Dr Julio Castellanos, San Ignacio's Hospital, Bogotá

In Colombia, the work on the medical mission started in 1998. The aim was to register the impact of the non-international armed conflict on health services and, in particular, the difficulties the medical staff was facing in fulfilling its commitment of assisting the wounded and sick, under the rules of international humanitarian law (IHL). Although at that time the ICRC in Colombia had launched a campaign seeking to promote respect for and protection of health facilities and health personnel in the country, Colombia did not have a domestic institutional structure responsible for ensuring the respect and protection of the medical mission, nor for disseminating international standards on that topic.

Given this scenario, the ICRC and the Colombian Red Cross began to organise a series of meetings to which they invited external entities such as the Ministry of Health and Social Protection and the Emergency Control Centre of the Ministry of Health of Cundinamarca. Later on, the Presidential Programme for Human Rights and International Humanitarian Law also joined in. As part of these meetings a process of reflection began, which can be summarised by the following questions: should the campaign be directed at merely disseminating IHL related to the protection of the medical mission in general? Or should this campaign ultimately aim at reducing the number of victims through the prevention of specific violations of the respect due to the medical mission by disseminating IHL in conflict-affected areas of Colombia?

Recognising that the state has the primary responsibility for guaranteeing compliance with international standards on the necessary respect for and protection of the medical mission, other entities such as the Prosecutor-General of the Nation, the Prosecutor's Delegate, the Attorney General's Office and academic circles were subsequently incorporated into this space, which is now called National Permanent Roundtable for the Respect of the Medical Mission.

Since its inception, the Roundtable has had several objectives. Among them is to create preventive mechanisms such as informing all concerned actors of what the protection of the medical mission involves, including, among other things, drawing attention to the victims of the Colombian non-international armed conflict. It is also intended to provide a space to elaborate standards and guidelines addressed to the personnel of the medical mission to orient its behaviour towards preventing situations of risk for themselves (being correctly identified with the emblem, following security standards, etc.), as well as to facilitate the provision of effective health care and assistance to the victims.

Dr Francisco Moreno, Colombian Red Cross

The work of the Roundtable reacts to certain internal needs and realities that impose the necessity to strengthen the respect for, and protection of, the medical mission in the country. It also reflects the commitment of the Colombian state towards the 31^st International Conference of the Red Cross,Footnote ² the Colombian Red Cross, and the ICRC itself, with regard to sensitisation to the necessary respect, protection and access to health services of victims of the armed conflict. This commitment has been honoured through the concrete actions of the Roundtable.

Dr Julio Castellanos

Among the various manifestations of the armed conflict in Colombia, it is clear that there are direct and indirect effects on access to health care by individual victims and by entire communities, in terms both of frequency and of adequate quality to ensure appropriate medical attention. We have observed the occurrence of direct attacks against the different elements that make part of the medical mission, such as threats to the integrity of health personnel, attacks on their facilities and even threats against the medical actions necessary for the welfare of the population. We have also witnessed attacks against the lives and integrity of the sick and wounded that require immediate attention, and the conflict in general affects the access of civilians to the provision of health services.

This situation has motivated the Roundtable to take action over the years and has allowed us to bring about the building blocks for the construction of a public policy to address the issue. Likewise, it has directed the Roundtable's activities to emphasise the obligation to respect and protect the medical mission and to disseminate information related to the work of health personnel in Colombia as well as to promote their duties and rights amongst all of the actors concerned.

Initially we prioritised the work of the Roundtable at the national level, since several violations to the health services occurred transversely and in different forms throughout the entire country, as a result of the armed conflict. However, as time passed, we realised the need to have presence not only at the national level but also at the regional level, particularly in those departments where major attacks on the medical mission were identified.

According to the records we keep on situations of non-respect of the medical mission (retention of ambulances, requests to doctors for confidential information on certain patients, etc.) in different – mainly rural – regions of the country, we have identified that, unfortunately, between 2011 and 2012, the aforementioned events have increased, affecting even more the victims’ access to health services.

Dr Luis Fernando Correa, representative of the Ministry of Health and Social Protection

The Roundtable has developed different activities throughout the country. Among these, it is relevant to emphasise not only workshops of dissemination but also the elaboration of regulations for the promotion of respect for the medical mission. An example of the latter is the current Colombian Manual of the Medical Mission – approved by Resolution 4481 of 28 December 2012 of the Ministry of Health and Social Protection – that provides guidelines for the protection of health personnel, their material and facilities.Footnote ³ It is noteworthy that this manual defines as ‘infractions’ to the medical mission any ‘conduct that by action or omission affects the components and activities of the Medical Mission or its direct beneficiaries (patients or communities) and that is related to situations of public order, in disregard of one or several duties and rights’ of the medical mission; and as ‘incidents’ affecting the medical mission ‘any action or omission, direct or indirect, which prevents, delays or limits access to its services and that is not considered a violation of IHL’.Footnote ⁴

Furthermore, since 2009, the Roundtable has encouraged and developed activities such as national seminars on issues related to the respect for the medical mission. From these experiences, it was deemed necessary to replicate such activities at the local level. So, in 2011, the Roundtable organised regional roundtables in the departments of Antioquia, Arauca, Nariño, Cauca, Norte de Santander, Bolivar, Huila and Chocó.

The Roundtable has also been involved in the training of health personnel in the country, through an agreement signed with the Colombian Red Cross.

Finally, with the support of the ICRC, the Roundtable has worked on the question of the use of the medical mission's emblem in the country by the people and institutions that are part of it.

Dr Jorge Cubides, advisor of the Presidential Programme for Human Rights and International Humanitarian Law

The Roundtable has faced several challenges since it started its work. Firstly, the reality and dynamism of the armed conflict present particular difficulties due to the presence of different armed actors, each one with specific attitudes towards the activities of the medical mission in different parts of the country. In this sense, the Roundtable has always been conscious of the importance of raising awareness among these actors on the need to respect medical structures, personnel and health activities in general. In this respect, the protection work that the ICRC carries out, given its access to the parties to the conflict, is necessary and complementary to the work of the Roundtable. In general, the Roundtable's activities seek to guarantee the civilian population's access to health services.

Secondly, the vulnerability of health personnel in remote and isolated areas of the country and the difficulty for the population to have access to them also represent challenges in terms of guaranteeing the protection of the medical mission. For this reason, the Roundtable has facilitated activities to engage state authorities in charge of promoting the protection of health-care personnel, in order to clarify the framework of responsibilities in case any dangerous situation occurs or violations are perpetrated against the components of the medical mission. The Roundtable has also promoted self-protection mechanisms for health personnel, whose only and exclusive mission is to provide quality medical services to the population.

Thirdly, the involvement of state agencies related to the protection of the medical mission (such as the police, the army, mayors, governors and health personnel), and, of course, of non-state armed actors, has always been (and remains) a challenge for the Roundtable. However, despite the change of political administration every four years, to date the Roundtable has received continuous support from the institutional authorities.

Fourthly, the Roundtable has had an additional challenge, which is to prevent and punish the misuse of the emblem by unauthorised personnel.

Dr Tatiana Flórez, ICRC

One the most significant contributions of the Roundtable has been to achieve a generalised understanding and acceptance of the fact that the protection of the medical mission goes beyond the context of health services and personnel, and does not only involve the authorities strictly related to this field. Today, it is understood that its protection involves political authorities like the government, the ombudsman and the Attorney General's Office, among other state entities.

Another important contribution of the Roundtable has been its replication at the regional level. Indeed, it has been shown that the work that it performs at the regional level allows the local authorities to feel supported by the central state institutions, which in turn have the support of the Colombian Red Cross and the ICRC. This has led to the empowerment of local authorities and, especially, the possibility of coordinating their responses in relation to events that affect the medical mission's activities.

Dr Julio Castellanos

This is a fundamental question. There were several reasons for creating the emblem of the medical mission for the exclusive use of civilian health personnel in Colombia. One should clarify that the decision to do this relied mostly on a rational and practical analysis, rather than a legal analysis, of the dynamics of the armed conflict in Colombia during 2000 and 2002.

The first reason relates to the issue of ‘identity’. In the context of the Colombian armed conflict, the use of the red cross on a white background is allowed for both civilian and military health personnel. However, in view of the high vulnerability of military personnel (including their health-care workers) at that time – considering possible attacks against them by non-state armed groups – it was deemed necessary to provide civilian medical personnel with their own emblem for their exclusive use during the deployment of their activities within the context of armed conflicts, natural disasters or emergencies.

The second reason was the conviction that this emblem would allow civilian personnel to have the necessary protection beyond potential political decisions of whether there is an armed conflict or not, thus overcoming the possible implications of the non-application of IHL norms related to the protection of the medical mission.

The third reason relates to the issue of ‘visibility’. At the time of the eruption of the volcano at Armero in 1985, it was observed that rescue and support organisations that participated in the relief effort, apart from the Civil Defence and the Colombian Red Cross, had neither uniforms nor distinctive signs to facilitate their identification. While the Civil Defence and Colombian Red Cross responded to the emergency quickly and effectively, other rescue and support organisations, identified with different colours and signs, were slower in their response to this disaster because of a perception that they were not part of organised relief efforts. For this reason, the Roundtable thought of facilitating the visual identification of such personnel, carrying out a technical study that enabled the development of an emblem that would rely on symmetry and propitious colours for their identification in the field. This emblem is also used on their ID cards and the respective permission to carry them.

Figure 1: Emblem of the Colombian Medical Mission, created by Resolution 1020 (of 5 August 2002) and confirmed by Resolution 4481 (of 28 December 2012).

Finally, the fourth reason relates to the issue of ‘protection’. We could make an analogy saying that when an antibiotic is used for everything, it eventually becomes ineffective. It is clear that the emblem of the red cross on a white background was used for the identification of personnel of the Colombian Red Cross, of the ICRC, and also of the health-care personnel of the state armed forces. Creating an emblem that would only identify the different civilian elements of the medical mission allowed for better access by civilian medical personnel to victims of armed conflict, natural disasters or any other catastrophes, and also for their protection on the ground, preventing confusions, resistances and erroneous perceptions of their mission, which are unfortunately a reality in non-international armed conflicts.

Dr Francisco Moreno

While the National Roundtable discusses general issues of interest throughout the whole national territory, such as the legal framework for the protection of the medical mission, as its work advanced we saw the need to empower the authorities at a regional level. Thus, we took the decision of identifying the regions that faced most difficulties in terms of protection of and respect for the medical mission and proposed to them the creation of institutional spaces in which the governors of the different regions would express their commitment on the issue. Nowadays, the regional roundtables are set up by administrative acts of constitution and their composition is similar to that of the National Roundtable, but structured in accordance with the needs of each department.

Dr Luis Fernando Correa

To date we have put in place four regional roundtables, in the departments of Norte de Santander, Arauca, Cauca and Nariño.

For the entities that participate in these roundtables, it was considered essential to promote not only the participation of authorities linked to the health sector, but also that of authorities with decision-making capacity that could give legitimacy to the issues addressed. In this way, the constitutive acts of these bodies asked for the participation of health and government secretaries (responsible for guaranteeing, respectively, health and security services in the regions) as well as the ombudsman and the Attorney General's Office. The process also involved the inclusion of departmental representatives of local civil society, such as universities, local medical personnel, non-governmental organisations, local representatives of the Colombian Red Cross, or officials of the World Health Organisation. Sometimes, members of the judiciary have joined for the purpose of monitoring possible offences against the medical mission.

The National Police and the armed forces have also been invited to participate in these roundtables. Their presence has not only brought experience and knowledge regarding the practical relevance of IHL to the discussions, but has also made them more willing to provide their support to facilitate access to health-care services in times of emergencies or to prevent its obstruction in isolated areas of the country.

The topics covered at the regional roundtables are those that respond to local issues. For example, they discuss themes such as the use of the emblem by health institutions, the institutional response to offences against the medical mission as a result of the armed conflict or other situations of violence, the analysis of requests for the authorisation to use the emblem of the medical mission, and training activities for medical personnel.

Dr Jorge Cubides

Additionally, through the creation of these regional roundtables, the Colombian state executes its obligation to implement its public policy in terms of protection of the medical mission at the decentralised level. Thus, from the regional roundtables, created on the basis of administrative acts with binding force, regional authorities can take concrete measures in response to offences against the medical mission.

Dr Luis Fernando Correa

Initially, some of the factors included the identification of the neediest departments in terms of the protection of the medical mission, identifying best practices and replicating those best practices in other regions of the country.

Subsequently, the element that definitively contributed to the development of the regional roundtables was the commitment of the governors, which in turn stimulated other public officials to participate in the roundtables. The participation of hospital managers in remote regions, who experience first-hand the difficulties of providing health services, has been fundamental because they are the ones that understand best the local needs and bring to the discussions ‘a notion of reality’. The ICRC and the Colombian Red Cross have helped sensitise local officials in isolated areas in the wake of the conflict of the existence of these roundtables and the importance of their active participation in them.

A good example of implementation of a regional roundtable is the Norte de Santander roundtable. The elements that have led it to being a model one are, among others: the leadership and commitment of the local authorities, including those responsible for the health institutions; the collaboration between the members of the roundtable and the local police department; and the coordination of different institutions for the transfer of patients on safe and uncluttered roads.

The work carried out in other areas of the country should not be forgotten. The fact that the regional authorities have been willing to create roundtables in their regions denotes the importance they ascribe to this issue and their commitment to the protection of the local components of the medical mission.

Dr Tatiana Flórez

Over time, it has become apparent that access to health care for people who need it ought to be guaranteed in whatever situation may arise where the humanitarian consequences need to be addressed. The Colombian armed conflict has many diverse aspects and manifests itself differently in the different regions of the country. Therefore, there are parts of the territory in which violent situations occur that, although not necessarily amounting to violations of IHL, nevertheless impede people's access to health-care services. This led us to realise that the humanitarian consequences of these other forms of violence needed to be addressed in the same way as those that occur as a result of the armed conflict in order to improve victims’ access to health care, which is the main aim of the Roundtable and of the Colombian institutions concerned.

Dr Luis Fernando Correa

State entities that are linked to the National Roundtable have realised that the Colombian Red Cross and the ICRC are their greatest allies in this process. It is important to emphasise their commitment over the years, their leadership in the National Roundtable and their ability to convene different entities.

The presence of these two institutions at the National Roundtable has proved a strength since their access to different areas of Colombia, facilitated by their neutral and independent nature, enables them to have the necessary first-hand information to take decisions in terms of mobilisation, with the aim of ensuring the protection of the medical mission in the field.

We consider that their permanent support during all these years has given visibility to the National Roundtable and we hope to continue counting on the support of both institutions, in the interest of promoting respect for and protection of the medical mission in Colombia.

Dr Jorge Cubides

It is also important to highlight that, in conjunction with the ICRC, the National Roundtable has promoted a series of talks with prosecutors from various parts of the country with the aim of raising awareness on the rules relevant to the protection of the medical mission, and in particular on the prohibition against punishing any person for having performed medical activities in accordance with medical ethics. This is a contribution for which the authorities are also grateful because it reinforces the right of the sick and wounded to be cared for and contributes to the implementation of IHL as well as Colombian domestic law.