—from Epidemiological
Bulletin , Vol. 25 No. 2, June 2004—
Country Profiles: Paraguay
General situation and trends
After a long period with authoritarian regimes, an incipient
democratic system is finally in place in Paraguay, but there are still difficulties
that undermine effective exercise of the constitutional state, including the
capacity to address social and economic issues and to embark on an institutional
reform process aimed at streamlining public administration.
The country's population in 2000 was estimated at 5,496,450, with an annual
growth rate of 2.6%; 41% were estimated to be less than 15 years old, and 7.3%
were 60 years or older (Figure 1). The population density in 2000 was 13.5
inhabitants per km2. Urban development has not occurred in a balanced way,
with a large urban population concentrated in a small land area (65% of the
urban population occupying only 5% of the national territory). The estimated
crude birth rate was 34.1 per 1,000 population in 1990-1995 and 31.3 in 1995-2000.
Life expectancy at birth increased from 66.3 years for men and 70.8 years for
women in 1990-1995 to 67.5 years and 72.0 years, respectively, in 1995-2000.
According to the Bureau of the Census, Statistics, and Surveys (DGEEC), the
estimated total fertility rate was 4.6 children per woman in 1990-1995 and
4.2 in 1995-2000.
Figure 1: Population structure, by age and sex, Paraguay, 2000.
In the past decade, the Paraguayan economy has been unable
to find an alternative to primary production, which is currently facing a crisis,
especially in the area of cotton growing, or to develop a model that will enable
the national economy to compete in the MERCOSUR regional integration initiative.
In the 1970s and 1980s, the country's GDP grew at an average annual rate of
8.1%, but in the 1990s, the rate dropped to 2.3% (Figure 2). The per capita
GDP was US$ 1,634 (in constant 1982 U.S. dollars) in 1996 and US$ 1,535 in
1999. In that year, it was estimated that 33.7% of the population was living
below the poverty line, representing 1.9 million people (46% of whom lived
in extreme poverty). Open unemployment in the population aged 10 and older
is 6.8%.
Figure 2: Gross domestic product, annual growth (%), Paraguay, 1991-2000.
The estimated crude death rate was 6.0 per 1,000 population during 1990-1995
and 5.4 in 1995-2000. The DGEEC estimates the number of deaths based on data
from the census; estimates of underregistration for the period 1996-1999
range from 37% to 41%. Between 46% and 48% of registered deaths were not
medically certified, and 16.7% of them were due to signs, symptoms, and ill-defined
causes, with a range from 10% in 1996 to 20% in 1999. The Figure 3 is shown
proportional mortality by broad groups of causes and sex.
Figure 3: Mortality (%), by broad groups of causes and sex, Paraguay, 1999.
Specific health problems
Analysis by population group
Health of the children (0-4 years): In 1999, there were 90,007 registered live
births and 1,749 deaths among children under 1 year of age, for a registered
infant mortality rate of 19.4 per 1,000 live births, down slightly from 19.7
in 1995. In 1999, registered neonatal mortality was 10.7 per 1,000 live births,
up from 9.8 in 1995. The rate in 1999 represented 55% of all registered deaths
in children under 1 year of age, compared with 50% in 1995. In 1999, the population
of children aged 1-4 years was estimated at 607,389, or 11.3% of the total.
That year there were 458 deaths, for a mortality rate of 75 per 100,000 children
between 1 and 4 years old. The leading causes were communicable diseases, with
a rate of 39.5 per 100,000. The mortality rate for children under 5 years was
24.5 per 1,000 live births in 1999.
Health of the schoolchildren (5-9 years): As of 1999, the group of children
aged 5-9 years was estimated to number 716,471, or 13.4% of the total population.
This age group had a mortality rate of 26 per 100,000. External causes headed
the list and were responsible for 37.8% of the deaths in this age group.
Health of the adolescents (10-14 and 15-19 years): In 1999, the population
10-14 years old was estimated at 655,917, and that of adolescents aged 15-19,
at 576,090. The group aged 10-19 years represented 23% of the total population.
One-third of the population between 13 and 18 years (44% in rural areas) received
no formal education in 1999. In 1999, the mortality rate was 32 per 100,000.
External causes headed the list for both sexes (15 per 100,000).
Health of the adults (20-59): In 1999, adults represented 44% of the population
and accounted for 26.5% of all registered deaths. The risk of dying was 1.8
times greater for men. Among 20-39-year-olds, external causes were the most
common cause of death, representing 47.8% of all deaths in that age group;
mortality rates were 52 per 100,000 for both sexes (90 per 100,000 men). In
the 40-59 age group, diseases of the circulatory system were the most frequent
causes of death, with an overall rate of 107.2 per 100,000 (122.7 per 100,000
men). Maternal mortality registered a rate of 114.4 per 100,000 live births
in 1999, a reduction of 23.8% with regards to 1990.
Health of the elderly (60 years and older): In 1999, the population aged 60
and older was estimated at 283,663 and represented 5.3% of the total. This
group had 56.7% of all registered deaths and 51.4 % of those medically certified.
The specific mortality rate for this age group was 3,630 per 100,000.The leading
cause of death was diseases of the circulatory system, with an overall rate
of 1,226.2 per 100,000.
Health of the workers: Because Paraguay is an agricultural country, one of
the main health risks for workers is exposure to pesticides. Before the National
Toxicology Center (CNT) was created in July 2000, there was no registry of
poisoning cases. In the last six months of 2000, the CNT registered 500 cases,
most of them in agricultural workers exposed to pesticides. In 2000, there
were 2,500 work-related accidents.
Analysis by type of health problem
Vector-borne diseases: The period 1993-1997 had an annual average of 624 reported
cases of malaria, but in 1998 the number rose to 2,091, and the Annual Parasite
Index (API) was 0.5 per 1,000 population. Then, in 1999-2000, an important
epidemic occurred, with 9,946 reported cases in 1999 (API 2.2 per 1,000);
in 2000, there were 6,853 cases (API 1.4 per 1,000). Most of these cases-82%
in 1999 and 80% in 2000-occurred in the three departments at highest risk:
Alto Paraná, Caaguazú, and Canindeyú. After a decade
of epidemiological silence, dengue transmission was detected in February
1999, and an epidemic ensued affecting a large part of the country. During
1995-1998, the annual incidence of cutaneous leishmaniasis ranged from 105
to 175 reported cases. In 1999 the program was re-structured; that year the
number of cases to 409, and in 2000 there were 562 cases. Visceral leishmaniasis
has been rare in Paraguay. The last two documented cases occurred in 1995
and 2000.
Diseases preventable by immunization: Pursuant to its commitment to eradicate
measles, the country has significantly reduced the incidence of this disease.
A total of 69 cases were reported in 1995, 14 in 1996, 200 in 1997, and 70
in 1998, when a successful campaign was undertaken to vaccinate the population
under 15 years of age. The circulation of measles has been interrupted since
November 1998. The last case of polio was reported in 1985; in 2000, the rate
of flaccid paralysis was 0.9 per 100,000 population less than 15 years of age.
The last case of diphtheria was recorded in 1995. In 2000, there were 24 reported
cases of pertussis. There were 7 reported cases of neonatal tetanus in 2000.
It is estimated that 70% of children under 5 years old have been vaccinated
against measles, 82% against polio, and 83% against tuberculosis (BCG) (Figure
4).
Figure 4: Vaccination coverage among the population under 1 year of age, by vaccine,
Paraguay, 2000.
Intestinal infectious diseases: Since 1997, there have been
no reported cases of cholera. Diarrhea was the third leading cause for outpatient
consultations in the health services of the Ministry of Public Health and Social
Welfare (MSP y BS), ranging from 8% to 12% in the different age groups. The
mortality rate for acute diarrheal disease (ADD) in the general population
was 8.3 per 100,000 in 1996 and 6.4 per 100,000 in 1999.
Chronic communicable diseases: The high annual incidence rates of tuberculosis
(ranging from 35 to 42 per 100,000 population during 1995-1999) show that this
disease continues to be a major public health problem. The mortality rate from
tuberculosis was 4 per 100,000 population during that period. In 2000, the
national prevalence rate for leprosy was 1.1 per 10,000 population.
Acute respiratory infections (ARI): ARI continue to be the leading reason
for outpatient consultations. They account for 36% of all consultations in
the general population and 50% of consultations for children under 5 years
old. During 1996-1999, ARI were responsible for 6% of all deaths in the general
population, with mortality rates of 22.3 per 100,000 population in 1996 and
19.1 per 100,000 in 1999.
Zoonoses: During 1995-2000, 34.3% of the human cases were reported in the
central region, with a rate of 1.0 per 100,000 population. In 1999, national
authorities began to update control activities; as a result there has been
a significant drop in the number of canine rabies cases (from an average of
34 cases a month in 1998 to 4.3 in 2000), and there were no cases of human
rabies between May 1999 and October 2000, when the last case was reported.
HIV/AIDS: The cumulative number of AIDS cases diagnosed between 1986 and January
2001 was 584, and the number of deaths from AIDS during the same period was
293 (for a case-fatality ratio of 51%). The prevalence is low in the general
population; cases continue to be found predominantly among urban men; and incidence
among drug users is still quite low. The incidence rate by sex is shown in
Figure 5.
Figure 5: AIDS incidence, by sex, with male-female ratio, Paraguay, 1994-1999.
Diseases of the circulatory system and malignant neoplasms: Diseases of the
circulatory system were the leading cause of death in the country during the
1996-1999 period, representing an annual average of 33% of all deaths in both
sexes. The mortality rates for malignant neoplasms in the general population
remained stable over the 1996-1999 period, fluctuating between 42 and 45 per
100,000 population. This group of diseases ranked third as a cause of death
during the period (14% and 16% of the total).
Emerging and re-emerging diseases: The first serologically diagnosed cases
of hantavirus pulmonary syndrome appeared in 1995. Between 1995 and 2000, a
total of 60 laboratory-confirmed cases were diagnosed, with an average case
fatality ratio of 23.8%.
Response of the health system
National health policies and plans
The National Constitution of 1992 declares that health is a fundamental right
and entrusts the State with its protection and promotion in the interest of
the community. In addition, it charges the National Health System with the
execution of integrated public health actions and the formulation of policies
that will permit the concentration, coordination, and complementation of programs
and resources in the public and private sectors. The National Health System
was created in 1996 when Congress enacted Law 1,032.
Health sector reform strategies and programs
The health sector reform process began with the enactment of Law 1,032, based
on the principles of equity, quality, efficiency, and social participation.
The Government has created the Secretariat of State Reform, in which the
health sector participates in the definition of policies on some of the issues
of sectoral reform.
Institutional organization
According to Law 1,032, coordination of the sector is the responsibility of
the National Health Council, which represents its key institutions and is
chaired by the Minister of Health. The Council is legally responsible for
coordinating and monitoring the plans, programs, and activities of public
and private health institutions. However, it does not currently exercise
this coordination function, which has been assumed by the MSPyBS. Two sectors
are responsible for health care delivery. The public sector comprises the
MSPyBS, the Social Security Institute (IPS), the Armed Forces Health Service,
the Police Health Service, the National University of Asunción, the
department-level and municipal governments, and several autonomous agencies
and decentralized state enterprises. The private sector, in turn, is made
up of private universities, nonprofit groups (NGOs), and for-profit entities,
including hospitals and private clinics. Insufficient coverage is a serious
problem in Paraguay: only 58% of the population is covered by the public
sector and 15% by private services. Hence, about 27% of the population has
no access to a health system.
Organization of public health care services
Disease prevention and surveillance systems: Disease prevention and control
is the responsibility of the MSPyBS, and in particular, the General Office
of Health Surveillance and the General Office of Health Programs. Responsibility
for health information and trend analysis is shared by the Office of Planning
and Evaluation and the Office of Health Surveillance.
Potable water, excreta disposal, and sewerage services
As of 2000, an estimated 44% of the Paraguayan population had access to potable
water. With regard to basic sanitation, 45% of the population has sanitary
excreta disposal systems, and 92% (99% of the rural population) has an adequate
arrangement in situ.
Food safety
The National Food and Nutrition Institute is currently guided by the Strategic
Food and Nutrition Plan 1997-2000, through the Departments of Prevention
and Control of Malnutrition, Prevention and Control of Micronutrient Deficiencies
and the Food and Nutrition Surveillance System. Since 1999, the Institute
has coordinated the development of food guidelines for Paraguay with the
participation of several other institutions.
Organization of individual health care services
Public subsector: The MSPyBS provides services in the 18 health regions at
three levels of care. Its actions include prevention and health promotion,
curative care, and rehabilitation. It also provides emergency care and ambulance
service, and it makes drugs available at its establishments or in local dispensaries
at subsidized prices. The IPS provides benefits for salaried workers in the
event of disease, disability, old age, survival, and death. Its activities
are financed by contributions based on the taxable income. The employer contributes
14%; the worker, 9%; and the State, 1.5%. The Armed Forces Health Service
treats active and retired military personnel and their families as well as
the civilian population in those regions where no public or private health
care is available. The Police Health Service takes care of present and former
police personnel and their families as well as prisoners. The National University
of Asunción provides health care services, which are partially free,
at the Clinical and the Neuropsychiatric Hospitals, both of which are in
Asunción. In the departmental governments, the Secretary of Health
is by law the highest authority on the Regional Health Council and works
in coordination with the municipalities of the department, on the one hand,
and the central government, on the other. They offer prevention programs
and medical care for the entire population of the dams' areas of influence.
There are 30 NGOs in the country providing direct health care to the most
needed populations. Private subsector: This for profit subsector includes
not only medical offices, but also 33 companies that provide prepaid medical
services through hospitals and private clinics, most of them in the Asunción
area and the Central Department. The Paraguayan Red Cross has a 125-bed maternity
hospital that is financed with contributions from a private nonprofit foundation.
Human Resources
In 2000, the MSPyBS had 3,427 physicians, 439 dentists, 350 biochemists, 1,567
licensed nurses and midwives, 1,035 technicians, 241 other professionals,
4,542 nursing auxiliaries, 3,852 administrative employees, and 3,474 support
staff. There are 6.4 physicians per 10,000 population, 0.8 dentists, 0.7
biochemists, 2.9 licensed nurses or midwives, 1.9 technicians, and 8.5 nursing
auxiliaries.
Health sector expenditure and financing
The public sector's sources of financing are mixed: funds come from the national
budget, worker and employer contributions, premiums, direct payments for
services, fees, and external cooperation. There is little control over the
processes or the results. The public establishments charge fees that are
unrelated to real costs, and their revenues are remitted to the Ministry
of the Treasury. Per capita spending on health in 1999 was US$ 105.30.
External technical cooperation and financing
The Government has entered into bilateral and multilateral international agreements
for technical and financial cooperation with a view to expanding the coverage
of health services and improving the quality of care provided to the population.
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Epidemiological
Bulletin , Vol. 25 No. 2, June 2004
