sivigila from May 31, 2022, the maternal mortality ratio in migrant or refugee women in Colombia was 61.8 (37 cases) for 2020, and 91. .8 (56 cases) by 2021. In 2021, 87.5% of the cases of maternal mortality were not affiliated to the SGSSS at the time of death. However, monitoring this group in particular is a challenge if they do not have a fixed residence or belong to an assistance program that allows their placement during the gestation period. 140 In recent years, breast cancer has become a serious public health problem for women in Colombia, having the highest incidence (37.5 per 100,000 women) and mortality (11.3 per 100,000 women) among all cancer pathologies among women between 2012 and 2016. In addition, detection and early detection rates have not improved and, in fact, have worsened during the pandemic. The program has a low probability of generating negative social impacts, however, two key aspects must be addressed. 1). It is evident that the figures generated by the two notification systems do not coincide with each other, so it must be considered that an urgent action is to align the information systems so that the figures they provide are reliable. 2) The social determinants of the increase in cases of breast cancer in the national territory that, when differentially identified due to some differences such as ethnicity or geographic location, would make it possible to focus efforts to focus attention and have timely processes of detection and attention. Although in Colombia there have been multiple actions aimed at cancer care as a disease of national public interest in the first decades of the 21st century, there are no current regulations exclusively for breast cancer. The Program supports the Government Plan to Accelerate the Reduction of Breast Cancer, which has a population approach to guarantee high coverage in the early stages of care. The Program includes an increase in the screening rate in vulnerable women as an intermediate indicator and proposes advancing in the care continuum to measure the rate of early detection of breast cancer in vulnerable women with a positive DLI diagnosis. 141 Regarding child malnutrition: Although the program has a very low possibility of generating negative social impacts, the reduction of malnutrition in early childhood requires addressing multiple determinants, both social and structural. It should also be considered that malnutrition in Colombia is due more to factors associated with purchasing power than the availability of food in the national territory; there is a risk of perpetuating actions aimed only at providing food to the most vulnerable population and not at remedying the gaps of economic inequality, for example, in access to employment. The Government is focused on developing a plan to address the problem that includes a food stamp program called Bono Hambre Cero. The Program seeks to complement the efforts of the GoCo and will support early actions in the care continuum, starting with the development of a nominal follow-up by the MSPS and the implementation of an information system that follows each child from the diagnosis of malnutrition until the administration of the treatment. In addition, the implementation of said information system together with the increase in the malnutrition diagnosis rate are included as intermediate indicators. The DLI in this outcome chain is the rate of treatment delivery to children diagnosed with acute malnutrition. 49 142 Core Principle 6.- Summary of findings: no exclusion of any group in terms of caste, religion or geography is expected for the activities of the Program, considering that the most vulnerable population in the country refers to ethnic groups, women, LGTBQ+ groups, boys, girls and adolescents, migrants and people living in poverty, all considered subjects of actions and protection by the State and beneficiaries of this PfR. Furthermore, the country's health sector has been responding to the phenomenon of Venezuelan migration since 2015 and has recently strengthened its plan. The attention of returnee Colombians, who had left Colombia as a result of the armed conflict, has also been incorporated. However, increasing demand for services has increased the burden on primary care centers and local hospitals. In the case of victims caused by or in relation to the armed conflict, in the individual, family and community spheres, the Program for psychosocial and integral health care for victims (PAPSIVI) has been implemented, containing a set of activities, procedures, and interdisciplinary interventions designed by the MSPS for comprehensive health care and psychosocial care. The Program will also contribute to addressing the concerns that the GoCo has seenin the first stage of PAPSIVI over the course of almost six years, and a second stage remains to be implemented. 143 A key concern from recent times is linked to the migration of population from Venezuela. This influx of Venezuelan migrants and Colombian returnees is generating significant fiscal, economic and social pressures on health institutions and services, particularly in receiving areas. Priorities that emerge in the migration process are associated with: (i) Psychosocial impact due to network fragmentation; (ii) Pregnant women, children and adolescents without access to promotion and prevention actions; (iii) Gender violence, trafficking in persons, etc; (iv) Risks associated with transmissible events; (v) Chronic decompensated conditions (mental health, AHT, diabetes and asthma among others); (vi) Overloaded health systems, leading to demanding overload of use of inputs (medicine, personnel, etc). 144 Approximately 1.4 million Venezuelans receive assistance through different strategies depending on whether their status is linked to the Special Residence Permit (PEP), or Border Mobility Card (TMF), among other mechanisms which include vaccination systems for children, birth care, initial emergency care, etc. However, there are still difficulties caused by the migrants' own irregularities (illegal entry, stays beyond time allowed), as well as by not being able to enroll in the subsidized health regime for not complying with the requirements set forth in the Potential Beneficiaries of Social Programs Identification System (SISBEN). 145 Venezuelan migrants living in Colombia are exposed to poor socioeconomic conditions and poor access to the health system. This disadvantaged position puts them even more at risk of disease. This is the case of HIV: the prevalence among migrants is twice the prevalence in the native population (0.9% and 0.5%, respectively). The Government is placing a lot of emphasis on the regularization of migrants and access to the health system. In parallel, the Program seeks to support efforts to promote access to effective treatment among migrants with HIV. First, the Program supports actions to advance in the centralized procurement of generic antiretrovirals and includes increased HIV detection in migrants as an intermediate indicator. As DLI, the Program incorporates the rate of HIV-positive migrants who have access to adequate treatment as defined in the Clinical Practice Guidelines. 146 An identified social problem refers to the possibility of making errors in the targeting and prioritization of populations that exclude them from having the benefits of the program. Considering that the State has at least 42 information system 37 s and that, although they share criteria, the data may be fragmented or centralized, making it difficult to identify and monitor 37 Texto preliminar del proyecto de reforma al sistema de Salud (2023). Consultado en: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/proyecto-ley-reforma-salud-msps.pdf 50 potential beneficiaries. The Program requires work to articulate existing tools or the strengthening of information systems that are under development, to minimize this risk. 147 The Program, by improving efficiency and quality, will also contribute to strengthening the Integrated Gender Violence Information System (SIVIGE) with the objective of providing, integrating, harmonizing and disclosing statistical information on gender violence38, (visibility tool for prevention and monitoring of protective measures, care, reparation and access to justice for victims of gender violence or people at risk of being its victims). 148 The general social risk was classified as "moderate" because possible risks in the selection of the most vulnerable. The risks in the selection may be due to reasons such as few resources for the development of strategies or territorial systems for their identification and follow-up; weakness in the application of unified tools to target and prioritize the population, restricted access for geographic and security reasons to ethnic communities, and lack of data to track people who do not yet have their immigration status defined. This will be mitigated through the strengthening of the intercultural approach to health, gender and diversity, the strengthening of information systems for monitoring the prioritized population and a solid communication strategy, stakeholder participation and attention to complaints and claims (PQRS) of the MSPS. On the other hand, there is no land acquisition, resettlement, or loss of access to natural resources, and there is no serious risk of exacerbating social conflicts, in relation to land tenure or use. 149 The analysis of the health and gender situation includes the identification of historical, political, social, economic, cultural and health aspects that produce differences in the relationships between men and women. According to statistics from the National Administrative Department of Statistics (DANE), in the second quarter of 2018 the participation rate for men was 74.8% and 53.6% for women; the employment rate 69.3% for men and 46.9% for women; and the unemployment rate 12.4% for women and 7.4% for men. There is also evidence of segregation of occupations by gender, where women work more in service sectors. All these figures show the disparity between men and women, and women are at a clear disadvantage, the same occurs in the expression of poverty. 150 The most evident gap around breast cancer is expressed in the difference in time from clinical perception to diagnosis and care between the types of users depending on whether they are in the contributory regime or the subsidized regime. Although it is clear that the high cost of using diagnostic tools is decisive, perhaps it is even more relevant to expose the incidence of the weak hospital infrastructure that shelters 30% of the Colombian rural population that has been dispersed throughout the national territory. In this sense, it is urgent to address early detection, if due to the limitations of women in their territory, the displacements and efforts for breast cancer care are greater in cost and effort for the most vulnerable. 151 In Colombia, the rates of violence against women are higher than the Latin American average. According to data from the Coroner's Office, between January and February 2019, 138 homicides of women, 2,471 cases of domestic violence, 3,263 cases of alleged sexual crime, 5,501 interpersonal violence and 5,877 cases of partner violence were recorded. According to the forensics report, from the Coroner's Office, in 2018, 10,794 cases of violence against children and adolescents in the country were reported. 152 The Program has some negative impacts, which could be derived from possible exclusions of populations due to targeting errors or restrictions for security and public order that limit 38 Physical, psychological, sexual and economic violence. 51 access to benefits for some of the vulnerable groups identified. In particular, this Program is expected to generate fundamental social benefits by improving the quality and efficiency of health services. This will be carried out with a transversal gender perspective, particularly through (i) the training of health personnel in gender and diversity; (ii) technical assistance to the Regions to implement a gender and diversity perspective in PHC services; (iii) the development and dissemination of communication strategies that contribute to these gender and diversity perspectives; and (v) the design and implementation of a guide to medical procedures to identify and provide care services to people who have suffered/suffered from GBV. Recommendations on social aspects. 153 Based on the evaluation, the table below presents the key social problems identified and the recommendations or the way forward for the evaluation. 52 Table N° 2 Recommendations on social aspects Key social issues Recommendations / Way Assessment / Key findings identified forward For Indigenous peoples: Finalize the protocolization, issuance of the administrative act and the adoption of the SISPI at XII. Pact for equal opportunities for the territorial level. ethnic groups: indigenous, Black, Afro, For Afro-Colombian, Raizal Raizal, Palenquero and Rom. Generation and Palenquera Black Reduce inequalities in of differentiated actions that create communities, and the Rom health care services in conditions of equality in the access to people: remote districts, with goods and services to advance in the Finalize the protocolization, restricted access and materialization of the rights of which they issuance of the administrative act linked to ethnic are subject, under the principle of and the adoption of guidelines minorities or progressivity and considering their and guidelines for a socio- indigenous peoples. worldview and traditions. cultural adaptation of health services in their territories. It is important to have proper documentation of the prior consultations or consultations that have taken place during the process. The competent institutions and instances of the National Family Welfare System (SNBF for Spanish acronym) and the Strengthen the monitoring tools Intersectoral Commission for and ongoing actions of Comprehensive Early Childhood Care intersectoral implementation (CIPI for Spanish acronym) will within the framework of the accompany the territorial entities and strategy for care and prevention ethnic communities and authorities in the of child malnutrition that has interinstitutional and intersectoral been led by the ICBF. management of care prioritized in areas of Reduce the gaps in child nutrition and maternal and child comprehensive care for health, within the framework of Likewise, promote the National children, particularly in comprehensive care for early childhood, Plan for the Implementation of rural areas, in ethnic childhood and adolescence Taking into the Food-Based Dietary groups and in territories account the serious impact of malnutrition Guidelines (GABAS for Spanish with difficult access. on child development, axis 3 of the PND acronym) that is contemplated in 2022-2026 "Right Human to food" the PND 2022-2026 and on contemplates the availability, access to which the MSPS has been food and adaptation to the nutritional advancing with different entities needs of the population, among which are of the National Family Welfare prioritized, the promotion of exclusive and System. complementary breastfeeding up to two years of life and the strengthening of environments development programs that promote healthy eating. Strengthen the approach The Ministry has differentiated statistics to social determinants in by gender and the Integrated Information health care for women, System on Gender Violence (SIVIGE) Strengthen the use of information especially those living that provides important information to tools such as SIVIGE and train in remote areas and understand the situation of women, basic health teams and territorial ethnic communities, in however, these tools require strengthening entities that require it in the relation to breast cancer, and adoption of different actors and gender perspective. maternal mortality, and instances of the health sector. for the GBV cases that affect planning of pertinent and opportune their quality of life. 53 Key social issues Recommendations / Way Assessment / Key findings identified forward services of the actions to lead with women. The Health Sector Response Plan to the Migratory Phenomenon of Venezuelan Migrants and Refugees, is made up of indicative actions fundamentally oriented Strengthen identification towards health care in Colombian territory mechanisms, socioeconomic for people who enter the country as characterization and targeting of migrants. He already has several years of migrants coordinated by the Strengthen adequate experience. Migration area of the MSPS. health care for the needs The approval of the Temporary Protection of the migrant Statute in 2021 allows a wide series of Plan measures at the territorial population at different regularization measures and expansion of level to address health territorial levels. access to services in the health and social vulnerabilities that seriously protection sectors of this population. affect the lives of migrants, Likewise, the PND contemplates in Axis 5 especially related to pregnant "National Convergence" the protection women and children in a state of mechanisms for migrants and particularly malnutrition. the provision of co-financing resources by territorial entities to serve the migrant population. Reduce errors in the The MSPS has a Public Health targeting and Surveillance System designed to observe prioritization of and generate reports for the systematic populations and analysis of health events that allow the exclude them from Articulate mechanisms for planning, execution, and monitoring of having the benefits of capturing information at the public health actions; however, the the program, different levels that allow loading of information at the different managing information on the considering the levels and at the territorial level does not population characterized by risk different information happen in real time and relevant and thus targeting and systems of the information can escape. prioritizing interventions that institutions and In the same way, there are instruments correspond to these profiles. weaknesses in the use that can be reported or not to this system of unified tools for but that have key information to target the population, but it is fragmented or targeting the unknown by the competent entities. population. The MSPS provides technical assistance to territorial entities for the adoption of the protocols, guides, regulations, and Confirm the level of the Develop a solid technical tools that are required to be used for capacities of the assistance plan on key issues to better interventions, given the need for achieve the expected indicators territorial entities to greater involvement required by the and strengthen the management plan and manage the implementation of this Program, it is of public health priorities at the public health network. important to review and evaluate territorial level. capacities in the different levels to guarantee territorial appropriation of public health management. Guarantee the The Office of Social Promotion of the Strengthen information, disclosure of sufficient MSPS in previous years has developed education and communication information so that the "Information, education and strategies that allow populations individuals and groups communication strategies in health, to access the benefits of this know, understand, inclusive and accessible" with relevant Program and can present freely access the benefits of results to guarantee the informed and at any time, their concerns, this Program and can participation of citizens, especially the and suggestions about the health 54 Key social issues Recommendations / Way Assessment / Key findings identified forward present their concerns most vulnerable, through accessible services available in their or suggestions about mechanisms, friendly and not only the use territory. health services freely of PQRS. and at any time. 6.2 Environmental risks and considerations associated with the Program 154 This section provides an overview of the environmental risks associated with this Program, which are based on three of the ESSA Core Principles (CP), CP 1 and CP 3. CP 1 covers general aspects of environmental and social management, and its goal is to promote environmental and social sustainability in the design of the Program, avoiding, minimizing, or mitigating adverse impacts and promoting informed decision-making related to the environmental and social impacts of the Program. CP 3 is intended to protect public and worker safety against the potential risks associated with the provision of health services. 155 The Program's activities target the financial sustainability of the existing Colombian health system for vulnerable people and generate greater resilience of the health system to the effects of Climate Change. The operational phase may have certain impacts and risks, including medical waste and other solid and liquid waste within the health and transportation facilities and disposal of solid medical waste. If not managed well, these activities will pose a threat to the environment, public health, and safety at work. 156 Core Principle 1.- Summary of findings: Certain interventions under the Program would require sustaining current mitigation actions and sustainable approaches to better manage the environmental effects of the Program. These include, among others (i) Issues related to the generation, collection, segregation, storage, transportation, handling, and disposal of biomedical, solid and hazardous waste. It is important to pay special attention to the collection of information and the timely control connected with HCW flows, in the case where it is necessary to carry out interventions by making informed and timely decisions (eg: availability of consumables in the case of mass vaccination campaigns, increases in laboratory diagnoses, or surgical or cytotoxic treatments); (ii) Reduce the risk of getting infections inside health facilities. 157 With a coverage on the order of 98% enrolment in the SGSSS, large variations in the generation of health-care waste due to the project are not expected. The possible (minor) increases could be due to improvements in the quality of benefits and early diagnoses of diseases such as cancer or diabetes. Another cause of increases in health services benefits might be due to the enrolment of migrants. It is important to remember that a large majority are already receive services under different schemes, some through enrolment in the SGSSS, or through other schemes that include vaccination systems for children, birth care, initial emergency care, etc. The problem of possible increasing burdens from waste generated by the IPS requires special attention so that its management is maintained within the parameters established by the regulatory frameworks. An adequate forecast of patients to be serviced in the EPS, the types of diagnoses and medical practices to be carried out allow estimating the material, human and budgetary resources necessary for the adequate handling and final disposal of HCW. Its adequate management and the timely information regarding volumes and streams of HCW generated allow adapting possible gaps just in time. 55 158 The most remote places can present disadvantages for the final treatment of HCW and WEEEs. This is linked to the lack of economic attractiveness of providers of said service linked to the low volumes generated. 159 Core Principle 3.- Summary of findings: Certain interventions of the medical practices of the health system could expose health care providers and beneficiaries to risks associated with exposure to hazardous materials, infections, radiation, as well as sharps, etc. This would require the integration of mitigation actions provided in the inspection, oversight, and control (IVC) actions of sanitary and environmental risks in the workplace; improvement of the physical and psychosocial environment at work, promotion of occupational risk insurance, among others, within the framework of the General Occupational Risks System (SGRL for Spanish acronym). These include, among others: (i) the improvement of occupational health and safety practices for infection control, and protocols to address accidental spills; (ii) Provide protective clothing and personal safety equipment, as necessary; (iii) Ensure safe storage, segregation, transportation, and disposal of hazardous waste. Additionally, in the current design of the Program, physical infrastructure construction is not expected, including the rehabilitation, improvement, and operation of existing healthcare facilities, which is why no impacts related to works, construction, or occupation of new habitats are expected outside the current footprint of the health system. 160 The analysis allowed identifying the environmental risks in the sanitary waste management system: (i) Risks of infection for medical and healthcare personnel, and for patients with: needle and sharps punctures, exposure to blood and liquids in health centers, laboratories, emergency medical care services, medical posts, medical waste at disposal sites (temporary, transitory and / or final); (ii) Risks of infection of patients in healthcare facilities with inadequate epidemiological and infectious control / inadequate (infection transmitted through air, water and / or the use of poorly sterilized medical instruments; (iii) Air, soil and water contamination risks due to improper handling and management of sanitary waste; (iv) Risk for the management and disposal of chemicals and radioactive materials (generated in cancer centers, therapies, dialysis centers, X- rays, among others). 161 There is the possibility of managing HCW in Colombia. According to information from the Ministry of Environment and Sustainable Development, in 2020 Colombia has a biological risk waste management capacity of 444.02 t/day represented by 55 management companies with a current environmental license, and 4.66 t/day represented in 8 IPS located in Leticia (Amazonas), Nariño (Pasto), 4 in Medellín (Antioquia), Florida Blanca (Santander) and Manizales (Caldas). (Ministry of Environment and Sustainable Development, 2020). In 15 departments there is only one authorized RESPEL manager and 9 departments without any offer of local managers. 162 The District Environment Secretariat, with Resolution 5262 of December 16, 2021, establishes the obligation for health care waste generators that amount to approximately 47,000 to register in the Registry of Hazardous Waste Generators, in accordance with the aforementioned standard, regardless of the moving average of generation. For this reason, between 2021 and 2022, in the registry, the registration of generators increased by 1,294 establishments (16%). 163 According to the results of the Registry of Hazardous Waste Generators during 2021, it is concluded that 90% of the total generation of this waste in the country is made up of 10 RESPEL streams, including streams Y9-A4060 (Waste mixtures of oil and water or hydrocarbons and water) 61%, Y1-A4020 (Clinical waste) 10%, and Y8-A3021 (Mineral oil waste) 5%, which together represent 76% of the national generation. 56 164 Stream Y1+A4020, clinical waste, reports its highest generation in the cities of Bogotá D.C., Medellín, Cali, Barranquilla and Montería, and the highest type of management reported, in quantity, was treatment (77%); in the first place, the thermal by autoclave (53%) and, secondly, the thermal by incineration. This type of waste has had a significant increase in its generation (51%) during the years 2020 and 2021 (63,426 and 62,909 Tons per year respectively) compared to previous years (42,731 and 41,995 Tons per year for 2018 and 2019), mainly associated with the health emergency by COVID-19. Of the 43,942 tons reported, corresponding to 1,614 establishments (Hospital and clinic activities, with ISIC 8610 hospitalization), 0.3% had the following destination: Used, 80% Treated, and 20% Disposed. If the establishment generates less than 10 kilos of RESPEL per month, it is considered exempt from the obligation unless the environmental authority so requires.39 165 The health sector is the one with the highest reporting in the RESPEL registry, with 33% of the number of establishments (5,809) and is considered among the first three generation streams of 33 of the 40 environmental authorities. 166 An increase in medical practices and HCW generation can overload the personnel dedicated to its management and/or demand the incorporation of personnel for these tasks . Therefore, it is necessary to uphold continuous training efforts in the management of HCW. In addition to the inclusion of modules on the management of HCW in the training of human talent, there are opportunities in equalizing knowledge and skills in the most remote places, especially in safety regulations for patients and health establishment personnel in regard to infectious diseases, and sharps, among others. 167 The integration of mitigation actions is provided in Colombian regulations, especially provided in the inspection, oversight and control (IVC) actions of health and environmental risks in workplace settings, improvement of the physical and psychosocial environment at work, promotion of occupational risk insurance, among others, within the framework of the General Occupational Risks System. These include, among others: (i) the improvement of occupational health and safety practices in healthcare facilities through the design of Infrastructure, infection control, and protocols to address accidental spills; (ii) Provide protective clothing and personal safety equipment, as necessary; (iii) Ensure safe storage, segregation, transportation, and disposal of hazardous waste. All aspects are provided in the national regulations described in the regulations section that includes good industry practices. 168 The proposed Program is expected to increase positive environmental benefits in the health sector. It will help to improve the quality of health services that cover aspects of better environmental hygiene and waste management, based on better access to information, and on the training of human talent. Along with the improvement and specialization of health services, it is expected that standardized hospital management practices for medical waste, occupational health and safety, will spread awareness, and improve the collection and transportation of medical waste in the most remote areas. 169 The rules related to air quality, proper management of HCW and prevention of environmental pollution, and legislation related to occupational health and safety must also be followed. All these activities are subject to the control of regional or municipal authorities, and include inspection, oversight, and control (IVCS) actions. Resolution 1229 of 2013 of the Ministry 39 Resolución 1023 de 2010, artículo 28, parágrafo 1o: “los generadores de residuos o desechos peligrosos que generen una cantidad inferior a 10 kg/mes están exentos del registro. No obstante, la autoridad ambiental, con base en una problemática diagnosticada y de acuerdo a sus necesidades, podrá exigir el registro de estos generadores, para lo cual deberá emitir el acto administrativo correspondiente”. 57 of Health, established that the sanitary IVC needs to be performed with a risk-based focus. The National Institute for Food and Drug Surveillance (INVIMA) designed and implemented a risk- based health surveillance model, which allows creating a risk profile for each of the entities monitored and thus generate a ranking to determine the levels and frequencies of inspections. 170 During the assessment the general adequacy of the environmental systems, of the institutional and legal framework for the management of medical waste at the IPS level was confirmed . The categorization and segregation system of HCW, the integral management plans for hospital waste and similar are implemented within the Colombian health sector. The integral management of waste generated in healthcare and other activities 40 has two instances, one within the health establishments (intramural) under the oversight of the MSPS, and another outside the Provider Entities (extramural) under the oversight of the MADS. At the sub-national levels, the Departmental, District and Local Health Directorates are responsible for the management of intramural HCW, being under the inspection of the MSPS. At an extramural level, the external management of the HCW is under the purview of the Regional Environmental Authorities41. 171 In Colombia there are currently 26 authorized facilities for the storage, treatment, use, and/or final disposal of hazardous waste and/or electrical and electronic equipment (WEEE) that correspond to the departments of Antioquia, Atlántico, Bolívar, Caquetá, Cauca, Cundinamarca, Chocó, Huila, La Guajira, Meta, Norte de Santander, Santander, Sucre, Tolima, Valle del Cauca, Putumayo, Amazonas, and Guaviare42. 6.3 Climate Change (CC), extreme weather events and disaster risks 172 The effects of CC and the risks of geophysical disasters represent a risk for the implementation of the Program, both for its direct effects to interfere with the dynamics of health systems, interrupt telecommunications services or impact the health of healthcare workers, patients or their families. 173 Colombia is made up of a wide geological, geomorphological, hydrological and climatic diversity, which as a whole represent a potential threat to the social and economic development of the country. The El Niño and La Niña phenomena affect precipitation regimes causing hydrometeorological events such as droughts, floods, torrential floods and mass movements, among others. 174 The occurrence of dangerous natural events is an indicator of the high vulnerability of communities located in areas prone to these phenomena. The territorial distribution of these consequences is not uniform and, in general, the municipalities that are most affected by the materialization of these environmental threats are usually those with the lowest levels of development and the greatest presence of vulnerable. In addition, the repetition and combination of these natural phenomena further aggravates the situation and prevents and delays development and social welfare. 175 In Colombia, 87% of the population is exposed to a high and medium seismic hazard, 28% to a high potential for flooding, and 31% to a high and medium hazard due to mass movements. 40 Decree 351 of 2014 (Compiled in Decree 780 of 2016 - Single Regulatory Decree of the Health Sector-) 41 Regional Autonomous Corporations, Corporations for Sustainable Development, and Urban Environmental Authorities. 42 Consulta en Web de IDEAM del estado de los gestores reportados por la Autoridad ambiental a la fecha de 31/05/2023, 7:11:56 pm 58 Population increases, the dispersion of human settlements and the location of assets in areas exposed to hydrometeorological phenomena are determining factors in the increase in risk, which in turn are closely linked to the conditions of poverty and vulnerable. 176 Colombia's population and infrastructure are among the most threatened by climate change and natural disasters. About 22% and 26% of primary health care centers and hospitals, respectively, are exposed to climatic hazards such as flooding. Extreme weather events, such as intense flooding, affect accessibility to health facilities, increasing transportation time. In addition, emissions from the health sector have increased by 30% in the last decade, globally representing an average of 5% of net global emissions, with estimates indicating that the Colombian health system is responsible for 2.35% of the total of GHG emissions in the country (Lenzen et al. 2020). 177 Climate change and the increase in incidents of extreme weather events (heat waves, droughts, floods, storms, etc.) they require a clear determination to adapt the systems. In this case human health in general and vulnerable groups in particular. In the Third National Communication on Climate Change, Colombia has identified the climatic relationship with human health, due to temperature and precipitation differences in climatic lapses, as well as the relationship with the vector Aedes aegypti as a vector of a significant number of viruses that affect the Colombian population (dengue in particular, and malaria). The increase in the minimum nighttime temperatures in the foothills of the Andes and with changes in the hydrological cycle induced by the phenomenon of the El Niño-Southern Oscillation Phenomenon (Fenómeno de Oscilación del Sur de El Niño, ENOS) favor the development of vectors. 178 In Colombia, malaria continues to be a priority public health problem, because about 66% of the municipalities in the national territory are located at altitudes equal to or less than 1,600 meters above sea level. (740 municipalities), these present climatic, geographical, and epidemiological conditions that facilitate the transmission of the disease, in addition to conditions associated with the high migration of the Colombian population and the Malaria Surveillance Protocol 6 of 30 foreigners (mainly associated with the temporary transit of migrants heading to other countries, particularly from the African continent and to a large extent from Venezuela or from endemic areas). In the national territory, the incidence rate of malaria has fluctuated in the last 60 years, with annual averages of 80,000 to 120,000 cases.43. 179 According to the analysis of the last epidemiological period, the country is in an alarm situation for malaria. In epidemiological week 21, 1,898 cases of malaria were reported, for a cumulative 29,608 cases, of which 28,903 are uncomplicated malaria and 705 are complicated malaria. The departments that contributed 93.4% of the cases of uncomplicated malaria were: Chocó (31.3%); Antioquia (18.7%); Cordoba (18.5%); Nariño (9.6%); Guainia (3.9%); Risaralda (3.9%); Cauca (3.7%); Guaviare (2.4%) and Bolívar (1.4%). In epidemiological week 21 of 2023, 705 cases of complicated malaria have been reported, coming from 28 territorial entities and 16 cases from abroad. Antioquia, Chocó, Bolívar, Córdoba, Nariño, Meta, Guaviare, Risaralda and Cauca reported 81.4% of the cases.44. 180 In 2020, the epidemiological behavior of dengue was in an outbreak situation during the first quarter of the year, related to the continuation of the epidemic phase of the event in the country that began in epidemiological week 08 of 2019; However, in epidemiological week 12 there was a marked decrease in the notification of the event, a situation that coincided with the detection of the transmission of the SARS CoV2 virus in the country and the measures adopted by the national government in the face of the health emergency due to the pandemic of COVID-19. At 43 INS Protocolo de Vigilancia de Malaria Código 465 Versión:05 Fecha: marzo 17 de 2022 44 INS Boletín Epidemiológico Semanal - Semana epidemiológica 21 21 al 27 de mayo de 2023 59 epidemiological week 21 of 2023, the national incidence of dengue was 118.4 cases per 100,000 inhabitants at risk; for the same period in 2022, the incidence was 65.5 cases per 100,000 inhabitants. Of the 38 departmental and district territorial entities of Colombia, Bogotá is the only entity without a population at risk for the event. The territorial entities of Amazonas, Vaupés, Meta, Guaviare, Tolima, Putumayo, Caquetá, and Cundinamarca persist with the highest incidences, registering rates above 230 cases per 100,000 inhabitants. According to the epidemiological situation by departmental and district territorial entity at risk for dengue, according to the endemic channel it is observed that 8.1% (3) of the entities are within what was expected; 5.4% (2) are in an alert situation and 86.1% (32) are above expectations, compared to historical behavior. Consequently, the Strategic Health Committee has been activated at the national level and measures were determined by the MSPS. In epidemiological week 21 of 2023, 140 probable deaths from dengue have been reported, of which 28 deaths from Tolima with 5 cases have been confirmed; Meta and Sucre with 4 cases each; Huila and Norte de Santander with 2 cases; Amazonas, Antioquia, Bolívar, Cartagena, Cesar, Córdoba, Cundinamarca, La Guajira, Magdalena, Nariño and Santander with 1 case each. For the same period of 2022, 26 deaths from dengue were confirmed. 181 A mere two-degree increase in temperature (from 24 ° C to 26 ° C) has been shown to more than double the number of infectious mosquitoes, which links temperature and precipitation variations with an increase in the incidence of diseases transmitted by malaria and dengue fever vectors. Compared to the 2000-2005 incidence rates, an increase of 11 percent and 35 percent is expected in cases of malaria and dengue (76,641 and 228,553, respectively) for 50- and 100-year scenarios, due to the climate change-driven increase in global temperature and precipitation. 182 The Sub-Directorate of Environmental Health has begun the process of sectoral integration on the subject of climate change based on the objectives set out in the NDC and its 2020 update towards the Formulation of the Comprehensive Climate Change Management Plan (PIGCCS) of the Health Sector, and in its orientation for the elaboration of the Territorial Plans of Adaptation to Climate Change from the Component of Environmental Health (PTACCSA), and of the Climate Change Mitigation Guide for the health sector. Additionally, it is responsible for the execution of the memorandum of understanding with the NGO “Health Care Without Harm” to estimate the climate footprint of the Colombian national health system at the facility level. 183 The process still remains to be initiated to achieve the objectives proposed in the 2020 NDC update: (i) Design and implementation of an Early Warning System (SAT for Spanish acronym) associated with climate variability; (ii) Design of a statistical tool that allows analysis of information on climate-sensitive health events and supports public health surveillance actions for the Territorial Health Directorates (DTS); (iii) Tool for monitoring and prediction of Vector-borne Diseases; (iv) Tool for vulnerability analysis of public sector health service provider institutions to climate variability and change45. 184 In the same way, it remains to start the process of implementing the objectives of the PND 2022-2026 approved by Law 2294 of 2023 on climate change, environmental health and vulnerability reduction in the face of climate risks and disasters. 185 The Comprehensive Health Risk Management (GIRS for Spanish acronym) depends on the Vice Ministry of Social Protection. The GIRS is a public policy planning instrument to achieve timely, effective, equitable, efficient and sustainable access to the services covered by the health benefits plan (PBS for Spanish acronym); It is part of the transversal strategy of the Comprehensive Health Care Policy (PAIS for Spanish acronym) based on the articulation and interaction of the agents of the health system and other sectors to identify, quantify, analyze, monitor and intervene 45 Actualización de la Contribución Determinada a Nivel Nacional de Colombia (NDC) Anexo 3 60 (from prevention to palliation ) avoiding or reducing risks to the health of individuals, families and communities, aimed at achieving results in health and the well-being of the population. In this way, the GIRS anticipates diseases and injuries so that they do not occur or are detected early to prevent, shorten, or alleviate their evolution and consequences. 186 The GIRS is currently operationalized by the EPS from individual risk management through the identification, evaluation, measurement, treatment, follow-up, and monitoring of risks that compromise the health of the affiliated population, the operation of the entity and its sustainability in the system, in order to provide health services and technologies in a comprehensive manner to promote health, prevent, treat, rehabilitate, alleviate or cure the disease. The EPS manages risk through the operation of Care Networks, which include service providers and health technology providers based on comprehensive care, continuity of care, access, and opportunity in the provision of services and provision of health technologies, aimed at promoting health, disease prevention, diagnosis, treatment, rehabilitation, and palliation. The individual component managed by the EPS must be collaboratively articulated with other entities such as the ARL, community, scientific associations, academia, individuals, and their families through self-care. The Territorial Entities (ET) must operationalize health risk management in collective and community intervention through the implementation of territorial health plans (PTS for Spanish acronym), execution of Collective Intervention Plans (PIC for Spanish acronym) among other tools. 187 The National Unit for Disaster Risk Management of the Presidency of the Republic of Colombia (UNGRD) aims to direct the implementation of disaster risk management, addressing sustainable development policies, and coordinate the operation and continuous development of the National Disaster Risk Management System of Colombia (SNGRD for Spanish acronym)46. In 2018, it has prepared the Risk Atlas of Colombia with the objective of publicizing various studies and advances in relation to the evaluation of the different threats of natural and technological origin, and the results of the probabilistic risk evaluation for different threats, based on appropriate risk metrics for decision making. In addition, the Atlas presents maps of seismic hazard, flooding, tsunami, tropical cyclones, forest fires, drought, and landslides at the national level. At the departmental level, multi-hazard risk profiles are presented with maps of the expected annual loss to represent the physical risk, and the results of the comprehensive disaster risk index to account for the potential impact, taking into account aggravating factors associated with the socioeconomic fragility and lack of resilience at the municipal level. The comprehensive disaster risk index prepared by the UNGRD has been obtained using the results of physical risk and a series of relevant socioeconomic variables that account for the impact that damage and losses can have at each site. 188 The National Disaster Risk Management Plan (PNGRD for Spanish acronym) of Colombia is the instrument of the SNGRD, which defines the objectives, programs, actions, managers and budgets, through which the processes of risk awareness, risk reduction and disaster management within the framework of national development planning. The PNGRD is found from its general objective and its five specific objectives, aligned with the four priorities subscribed in the Sendai Framework 2015-2030, and incorporates and intends to articulate with the objectives of sustainable development and adaptation to climate change. The PNGRD defines programs and projects that aim at the following strategic lines related to these issues: 1) Synergies between adaptation and mitigation, 2) Adaptation based on socio-ecosystems, 3). Articulation of adaptation to climate change and risk management, including the design and implementation of an early warning system, 4) Adaptation of basic infrastructure and sectors of the economy, 5) Incorporation of adaptation and resilience considerations in sectoral planning, territorial and development. 6) Promotion of education on climate change to generate behavior changes. 46 Creado por la Ley 1523. 61 189 The Health Disaster Risk Management Group, under the Office of Territorial Management, Emergencies and Disasters of the Office of the Minister, implements the National Emergency Response Strategy in Health (ENRES for Spanish acronym) supporting a timely and adequate response in coordination with the Entities Health Territories. The Strategy is integrated with (i) the Communications and Coordination Center for the response to emergencies in the health sector; (ii) Regulatory Centers for Emergencies, Emergencies and Disasters (CRUE for Spanish acronym); (iii) Health Sector Reserve Center (CRSS for Spanish acronym). 190 The Communications and Coordination Center for Emergency Response in the Health Sector monitors, collects, analyzes, prioritizes, and disseminates information on health emergencies or disasters. Its functions are: (i) functional management with the CRUE, to coordinate with the emergency network the care of patients affected by the emergency in the territory; (ii) provide technical advice and recommendations for the appropriate response to different natural and anthropic events; (iii) articulation and functional management with the health care devices for emergencies of the National System of Social Security in Health and the National System of Risk Management; and (iv) carry out Early Warning functions for health emergencies by monitoring official and unofficial information sources and disseminating alerts to the entities of the National Social Security Health System and the National Risk Management System. 191 The Regulatory Centers for Emergencies, Emergencies and Disasters (CRUE) are units of an operational, non-assistance nature, responsible for coordinating and regulating, in the territory of their jurisdiction, access to emergency services and health care for the affected population in emergency or disaster situations. 192 The objective of the Health Sector Reserve Center (CRSS) is to improve the response of the hospital network in urgent, emergency or disaster situations and to guarantee better scenarios for the response and management of those affected in these events. 193 PforR is supporting the implementation of a new infrastructure framework and enabling standards that includes social and environmental standards such as DLI. As intermediate indicators, the Program includes (i) increasing the number of primary health care establishments by implementing this new infrastructure framework and (ii) implementing the Comprehensive Sector Management Plan for Climate Change. 62 Table N ° 3: Level of concern with the possible environmental impacts and risks associated with the operation and use of healthcare facilities. Environmental Current state Level of concern Impacts / Risks 1) Complete regulatory framework. Low: In most of the sanitary Health care waste facilities (IPS) and health authorities 2) Enforcement System established management. Increased that treat HCW adequate 3) Institutional capability varies by region, visibility of the need for capabilities are in place according to with more resources in large, populated HCW management, regulations. The HCW generation centers. treatment and disposal at record (including vaccination 4) Less positive situation of isolated and records) in PHC centers is remote sites. remote sites practically non-existent. Low: The HCW generation, 1) Complete regulatory framework. management, and final disposal 2) Ex post monitoring, auditing, and reporting system (especially in enforcement information system, grouped places with higher poverty by environmental authority indicators and disadvantageous Treatment and final 3) Institutional Capability in managers. health indicators), for making timely disposal of HCW. Greater difficulties in sites with low and informed decisions, still population density and far from treatment presents disadvantages for which centers. the generation of information 4) Unfavorable situation of isolated and impacts the makes decisions and remote sites. budgetary programming to meet changing needs. Low: There is no institutionalized 1) Complete regulatory framework. registration plan or program for the 2) Monitoring, auditing and enforcement planned obsolescence of EEE in information system health centers. There is no evidence 3) Management systems and final disposal on institutional training processes WEEE generation. 4) Need for continuous information of for those responsible for the Increase in the generation possible generators. acquisition of electronic devices and of WEEE. 5) Need for searches of integral uses of the equipment, for users, and for those WEEE. responsible for inventories that 6) There is a WEEE Management Plan with contribute to rapid and adequate recovery of e-waste components in initial management and final disposal of stages. the components. Low: It is important to keep the 1) Post-consumption programs for certain reporting system on generation, Chemical waste RESPEL (expired medications, lead acid management and final disposal of (expired medications, batteries and pesticide containers, among this type of waste, especially in the radioactive, cytotoxic, others) were established. initial states of incentives in the cytostatic). 2) Educational campaigns are promoted diagnosis of cancer, in order to and informative at all levels. make timely and informed decisions. 1) The Nationally Determined Contribution Moderate (NDC) of Colombia for 2020 includes in Mechanisms for the implementation the country's climate commitments for the of the update of the updated NDC Effects associated with year 2030, for the health sector two still remain to be established, climate change. adaptation goals (i) that 100% of the tending to: territorial entities of the health sector (i) Design and implementation of an departmental, district and municipal levels Early Warning System (SAT) of categories 1, 2 and 3, formulate associated with climate variability; 63 Environmental Current state Level of concern Impacts / Risks adaptation actions that allow preventing (ii) Design of a statistical tool that climate-sensitive diseases such as dengue, allows analysis of information on malaria and zika, among others, by the year climate-sensitive health events and 2030. 40% of these entities must supports public health surveillance implement these actions for that date; (ii) actions for the Territorial Health By 2030, 40% of the Institutions Providing Directorates (DTS); Health Services in the public sector will (iii) Tool for monitoring and implement adaptation actions in the face of prediction of Vector-borne possible events associated with climate Diseases; variability and change. (iv) Tool for vulnerability analysis 2) The Subdirectorate of Environmental of public sector health service Health is in charge of preparing the provider institutions to climate Comprehensive Sectoral Climate Change variability and change. Management Plan (PIGCCS) for the Colombian health sector. It has already Additionally, it is still pending to prepared the guidelines for (a) the complement the objective and scope Formulation of Territorial Plans for of Decree 2972 of 2010 for the Climate Change Adaptation from the coordination of the formulation of Environmental Health Component the Comprehensive Environmental (PTACCSA), and (b) Climate Change Health Policy (PISA), for the Mitigation for the health sector. creation of the Unified 3) Through the ministerial agreement with Environmental Health Information the NGO " Health Care Without Harm " System (SUISA), and the (SSD for Spanish acronym) the climate regulations of the Territorial footprint of the national health system will Environmental Health Councils be estimated based on a sample of (COTSA). establishments, capacities will be generated in the use of the SSD climate impact There is still a lack of information monitoring tool , and technical support will on the possibilities of mitigation to be provided to determine the dimension CC in the health sector. and composition of its climate footprint. 4) The National Strategy for Response to Health Emergencies is the strategy of the MSPS to carry out the management of health emergencies and support a timely and adequate response in coordination with the Territorial Health Entities. 64 Table N ° 4 Key risks and gaps and potential measures to align with the ESSA Core Principles. Activities group Potential measures to align with Key risk and gaps. Outcomes area. the ESSA Core Principles. Environment Environment 1) Standardize and improve the No significant environmental risks HCW generation record (including and slight gaps. The HCW vaccination records) in PHC centers. generated with the increase in the 2) Maintain an updated registry of benefits of the EPS are treated HCW management and final under the regulatory and disposal operators and contribute to administrative frameworks of the intra- and inter-regional articulation GoCo. The implementation of tools to promote the rational use of (especially in places with higher medicines avoids the generation of poverty indicators and chemical residues. disadvantageous health indicators) to generate opportunities for Social operational articulation that allows Social risks basically refer to the generating treatment mechanisms exclusion that could arise when and final disposition of all the HCW. focusing or prioritizing health 3) Design a proposal for a actions under criteria that have not registration plan or program for the been unified or validated among the scheduled obsolescence of EEE in competent institutions. Also, the health centers for post-consumer fact that the lack of connectivity, recovery and comprehensive Results area 1 security restrictions or geographical management of WEEE. Including a improve effective access, can hinder the actions of basic health teams in the most procedure to raise awareness / access to health remote territories, limiting full training of those responsible for the services for access to the health service for the acquisition of electronic devices and vulnerable most vulnerable population. An equipment, of users, and of those people. identified gap is related to the health responsible for inventories for a models of ethnic groups that have responsible acquisition, and a rapid not yet been protocolized, thus and adequate management of limiting possible articulations of the obsolescence for the management health system with these instances to and final disposal of equipment, and guarantee access and relevant health components. for communities that have neither resources nor health infrastructure. Social: health in their territories. The MSPS i) Develop/strengthen decentralized maintains permanent work with ethnic groups and especially the tools that facilitate the systematic and SISPI is in the framework of a prior timely management of the consultation that would allow information that is collected at the progress in the adoption of these territorial level by the basic health health guidelines by 2024. teams ii) Guarantee the inclusion of differential identification variables (ethnicity, gender, rurality) in the epidemiological profiles on which health actions are prioritized and planned. In particular, it is suggested 65 Activities group Potential measures to align with Key risk and gaps. Outcomes area. the ESSA Core Principles. to consider the recognition and linking of indigenous girls or girls in their diversity, taking into account the possible social risk of exclusion that has been identified in the ESSA. iii) Strengthen in the most remote regions, integrated care networks that support prevention and health care actions without the population having to move outside their territory. Environment Environment With risks and gaps Moderate Environmental. Preparation of procedures for adaptation to CC of the health Colombia is highly vulnerable to system based on: CC and geophysical hazards mainly due to its diverse geographic (i) The design of an Early Warning features and due to its System (SAT) associated with socioeconomic context. About a climate variability, establishing quarter of health facilities are programmatic agreements with the exposed to climatic hazards such as key stakeholders involved; flooding. In addition to the direct (ii) Advance in the institutional impact on the facilities, the effects agreements that make the design of of CC have a direct impact on a statistical tool viable, which allows people's health as well as by favoring the development of the analysis of information on Results area 2: vectors and the possibility of climate-sensitive health events and Improve the disease transmission, among other supports public health surveillance resilience of the causes, in addition to hindering actions for the Territorial Health health system in both access to and provision of Directorates ( DTS); the face of climate health services. (iii) The design of a tool for the change and threats monitoring and prediction of to public health. Due to the frequency, intensity, and Diseases Transmitted by Vectors; different types of events that impact (iv) The design of a tool for health, generated by the effects of analyzing the vulnerability of public CC (especially in the most sector health service provider vulnerable populations), the health institutions to climate variability and system is not yet adapted to generate alert and response change. systems. preventive measures that (v) Preparation of an administrative prepare both the health system and act that defines adequacy and its users. mitigation standards for the infrastructure of health providers. Colombia, through its NDC, has identified ambitious lines of action Establish the baseline for the for the adaptation and mitigation of generation of Greenhouse Gases CC, and has established an (GHG) of the Health System and agreement to know the baseline of establish a program that guides and GHG generation and the use of 66 Activities group Potential measures to align with Key risk and gaps. Outcomes area. the ESSA Core Principles. diagnostic tools on the carbon encourages establishments in the footprint of hospitals. of the health adoption of mitigation measures. sector. However, the approach to mitigation and adaptation to CC in the health sector is still weak. The qualification and certification requirements of health care centers require a strengthening of requirements to avoid vulnerabilities to the effects of CC and geophysical impacts. Social Social: Evaluate the results of the With moderate risks and social implementation of the RISS to gaps. The MPSP has made an effort adjust the development of to plan and implement the RIISS in coordination and strengthening the territory; However, the actions, at least in relation to the fragmentation of health services following topics: persists from the moment of i) Characterization of the population diagnosis and the attention of the in the territories beneficiaries, in addition to an intersectoral lack of coordination ii) Assessment and improvement of that ends up ignoring the conditions referral and counter-referral systems that affect the health needs of a based on principles of quality, territory and not a standardization inclusion, and accessibility for mediated by costs of the populations, especially the most interventions. In the most remote vulnerable and in regions with regions, investment is required to access restrictions and health improve or create precarious health infrastructure. infrastructure, in such a way that iii) Promote the active participation access to comprehensive and of users in the identification of quality care does not require needs, demands and capacities displacement at high cost and effort required by socially and culturally for the beneficiaries. relevant health care in their territories. 6.4 Gap análisis. 194 The following table analyzes the capabilities gaps to address the risks identified in the previous stage and that will serve to make the recommendations of the ESSAs and the actions that are a part of the Program Action Plan (PAP). 67 Table N° 5 Analysis of capacity gaps to address the identified risks. Institution / Key Actor Roles and Responsibilities Gap analysis For Indigenous peoples: The SISPI has yet to be completed, the issuance of the administrative act of the Ministry of Health and presentation at the Permanent Consultation Table has not XII. Equality of Opportunity Pact yet been carried out. for ethnic groups: indigenous, Black, Afros, Raizales, The SISPI articulates, coordinates and complements the Palenqueros and Rom. SGSSS (Article 74 of Decree 1953 of 2014). Generation of differentiated actions that create conditions of Afro-Colombian, Raizal and Palenquera Black equality in access to goods and services, especially to land, communities, and the Rom people: to advance in the materialization of the rights of those who It remains to conclude and issue administrative acts on the are subject, under the principle of progressivity and taking guidelines with guidelines and guidelines for a socio-cultural into account their worldview and traditions. adaptation and inclusion of the intercultural approach that Office of Social Promotion contemplates their standards of care that respect their ethnic (MSPS) and cultural identity, forms of social organization and linguistic characteristics, without the need to create a special health system for each ethnic group. Health Participation Policy (PPSS): its objective is the intervention of the community in the organization, control, management and enforcement of the institutions of the It is required to verify if the report of the territorial entities health system as a whole. For this, the Territorial, has been carried out in the stipulated times and if the Departmental and District entities must consolidate their information reported through the PISIS platform is information and that of the actors responsible for the consistent. processes of social participation in health of their jurisdiction and report it to the Ministry of Health and Social Protection. Design of the Health Sector Response Plan to the Absence of concrete definitions regarding the scope of health Immigration Phenomenon. This plan is indicative, coverage, and complementary financing options for migrants emphasizing the actions that need to be designed by each Migrations (MSPS) from Venezuela. Identifying and measuring the risks and territorial entity to address individuals in the territories and impacts on the health and customs of migrants and the host communities affected by the migration phenomenon society remains pending. Completing definitions and originating in the Bolivarian Republic of Venezuela. Institution / Key Actor Roles and Responsibilities Gap analysis implementing health information systems linked to the migratory phenomenon remains pending. Determination of public Environmental Health policies and random inspection of compliance with regulations at subnational levels. In recent years, progress has been made in access to information on the generation of HCW, and in the implementation of a Census of health care establishments for the year 2022 reported by ETS. It has The analysis of the internal management of HCW is ex post, strengthened the ETSs in the IVC report of health care which does not allow guaranteeing the flow of information if establishments in 2022. In support of this strengthening, the changes occur in the generation patterns of HCW (amounts, MSPS has issued Resolution 367 of 2023, amending articles types). In this way, the information for a modification of Subdirectorate of 6 and 8 of Resolution 3496 of 2019, which establishes the policies, input needs and resources, could arrive late in the process for the strengthening of environmental health face of trends of general increases in HCW or of a particular Environmental Health management at the territorial level. In addition, the issuance waste stream that demand timely or specific treatment. (MSPS) of the Comprehensive Health Care Waste Management Manual (GIRASA) is in the process of being issued. The preparation and formalization of the Comprehensive She is also responsible for the Formulation of the Climate Change Management Plan (PIGCCS) of the Health Comprehensive Climate Change Management Plan Sector, and the procedures for adaptation to the CC of the (PIGCCS) of the Health Sector. In addition, it guides the health system are still pending. EPS through the preparation of Guidelines for (a) the Formulation of Territorial Plans for Adaptation to Climate Change from the Environmental Health Component (PTACCSA), and (b) the Climate Change Mitigation Guide for the health sector. This agency governs environmental management and renewable The decentralization of the management of clinical waste at natural resources. It leads the National Environmental System subnational levels generates knowledge of waste management (SINA). It is the application authority for Hazardous Waste ex post through an annual report (IDEAM-MADS) regarding Ministry of Environment and WEEE. It also has as objectives to develop the technical the external management of HCW, in arrears. and Sustainable and operational bases necessary to advance in the There is no disaggregated information for the sub-categories: Development (MADS) management of climate change in the different sectors and Y1.1: For pathological waste, Y1.2: for biosanitary waste, territories of the country, in association with public and Y1.3: For sharps waste; and Y1.4: For animal waste. private actors of the local, national and international order. 69 Institution / Key Actor Roles and Responsibilities Gap analysis Autoridad Nacional de Es la encargada de que los proyectos, obras o actividades If there were changes in the generation patterns of HCW Licencias Ambientales sujetos de licenciamiento, permiso o trámite ambiental (amounts, types), the information for a change in policies, (ANLA) cumplan con la normativa ambiental input needs and resources, could arrive late in the face of trends of general increases in HCW or a stream of waste in particular that demanded timely or specific treatment. To Institute of Hydrology, Provides technical and scientific support to the National correct this fact, there is an agreement between IDEAM and Meteorology and Environmental System, it produces reliable, consistent, and timely the Environmental Health Sub-directorate for access to Environmental Studies information on the state and dynamics of natural resources and the RESPEL generation and destination information (Minutes of (IDEAM) environment. May 31, 2021) that works at the request of the Sub- directorate. At the national level, capacity gaps are recognized in the most remote places. It will be necessary to develop activities by the territorial authorities of information and training of key actors related to the proper handling of HCW (sharps, Design of agendas and strategies for the incorporation of the issue biocontaminated, chemical substances, among others) and Territorial Health Entities of environmental health in relevant instances, enabling the WEEE, and its impact on the environment and health. at the Departmental, creation of interinstitutional and Intersectoral spaces on health and It is necessary to strengthen the participation of social and District and Municipal level the environment at the territorial level community organizations for their participation in relevant (Territorial Environmental Health Councils - COTSA) decision-making processes and to create awareness and community participation mechanisms at the territorial level, which include the aspects of risks and impacts associated with the management of HCW, WEEE, and Climate Change (Adaptation and mitigation). No significant gaps have been identified. At the departmental and district level, the IVCS plans of the respective jurisdiction Territorial Health Entities are established, in coordination with INVIMA, in accordance They are responsible for inspection, oversight and control with the national ICVS plan. The tracking performed by the at the Departmental, health (IVCS) in the internal management of HCW. MSPS is document-based and spaced in time to exercise District and Municipal level oversight. The Subdirectorate of Environmental Health has incorporated the Census of health care establishments that includes IVC actions. 70 Institution / Key Actor Roles and Responsibilities Gap analysis shall grant or deny the environmental license for the The Regional Autonomous construction and operation of facilities whose purpose is the Corporations and those for storage, treatment, use, recovery and/or final disposal of Sustainable Development, Uneven territorial availability of WEEE recovery and hazardous waste, and the construction and operation of management operators. Large Urban Centers and sanitary landfills for hospital waste and the construction and The recovery of materials is influenced by market variations. the environmental operation of facilities whose purpose is the storage, authorities created by Law treatment, use (recovery/recycling) and/or final disposal of 768 of 2002 Electric and Electronic Device Waste (WEEE) and waste batteries and/or accumulators. The generators, deactivation service providers and providers of the special hospital waste and similar cleaning services, design and implement the PGIRH according to the activities No gaps have been identified. The audits of the PGIRH are they perform, having as their starting point their institutional carried out at least once a year by the Territorial Comptroller At the health center level commitment of a sanitary and environmental nature, which and with the participation of the MSPS. shall be: real, clear, with proposals for continuous improvement of the processes and targeted at minimizing risks to health and the environment. 71 PROGRAM ACTION PLAN (PAP). 195 The MSPS maintains a permanent work with the ethnic groups and especially indigenous communities for the joint construction of the SISPI. This is within the framework of the consultation prior to the health reform, which would allow progress in the adoption of these health guidelines by 2024. 196 The priority areas identified in the Program and the corresponding indicators linked to disbursements (DLI) do not recommend activities/actions that cause significant damage to the environment. They also do not recommend actions that result in adverse environmental and social impacts that are sensitive, diverse, or unprecedented or irreversible. 197 ESSA proposes the Program's actions related to the six Disbursement Indicators (DLI): DLI 1. Children under 5 years old with acute malnutrition identified, reported, and receiving treatment for acute malnutrition in prioritized departments; DLI 2 Implementation of the integrated strategy to reduce maternal mortality in prioritized departments; DLI 3 Vulnerable women diagnosed with early stage breast cancer (IIA); DLI 4 Migrants with HIV have access to effective treatment; DLI 5 New infrastructure standards for healthcare providers, including energy efficiency standards and climate change adaptation measures; DLI 6 Development of a Comprehensive Climate Change Management Plan for the Health Sector. 198 ESSA proposes the following Program actions that make up the PAP in order to address the gaps identified. 199 Program Action 47 1: Strengthening of the adoption of the intercultural approach in health. It contemplates the continuity of the agreement, protocolization and adoption process that the MSPS has been carrying out with the indigenous peoples and the NARP and Rom communities to guarantee the intercultural approach to health in their territories. This is a fundamental action to support the objectives of this Program, understanding that diseases such as breast cancer, child malnutrition and maternal and child mortality differentially affect these populations according to the evaluation presented above. The fulfillment of this action involves: 1) the dissemination and territorial coordination of the guidelines with the peoples and ethnic communities involved; 2) issuance of administrative act in which the Ministry of Health defines the governance and administration scheme of the health systems and guidelines for each ethnic group; 3) Definition of the tools for registering differentiated information, the instances of follow-up and evaluation of the implementation of the own health systems and guidelines at the territorial level. 200 Program Action 2: Unification of the information tools for the management of information derived from the action of basic health teams. It consists of generating or strengthening the use of unified tools in criteria for capture and management the information that the basic health teams will generate periodically and systematically. This action is fundamentally aimed at articulating the mechanisms that fragment the information that the institutions in a territory have to plan comprehensive health actions in their jurisdictions. The steps to follow under this action are: 1) preparation of guides and protocols to manage information tools at different territorial levels; 2) socialization for the management of information capture tools of the territorial teams; 3) Reports of information systematized by the Directorate of Promotion and Prevention on the data captured by the basic health teams. 47 Acción del Programa correspondiente al PAP (Plan de Acción del Programa). 201 Program Action 3: Technical assistance for the development of territorial capacities for the management of public health. This action consists of the development of a solid technical assistance plan to be developed at the territorial level in departments and municipalities that are identified as needing to improve their capacities to address key issues for the achievement of the indicators provided for in the implementation of PHC, especially in the understanding of the social and gender determinants that have a differentiated impact on the health situation in their jurisdictions. The steps required to comply with this action are: 1) Selection of the Departments and municipalities that will receive technical assistance; 2) prepare a Technical Assistance Plan; 3) preparation of management reports on the plan and relevant results at the territorial level; 4) annual management report with information on the development of the capacities of territorial entities that received technical assistance. 202 Program Action 4: Information, Education and Communication (IEC) Strategies for an inclusive and territorially relevant health. It consists of strengthening the information, education and communication strategies that the MSPS carries out to generate ownership of health services. The emphasis of these strategies will be in addition to promoting participation with sufficient information for the populations about their right to health, the restoration of citizen confidence in the service and the health entities of their territories, through messages of transparency and effective response. to your needs. It is essential that the strategies contemplate the differential territorial, ethnic, gender and disability perspective so that they are implemented in a pertinent manner. The steps contemplated for this action are the following: 1) preparation of a document outlining IEC strategies to be implemented at the territorial level; 2) socialization of IEC strategies with territorial entities; 3) reports on the implementation of the information, education and communication strategies implemented. 203 Program Action 5: HCW management future scenarios. It consists of keeping an updated register of HCW treatment and final disposal operators. This activity has the purpose of generating knowledge of the capacities installed for the treatment and final disposal of HCW, knowing their geographical location, their operational and idle capacities. This information will make it possible to establish medium-term horizons in the event of potential stress situations in the health system, as occurred during the last pandemic, and to design action mechanisms in the event of closure of HCW treatment and final disposal facilities (temporary or permanent), avoiding the generation of environmental and social risks in such circumstances. In order to comply with this action, the following steps must be carried out: 1) Prepare semi-annual progress reports that reflect the management of HCW in the different departments, which allow identifying opportunities for operational coordination to generate treatment mechanisms and final disposal of all HCW.; 2) Preparation of annual technical reports of conclusions on the generation of HCW, treatment capacity, vacancies and/or interjurisdictional treatments, by jurisdiction and by flow of hazardous waste versus epidemiological trends and scenarios of geophysical risks and impacts of the effects of the CC. 204 Program Action 6: Compilation of information for the future development of a Plan or program of good practices on the obsolescence of Electrical and Electronic Devices (EEE) in health centers for post-consumer recovery and comprehensive management of Waste Electrical and Electronic Devices (WEEE). It consists of the preparation of a report that consolidates information by jurisdiction and its national integration (including information and conclusions of interannual changes) through a survey that provides information for the future the design a proposal for a plan or registration program for the planned obsolescence of EEE from health centers for post-consumer recovery and comprehensive management of WEEE. This activity has the purpose of raising awareness within the health system of the potential risks and impacts of post-consumer waste of electrical and electronic devices in health facilities. Addressing 73 this action is carried out through the following steps:: 1) The Subdirectorate of Environmental Health (SSA) will manage access to information from the environmental sector, which is responsible in the country for the WEEE management policy and the waste generation and final disposal information system; 2) Assistance in the design of the form (a survey in digital form) by the World Bank, with support from the SSA and MADS; 3) Led by the Service Provision Subdirectorate, the electronic forms will be sent via email to the Public IPS (of the different regions) of the state of generation and final disposal of WEEE in the health sector; 4) The online response of each Public IPS; 5) the analysis of the information collected; 6) the elaboration of conclusions where they will be identified: A) the potential sources of WEEE generation of the health system and establish the estimated times for its obsolescence of the EEE that are acquired or found in stock; B) Identification of inputs that allow the development of good practices on the operation of EEE and post-consumer recovery in the health system; C) Identification of inputs that allow the identification of training needs for operators of the different health services on good use practices and post-consumption management and disposal mechanisms of EEE; D) Identification of supplies that allow the design of a WEEE recovery program, in health establishments where at least the procedure to be followed in the event of planned obsolescence or breakage of an EEA or its components is indicated; E) Articulate with the MADS to establish a database of post-consumer collectors and EEE recyclers for information on all jurisdictions.. 205 Program Action 7: Adaptation to the CC of the health system. This activity is supported by: (i) Advancing towards the design of an Early Warning System (SAT) associated with climate variability, based on the articulation of the Climate and Health Bulletin built by the Conasa climate variability and change table, establishing agreements with the key actors involved (IDEAM, MSPS and territorial actors). For this, the design and implementation of a Pilot model will be carried out for monitoring and prediction of two Vector-borne Diseases, Dengue and Malaria); (ii) design of methodological guidelines of a statistical nature, which allows the analysis of information on climate-sensitive health events and supports public health surveillance actions for the Territorial Health Directorates (DTS); (iii) Preparation of recommendations for health providers to define adequacy and mitigation standards for health providers infrastructure. 206 Program Action 8: Climate Change Mitigation. This activity consists of 1) collect information that leads to establishing the baseline of the generation of Greenhouse Gases (GHG) of the provision of services of the Health System and 2) prepare a guide report that guides and encourages establishments in the adoption of mitigation measures. To help establish the baseline for GHG generation in the health sector, a; (i) List of hospitals and health centers that make up the representative sample for the evaluation of GHG generation at the facility level; (ii) List of participants in the training of the establishment teams in the use of the Climate Impact Monitoring tool developed by Health Care Without Harm, and the result of the training; (iii) document that reports the result of the sample analyzed and the estimate of greenhouse gas emissions from the Colombian health sector at the national level. 207 The program activities report (PAP) integrates the semi-annual report of the Program. When the information requirement of any action of the PAP indicates "Annual report" it must contain information from the annual reports and the progress at the time of the semi-annual report if there is no coincidence. 74 Table N° 6 Project Action Plan Action. DLI / Deadline Responsable Completion measurement PAP Agency PA 1: Strengthening of the adoption of the 1) Documented record of the dissemination and territorial intercultural approach in health. Continue the coordination of the guidelines with the peoples and ethnic support process for the adoption and communities involved. implementation at the territorial level (especially MSPS Semester II 2) Administrative act of the Ministry of Health that defines the in dispersed and rural areas) of the health office of PAP 2024 governance and administration scheme of the own health guidelines contemplated for Indigenous Peoples in social systems and guidelines. the SISPI and those agreed with Black, Afro- promotion 3)Tools for recording differentiated information, instances for Colombian, Raizal, Palenquero and Rrom communities. monitoring and evaluating the implementation of the own health systems and guidelines at the territorial level. Guides and protocols 2024 PA 2: Unification of the information tools for 1) Guides and protocols to manage information tools at semester II the management of information derived from MSPS different territorial levels Training and the action of basic health teams. Articulate Directorate of 2) Socialization for the management of information capture technical mechanisms for capturing information at different PAP Promotion tools of the territorial teams assistance 2025 levels that allow managing information on the and 3) Reports of information systematized by the Directorate of Semi-annual population characterized by risk and thus focus Prevention Promotion and Prevention on the data captured by the basic reports from and prioritize health interventions. health teams. . semester II 2025 PA 3: Technical assistance for the development 1) List of Departments and municipalities that will receive Initial stage of territorial capacities for public health MSPS technical assistance semester I 2024 management. Develop a solid technical Vice Ministry 2) Technical Assistance Plan Document to semester I- assistance plan on key issues to achieve the of Public 3) Annual management report with information on the PAP 2025 expected indicators and strengthen the Health and development of the capacities of territorial entities that Assessment management of public health priorities, including Service received technical assistance. the social and/or gender determinants that affect Semester II Provision 4) Capacity evaluation document for territorial entities that the health situation in the territory. 2025 received technical assistance. Action. DLI / Deadline Responsable Completion measurement PAP Agency PA 4: IEC strategies for inclusive and MSPS 1) Document outlining the IEC strategies to be implemented. territorially relevant health. Strengthen Communicati 2) Documented record of the socialization of the IEC strategies information, education and communication semi-annual PAP ons Group. – through the mechanisms determined by the MSPS. . strategies that allow populations to freely present report Ministerial 2) Reports on the implementation of the IEC information, their concerns and proposals to enjoy quality and relevant health services. Office education, and communication strategies. PA 5: Future scenarios of HCW management. 1) Prepare semi-annual progress reports that reflect the management of the HCW in the different departments, which allow identifying 1) semiannual. 1) Semi-annual technical report. opportunities for operational articulation to MSPS generate mechanisms for the treatment and final 2) Once a year. Environmental 2) Annual technical report. disposal of all the HCW; PAP Health 2) Preparation of technical reports of conclusions on the generation of HCW, treatment capacity, semi-annual Subdirectorate 3) Conclusions from technical reports on the generation of RES vacancies and/or interjurisdictional treatments, by report versus the treatment and final disposal capacity. jurisdiction and by stream of hazardous waste versus epidemiological trends and scenarios of geophysical risks and impacts of the effects of CC. PA 6: Compilation of information for the future development of a Plan or registration 1) First quarter. 1) Identification and formalization through reliable information MSPS program on the obsolescence of EEE in health (email or note) of focal points of each Subdirectorate. of centers for post-consumer recovery and 2) Within the Environmental comprehensive management of WEEE. 1st Semester. 2) PDF document of the survey designed in KoboToolbox with Health the assistance of the WB. PAP Subdirectorate 1) The coordination between the Environmental 3) In the 2nd , and Health Subdirectorate and the Service Provision Semester from 3) Report with evidence of form submission (list or screenshots Subdirectorate for the preparation of a survey in Service the beginning of of digital form access link submissions). digital form that will be carried out with the Provision the program. assistance of the World Bank; 2) The design of the Subdirectorate survey by the WB and the validation of the 76 Action. DLI / Deadline Responsable Completion measurement PAP Agency content by the MSPS; 3) Sending the electronic 4) In the first 4) Report on the progress of responses a) Number of responses forms via email to the Public IPS of the regions; half of the 3rd by Department; b) Relevant details; c) Observations. 4) The online response of each Public IPS; 5) the semester from analysis of the information collected; 6) drawing the beginning of 5) Report that consolidates information by jurisdiction and its conclusions. the program. national integration (including information and conclusions on interannual changes) recommendations on steps to follow. (Ex. 5) In the 2nd PowerBI). half of the 3rd semester from the beginning of the program. 6) At the end of the 3rd semester. PA 7: Adaptation to the CC of the health system. 1.1) Within the 1) Technical advances in the Design of a Health and CC SAT first 4 months of 1.1) Definition of the contents of the newsletter modules, the the start of the key actors identified, roles and responsibilities (technical Program. working document). 1) Advancing towards the design of an Early 1.2) Before the MSPS 1.2). Warning System (SAT) associated with climate 10th month of Environmental PAP Design a content proposal (technical document) for each of the variability, based on the articulation of the execution of the Health Climate and Health Bulletin built by the Conasa Dengue and Malaria climate prediction pilots and articulation Program. Subdirectorate climate variability and change table, establishing mechanisms based on the COTSA regulations with INS and 1.3) Four agreements with the key actors involved (IDEAM, IDEAM, for the activities of information providers, analysts months after MSPS and territorial actors). For this, the design and those responsible for communication. completing and implementation of a Pilot model will be 1.3) Analysis of supplier alternatives or SAT design. point 1.2) carried out for monitoring and prediction of two Vector-borne Diseases, Dengue and Malaria). 77 Action. DLI / Deadline Responsable Completion measurement PAP Agency 2.1) Definition of the content of the tool (technical working document) and creation of a map of key actors classified into at least three categories: a) Information providers (Climate, 2.1) Within the Geophysical, Epidemiological, Sociodemographic, etc.); b) first 12 months Information analysts; c) Responsible for the communication of the start of and reception of feedback. 2) Institutional agreements that make the viable the Program. 2.2) Include in the COTSA annual action plan (in the cases that the design of statistical methodological guidelines, 2.2) Within the MSPS the CC has been incorporated, those that will act as Pilots) the which allows the analysis of information on second year of Environmental agreements (technical working documents) with the key actors PAP climate-sensitive health events and supports public program Health involved who are information providers, analysts, and health surveillance actions for the Territorial execution. Subdirectorate communication managers, and recipients of information, the Health Directorates (DTS). 2.3) Within the Territorial Health Directorates (DTS). Includes proposals and third year of analysis of implementation alternatives. program 2.3) Create a methodological guideline for the analysis of execution. climate-sensitive diseases based on secondary information and that the territories that have the technical capacity to develop and implement it under a Pilot model and can support other Territorial Health Directorates (DTS) (scalability). 3) The design of a tool for the analysis of the Office of 3.1) Within the 3.1 Primary analysis of geospatial vulnerability identified by vulnerability of the Institutions Providers of Territorial Health Services of the public sector to climate first 6 months of the UNGRD, the SNGRD and its PNGRD (strategic lines 3, 4 Management, variability and change. the start of the and 5) and the products of the National Health Emergency Emergencies Program. Response Strategy (ENRES) of the MSPS. and Disasters 3.2) Within the 3.2 Collect local information on the current state of risks (OGTED). first 8 months of already identified by each public sector IPS and relate to the the start of the information collected for emergencies in front of the Resilient Directorate of Program. Hospitals Project. Health 3.3) Within the 3.3 Preparation of a technical working document that contrasts Services second year of the information in 3.1 and 3.2 with the climate scenarios. Provision (for 78 Action. DLI / Deadline Responsable Completion measurement PAP Agency project vulnerability 3.4 Identification of options for instruments or tools that allow execution. analysis) for a systematized analysis of the vulnerability of IPS in the 3.4) Before the public sector to climate variability and change. third year of execution of the Program. Infrastructure Sub- 4) Preparation of administrative acts that define Directorate of adequacy and mitigation standards for the DLI 5 See DLI 5 in the Program the Services infrastructure of health providers. Provision Directorate. PA 8: Climate Change Mitigation. 1) 1.1 List of hospitals and health centers that make up the representative sample for the evaluation of GHG generation at the facility level. 1.2 List of participants in the training of the establishment 1) Before the teams in the use of the Climate Impact Monitoring tool 1) Establish the baseline for the generation of third year of the MSPS developed by Health Care Without Harm , and the result of the Greenhouse Gases (GHG) of the Health System. 2) Prepare a guide to guide and encourage Program. Subdirectorate training. establishments in adopting mitigation measures. PAP 2) To the of 1.3 Document that reports the result of the analyzed sample and second year of Environmental the estimate of greenhouse gas emissions from the Colombian execution of the Health health sector at the national level. Program. 2) Lead the preparation of a recommendations report, which establishes recommendations aimed at the health sector regarding possible climate change mitigation measures that can be carried out by Health Service Provider Institutions. 79 Table N° 8: Budget Allocation of the Program Action Plan (PAP) (The activities are financed by the MSPS) DLI / Responsible PAP Action Estimated Budget PAP Agency PA 1: Strengthening of the COP$ 10,000,000,000 adoption of the intercultural PAP MSPS approach in health. PA 2: Unification of the information tools for the COP$ 7,266,638 management of information PAP MSPS derived from the action of basic health teams. PA 3: Technical assistance for the development of territorial COP$ 73,914,487 PAP MSPS capacities for public health management. PA 4: IEC strategies for inclusive PAP MSPS COP$ 390,000,000 and territorially relevant health. PA 5: Future scenarios of HCW PAP MSPS COP$ 201,600,000 management. PA 6: Compilation of information for the future development of a Plan or registration program on the obsolescence of EEE in health PAP MSPS COP$ 19,200,000 centers for post-consumer recovery and comprehensive management of WEEE. PA 7: Adaptation to the CC of the PAP MSPS COP$ 3,169,464,000 health system. PA 8: Climate Change Mitigation. PAP MSPS COP$ 950,960,000 CONCLUSIONS AND RECOMMENDATIONS 208 ESSA concludes that the Program presents a moderate environmental risk and a moderate social risk. 209 The institutional setup has the potential to develop the capacity required to deal with potential environmental risks and challenges. The Program's environmental risks are reasonably covered by Colombian regulations and institutional capacities, but will require attention to address other environmental challenges that arise from (i) the possibility of increasing the generation of diagnoses and treatments in the health sector with the consequent increase in HCW, especially in areas far from large population centers and with unfavorable socioeconomic indicators; (ii) the generation of WEEE in health services caused by the obsolescence of increasingly used appliances and equipment linked to the provision of health services; (iii) the effects of Climate Change and the risks of geophysical disasters, due to their direct effects to interfere with the provision of health services, interrupt telecommunications services or impact the health of health workers, patients or their families. 210 The Program has a low probability of any negative social impact. No land acquisition is anticipated, as the Program does not support any construction. The result areas focus on the quality of medical care throughout the country, and on the resilience of the health system to the effects of climate change. In addition, the Program contemplates the inclusion of indigenous peoples, ethnic minorities and other vulnerable communities linked to dispersed rural populations, victims of the armed conflict and returned Venezuelan and Colombian migrants. CONSULTATION PROCEEDINGS 211 To evaluate the environmental and social systems, information was compiled about Colombia National Constitution and regulatory and policy framework. Secondary data sources were also consulted, subsequently validated and complemented by means of consultations and interviews with the main stakeholders. Officials and technicians from different areas of the MSPS were also interviewed to gather evidence and functional knowledge, and review concerns. 212 The consultations began in February 2023, interviews were held both online and in person, and a workshop was held with the MSPS authorities to complete and validate the sections on environmental and social issues. 213 A new round of consultations was held on April 28 and May 5 of 2023, to enable a deeper dive into the environmental and social aspects of the ESSA. To evaluate the environmental and social systems which are the focus of the “Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience”, discussions and consultations were held with key stakeholders, linked to the MSPS. Special emphasis was placed on those areas involved with the scope of the Program. The interviews included representatives from the following departments: Office of the Vice Minister of Public Health and Provision of Services; National Planning Department (DNP); Teams from the MSPS and APS and CAPS Territorial medical teams- characterization of homes; Directorate of Epidemiology and Demography; Subdirectorate of environmental health; Assurance Directorate; Noncommunicable Diseases Subdirectorate of the Promotion and Prevention Directorate; Social Promotion Office; and Directorate of Medicines. 81 214 A draft of the ESSA report was shared with the MSPS via email for their consideration and feedback on June 9. After validation, a draft version was published for consultation on July 11, 2023, on the MSPS website MSPS https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/INEC/INTOR/evalu acion-sistemas-sociales-ambientales-essa-colombia-acceso-salud.pdf. 215 The findings of the draft ESSA report were shared at virtual workshops for civil society on July 11 to July 24 of 2023. Comments by email were also received until July 26, 2023. The participants included representatives from several institutions and organizations, which detail is in the Annex A. 216 The participants endorsed the findings of the draft ESSA report, while made valuable recommendations for the implementation of these actions to be carried out by the MSPS and monitored by the World Bank team. A summary of this public consultation meeting may be seen in Annex A. 217 The document was enriched thanks to the interaction achieved by the workshops and will be posted by MSPS and the WB on their websites. 82 ANNEX A - ESSA Consultations Report As part of the consultation process of the Evaluation of Social and Environmental Systems of the Program to Improve Access to Effective Health Services for Vulnerable People and Greater Resilience of the Health System, two virtual meetings were held, both on Monday, July 24, 2023 at 9 a.m. and 2 p.m. from Colombia. The consultation was oriented to know the perspectives of social referents and regional organizations, as well as associations or civil society organizations (CSOs) with an interest in aspects related to health, the environment, as well as CSOs that work for the rights of people belonging to vulnerable groups (ethnic groups, women, children, the elderly, LGTBIQ+, migrants). The invitations were sent by email and a follow-up was carried out requesting confirmation, then sending reminders of the consultation meetings available as well as the possibility of sending questions, suggestions, observations, and comments until July 26 until 6:00 p.m. in Colombia. These meetings had a duration of approximately two hours and were moderated by environmental and social development specialists from the World Bank and had the participation of representatives of social and environmental areas of the MSPS as observers. In addition to these three meetings, participants were given the opportunity to send comments and suggestions by e-mail until July 26, 2023, however, no suggestions or comments were received on the content of the EESA, the risks analyzed and the approach mechanisms considered in this document. As a conclusion to the consultation process, it is considered that the evaluation of the environmental and social risks and impacts and the action plan shared in draft format were validated by the participants of the different instances. Valuable recommendations have been received for the implementation of these actions that will be carried out by the MSP and will be monitored by the World Bank team. Agenda The first virtual meeting had the following structure: Duration Activity 20 minutes Opening and round of introductions 30 minutes Moderators greet participants and introduce themselves. There is a round of introductions for everyone at the meeting. 45 minutes Break-out groups Guidance questions: - Do the risks and impacts identified seem adequate to you, and do you consider that there are any other risks? - Do you have any recommendations for the Action Plan? - Any other suggestion? 20 minutes Plenary meeting Consultations of the participants are answered and modalities of the Program are clarified by results, geographic area of the program, target population, among other aspects. 5 minutes Closing remarks Moderators thank participants and explain that feedback will be incorporated into the consultation report that will be part of the final version of the ESSA. 83 During the group work, comments and suggestions arose that are summarized below, with the responses for each topic: Comments Answers Environmental issues There were no comments or questions. -------------------------------------------------------- Social issues What are the prioritized municipalities? It is clarified that the Program has a national scope and that the MSPS will be in charge of disseminating the pertinent information on the prioritization of departments or municipalities at the appropriate time. How to link indigenous girls or girls in their This contribution is taken into account to add to diversity, taking into account the possible social the recommendations on risks and social gaps risk of exclusion that has been identified in the identified in the ESSA in table 4. in the ESSA ESSA? document. Appendix 1 - Consultation invitation Estimado/a: We are reaching out to you in the context of the preparation of the “Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience " with the Colombian government. The Program aims to improve access to effective health services for the vulnerable population and increase the resilience of the health system to climate change and be better prepared for future pandemics. The Program is National in scope. In this context, we invite you to participate in the socialization of the ESSA draft where we want to contrast the evaluation findings with the knowledge and perceptions of actors who are somehow involved or may have an interest in the Program's activities. To do so, we provide you with the link where you can access the document, and we invite you to send your comments and questions in response to this email no later tan July 26, 2023 at 18 hs. We also extend an invitation to a virtual meeting to hear your questions or comments about the document that will take place on July 24, 2023 at 02 p.m. This meeting will be held with regional environmental and social leaders, as well as associations and Non-Governmental Organizations (NGOs) in the health area. We would appreciate it if you could confirm your availability to participate in the meeting as soon as possible. If you have comments, we appreciate you sharing them with us before the meeting to the following emails: cescobarvictoria@worldbank.org; mmorandi@worldbank.org It is important to highlight that the shared document is a draft prepared by the project team at the World Bank and that it has been published on July 11, 2023 with the purpose of carrying out consultation activities with interested parties. 84 • Access Link: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/INEC/IN TOR/evaluacion-sistemas-sociales-ambientales-essa-colombia-acceso- salud.pdf • Brief description of the ESSA (See below the Link and the signature, at the end of this email) • Link for virtual meeting: through the Microsoft Teams link below. Brief description of the ESSA: Reason for conducting the Assessment: The World Bank, in accordance with Operational Policy and Bank Procedure (OP/BP) 5.04-POL 107, conducted a Social and Environmental Systems Assessment (ESSA) of the country's health system that applies to the " Program for Improved Access to Effective Health Services for the Vulnerable and Enhanced Health System Resilience" (the Program) under a Program-for-Results (PfR) financing operation. The scope of the ESSA was to evaluate the systems that promote environmental and social sustainability, which enable: avoiding, minimizing or mitigating potential adverse impacts associated with the Program on natural habitats and physical cultural resources; protecting patients and accompanying persons and worker safety; considering issues related to indigenous peoples, ethnic groups, vulnerable persons, and migrants; and avoiding social conflict. Additionally, it identified the necessary actions to improve/strengthen national systems and mitigate potential environmental and social risks. The specific objectives of the ESSA include: (a) identifying potential environmental and social benefits, risks, and impacts applicable to the Program interventions; (b) reviewing policy and legal frameworks related to the management of environmental and social impacts of Program interventions; (c) assessing institutional capacity for environmental and social management systems within the Program system; (d) assess the performance of the Program system against the core principles of the PfR instrument and identify gaps, if any; and (e) submit recommendations and a Program Action Plan (PAP) to address gaps and improve performance during program implementation. The main risks and environmental impacts of the Program, as well as the focus of the ESSA, focus on (i) the Management of Waste from Health Care Establishments; (ii) The potential generation of Waste Electrical and Electronic Equipment (WEEE), motivated by the dismantling generated by the scheduled obsolescence of the electronic equipment necessary for the effective and efficient provision of quality 85 health services; and (iii) The impacts of natural disasters and those caused by the effects of Climate Change (CC) both due to their direct effects to interfere with the dynamics of the provision of health systems, such as interrupting telecommunications services or impacting on the health of healthcare workers. In relation to social risks, the ESSA evaluates the barriers for vulnerable groups, including indigenous peoples, to access or participate in the Program. In addition, the structure of the agencies involved, the mechanisms for consultation, participation and attention to complaints and claims are evaluated. The risks of creating or exacerbating social conflict, especially in fragile areas or situations, are also considered. As part of the preparation of the ESSA, a series of institutional actors from the public, private and civil society sectors have been identified as stakeholders in the Program. Based on this identification, actors are invited to participate in this virtual consultation instance. As mentioned earlier, the shared document is a draft that has been published for the purpose of conducting consultation activities with stakeholders. Appendix 2 – Invitation to indigenous leaders via WhatsApp (in Spanish) 86 Appendix 3 – Presentation 87 88 89