Pan American Health Organization

Panama

  • Overall Context
  • Leading Health Challenges
  • Health Situation and Trends
  • Prospects
  • References
  • Full Article
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Overall Context

Flag of PanamaPanama borders the Caribbean Sea on the north, Colombia to the east, the Pacific Ocean on the south, and Costa Rica to the west. The country’s current political-administrative divisions include 10 provinces, 77 districts (or municipalities), five indigenous regions (three at the provincial level), and 655 corregimientos, of which two are regional.

Demographics

In 2016, the country’s population was estimated at 4,037,043 inhabitants ().

The indigenous population constitutes 12.3% of the total () and is composed of the Guna, Emberá, Wounaan, Ngäbe-Buglé, Teribe, and Bri-Bri groups. The urban portion of the population, concentrated primarily in the provinces of Panamá and Colón (), accounts for 66.6% of the total ().

In 2014, life expectancy at birth was 70 years in the indigenous regions and 77.5 years among the population in other locations (80.7 years for women and 73.4 for men) ().

Figure 1. Population structure, by age and sex, Panama, 1990 and 2015

Panama’s population grew 59% between 1990 and 2015. In 1990, the population distribution was that of an expansive pyramid, especially in the over-15 age bracket. By 2015, the population reflected more aging and less expansiveness, particularly in the under-20 population, due to declining rates of fertility and mortality over the last two decades.

Source: Pan American Health Organization, based on data from the United Nations Department of Economic and Social Affairs. Population Division. New York; 2015.

The Economy

Economic conditions are determined by the Panama Canal, the Colón Free Trade Zone, and airport activity. Joining the Atlantic and Pacific Oceans, the Panama Canal accounts for 2% of the country’s gross domestic product (GDP). This figure is expected to increase in the coming years as investments to expand the canal are recovered (). Revenue from the Colón Free Trade Zone, which represented 8% of the country’s GDP (), declined 12% between 2013 and 2014 (). At the same time, airport activity benefits from increasing tourism and international recognition of Panama as a tourist destination ().

Economic growth is concentrated in the service sector, which accounts for 80% of growth, while manufacturing and construction contribute 12%, with the livestock sector making up the remaining 8% (). Several years of sustained construction growth were followed by a decline of 9% in the sector between 2015 and 2016 (). Estimated GDP growth for 2016 was 6.2%, the highest in the Region of the Americas (). Growth has been geographically concentrated (focused on 7% of the national territory), leading to unbalanced territorial development and major inequities () in: the Human Development Index (HDI), ranking 65th worldwide; the inequality-adjusted HDI, ranking 83rd; and the Gender Inequality Index, ranked 107th (). Policy has historically been economically oriented, with the social area – particularly the health sector – lagging behind. The country is currently reviewing and adjusting its fiscal model to meet the requirements of international organizations ().

Social Determinants of Health

In 2014, 21.4% of the country’s population lived in poverty, with women accounting for a higher percentage than men (Femininity Index of Poverty: 122.2), while 11.5% of the population lived in extreme poverty. Since 2008, poverty and extreme poverty have declined by 33.8% and 15.3%, respectively. In the urban population, poverty declined by 11.9% and extreme poverty by 3.3%, while the corresponding figures for the rural population were 40.9% and 28.3% (). As Figure 2 shows, the areas with the highest poverty levels in 2013 were the regions of Ngäbe Buglé (93.8%), Guna Yala (74.4%), and Emberá (73.6%) ().

Figure 2. Multidimensional poverty index, by province and indigenous region, Panama, 2015

Source: United Nations Development Program (UNDP). Atlas of Local Human Development. Panama, 2015.

As of 2016, unemployment in the economically active population was 5.2% (4.2% for men and 6.6% for women), with higher figures for urban areas than for rural ones. The percentage of women in the labor market (51.2%) is lower than that of men (79.5%) (). There has been year to year growth in formal employment.

In 2015, the country registered 493 homicides, a 22% decline from 2014 (), concentrated in the province of Panamá (55.9%). The victims were women in 10% of cases, while men, principally between the ages of 18 and 29, accounted for 90% of cases. There were 29 cases of femicide in 2015 (), compared to 39 in 2014 (). With regard to human trafficking, the majority of victims were female immigrants from countries within the region, who were being exploited sexually or were serving as domestic workers without verified work contracts (). Last year, 2,119 investigations of drug-related crimes were undertaken, over half (53.6%) of which involved possession, with 11.8% involving trafficking ().

The government is implementing the National Government’s Strategic Plan (), which focuses on the immediate needs of the population (water and sanitation, public lighting, solid waste management, urban transportation, housing, and health). For the 2016-2025 period, priority has been assigned to transforming the health system, in accordance with the new National Health Policy, which was formulated on a sectoral basis, with the Ministry of Health (MINSA) taking primary responsibility ().

Leading Environmental Problems

The availability of water has been identified as one of the country’s leading environmental problems. Both the quantity and quality of available water during the dry season are of concern, despite the fact that Panama’s average annual rainfall, at 2,930 mm (), is abundant.

The health impact of growing deforestation is unknown, as is the effect of energy development initiatives such as thermoelectric and hydroelectric power plants, some of which directly affect indigenous populations. Panama has not ratified Convention 169 of the International Labor Organization, which deals with indigenous and tribal populations and requires countries to consult indigenous populations about measures that may affect them.

The provinces of Panamá, Veraguas, Chiriquí, Colón, and Coclé are the areas most vulnerable to natural disasters (), due to their rapid growth and the fact that many settlements have sprung up in areas prone to flooding ().

The Health System

Public health in Panama is governed by the country’s Health Code. The public health system includes the Ministry of Health (created by Cabinet Decree No. 1 of 1969), which is organized according to 15 health regions, and the CSS (under Law No. 51 of 2007), which is structured in the same regional form, as well as by levels of complexity. The joint network of services includes 912 facilities, 836 run by the Ministry of Health and 76 by the CSS, the latter almost entirely second- and third-level facilities. In terms of their operational status, 12% (103) are not in full operation, and most of these (92%) (94 facilities) are primary care facilities. In the indigenous regions and in remote rural areas, only out-patient services run by Ministry of Health facilities are present. Efforts to tailor these facilities to the cultural norms of the populations they serve are still in their infancy. Private health services also exist in Panama, and are accessible directly or through private health insurers.

Nationally, there are 2.3 hospital beds per 1,000 inhabitants. Of these, 4,200 belong to the Ministry of Health system and 3,187 to the CSS, while 1,043 are in private facilities. The country’s urban areas have 2.9 beds per 1,000 inhabitants, while the rate in rural areas is 1.3 per 1,000.

In 2015, 84% of the population was covered by the CSS (), as the result of a consistent, gradual increase in coverage. The expansion of social security coverage is taking place in a context of job creation resulting from the country’s economic growth and from public and private investment. In addition to the CSS coverage, the Ministry of Health provides services to 47% of the population, under agreements between the two institutions that offer service in areas with no CSS facilities. A system is in place for mutual compensation where these crossed expenditures take place, but there is still no institutionalized system of cost management to standardize the system’s management centers. Incipient efforts in this regard are under way (). The Ministry of Health accounts for 30% of public health expenditure, with 50% of the beds, and employs 38% of the physicians, while the CSS accounts for 70% of public spending, 47% of the physicians, and 38% of the hospital beds.

Leading Health Challenges

Critical Health Problems

Panama’s leading health challenge concerns the nation’s pronounced disparities between the health status of the urban and rural populations (particularly the indigenous population) and inequalities in income levels. Such inequalities lead to disparities in the coverage of services and in access to comprehensive, high-quality health services. These disparities include the numbers and distribution of human resources; the presence of campaigns for promotion, prevention, and care services in the most marginalized areas (); health infrastructure; and the availability of drugs and other medical supplies, and health technology.

The failure to update and unify the legal framework governing health care is another matter of concern. With current regulations difficult to ascertain, inconsistencies result (). The country has begun to address this problem through a review and updating of the Health Code.

A third challenge results from the country’s predominantly conventional care model, which is markedly programmatic and disease-oriented, limiting the health system’s ability to guarantee the right to health. Health services are not yet organized into integrated networks. This leads to duplications and gaps in care, impeding implementation of the Primary Health Care (PHC) strategy (), and leading to long wait periods for medical and surgical care, and to uneven coverage for certain vaccines that are part of the broad National Immunization Program, which includes 23 vaccines.

Comparison of coverage between 2003 and 2013 shows a decline in polio vaccination coverage, from 83.2% to 81.1%, and a decline in measles vaccinations, from 83.3% to 81.0%. Coverage of the pentavalent vaccine (DPT-Hib-HepB) among children under 1 year old rose from 83.3% to 87.3%, a figure that remains suboptimal. Other vaccines have high coverage, as is the case with the BCG (98.6%) and rotavirus (95.5%) vaccines (). In one-year-old children, coverage remains at 100% for MMR1 and 90% for MMR2. The series has incorporated new vaccines, such as those for chickenpox and poliomyelitis (IPV), while the bivalent OPV vaccine has been altered, and vaccination for HPV has been expanded for both girls and boys 10 years of age.

With regard to national mortality figures, noncommunicable chronic diseases were among the leading causes of death in 2015 for both men and women (). Diseases of the circulatory system were the leading cause of death, with mortality and morbidity associated with these diseases being higher in men than in women ().

The second most frequent cause of death were malignant neoplasms, particularly those of the prostate, cervix, skin, and female breast, with mortality rates of 42.8, 21.9, 17.3, and 9.6, respectively, as of 2012 (). Injuries ranked third as a cause of death, with diabetes the fourth most frequent cause of death at the national level in 2015, affecting more women than men. The mortality rates for these two categories in 2014 were 35.1 and 26.9 per 100,000 population, respectively (Table 1) ().

Table 1. Leading causes of death for men and women, Panama, 2014

  Mortality
  Total Men Women
Cause No. Rate No. Rate No. Rate
Malignant tumors (neoplasms) 2,963.00 75.72 1,566.00 79.69 1,397.00 71.71
Accidents, self-inflicted injuries, assaults, and others forms of violence 1,782.00 45.54 1,507.00 76.69 275.00 14.12
Ischemic heart disease 1,733.00 44.29 1,044.00 53.13 689.00 35.37
Cerebrovascular disease 1,557.00 39.79 868.00 44.17 689.00 35.37
Diabetes mellitus 1,213.00 31.00 529.00 26.92 684.00 35.11
Other cardiac diseases 976.00 24.94 550.00 27.99 426.00 21.87
Pneumonia 673.00 17.20 352.00 17.91 321.00 16.48
Hypertensive diseases 645.00 16.48 336.00 17.10 309.00 15.86
Chronic diseases of the lower respiratory tract 548.00 14.00 289.00 14.71 259.00 13.29
Disease due to human immunodeficiency virus (HIV) 484.00 12.37 373.00 18.98 111.00 5.70
Other causes 5,597.00 143.03 3,028.00 154.09 2,569.00 131.87
Total 18,171.00 464.34 10,442.00 531.38 7,729.00 396.73

Rates per 100,000 inhabitants.
Source: Office of the Comptroller General of the Republic, National Institute of Statistics and Census (INEC). Vital Statistics. Mortality. Panama; 2014.

Human Resources

In 2011, there were 29.2 health workers per 10,000 inhabitants, exceeding the goal of 25 per 10,000 () set by the Pan American Sanitary Conference (). However, distribution was inequitable (only 12.3% of doctors were serving in the country’s rural areas, where 33% of the population lives) (), and the presence of health workers was much lower in indigenous regions, where no CSS (Caja de Seguridad Social, or Social Security Fund) facilities or personnel were present (Table 2) ().

Table 2. Health workers, at the national level and by institution, province, and indigenous region, Panama, 2014

  National Ministry of Health Social Security Fund
  Physicians Nurses Physicians Nurses Physicians Nurses
Province/Indigenous region No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate
Bocas del Toro 108 7.1 127 8.4 27 1.8 40 2.6 56 3.7 86 5.7
Coclé 272 10.7 350 13.7 81 3.2 120 4.7 171 6.7 226 8.9
Colón 238 8.7 237 8.7 58 2.1 50 1.8 143 5.2 173 6.4
Chiriquí 677 15.1 687 15.3 289 6.4 351 7.8 371 8.3 279 6.2
Darién 36 5.5 30 4.6 36 5.5 30 4.6 0.0 0.0
Herrera 248 21.0 381 32.3 100 8.5 130 11.0 113 9.6 239 20.3
Los Santos 180 19.0 193 20.3 134 14.1 155 16.3 42 4.4 36 3.8
Panama 3745 25.1 2593 17.4 1317 8.8 1218 8.2 1,648 11.1 893 6.0
Western Panama 381 7.1 290 5.4 109 2.0 133 2.5 188 3.5 136 2.5
Veraguas 253 10.4 332 13.6 99 4.1 180 7.4 124 5.1 145 6.0
Guna Yala indigenous region 15 3.6 17 4.1 15 3.6 17 4.1 ND 0.0 ND 0.0
Ngäbe Buglé indigenous region 26 1.3 25 1.3 26 1.3 25.0 1.3 ND 0.0 ND 0.0
Total 6179 15.8 5262 13.4 2291 5.9 2449 6.3 2856 7.3 2213 5.7

Note: Rates are per 10,000 inhabitants. ND: No data available.
Source: Office of the Comptroller General of the Republic, National Institute of Statistics and Census (INEC). Panama: Health services, 2014.

Training for human resources in health is overseen by nine universities, four public and five private. As of 2014, physicians trained as specialists by the public universities and abroad numbered 2,843, or 7.2 per 10,000 inhabitants ().

The public health system has training programs designed to bolster the capacities of the institutional workforce. Reflecting a desire to move forward in updating the capacities of health personnel, the 2004-2006 period saw the passage of Law No. 43 and the country’s Regulations Governing the System for Certification and Recertification of Health Professionals, Specialists, and Technical Personnel in the Health Disciplines (). However, the country does not have a study curriculum for health workers, with the exception of certain disciplines, such as nursing and psychology.

Given the lack of effective coordination between training institutions and health sector employers, it has not yet been possible to adopt further measures for human resources in health (). Although there is a policy regarding these human resources (), planning instruments are not yet in place to identify and meet the corresponding needs or to make projections. Since few Panamanian health professionals emigrate to work abroad (), there is not a problem with regard to the availability of human resources.

Health Knowledge, Technology, and Information

Scientific and technological research in Panama is governed by the National Research System (Law No. 56 of 2007) (), and is led by the medical research institution ICGES, or Instituto Conmemorativo Gorgas de Estudios de la Salud. Health research is supported by National Health Policy No. 7 (), and the National Secretariat of Science and Technology (SENACYT) has played an active role in this respect in recent years. The country has established the goal of increasing public investment in research, development, and innovation to 1% of GDP by 2020 (). While the State has invested in access to scientific information, the level of investment is still considered insufficient. Access is principally via the ABC platform (), a SENACYT strategy that facilitates access to digital sources of scientific and technological literature for the country’s population.

In 2010-2015, the country saw an increase in the development and incorporation of technologies for managing and delivering health services. Five hospitals and 20 Primary Health Care Centers for Innovative Health (MINSA CAPSI) were built. These facilities have digital technology and interconnections with the Virtual Hospital, allowing medical specialists to offer guidance to local teams providing patient care. The country is working to develop and implement a national eHealth strategy to ensure that the benefits of the health system reach everyone, regardless of geographic location. In 2015, Panama implemented its node in the Virtual Campus for Public Health created by the Pan American Health Organization (PAHO). This node was designed to develop and strengthen the capacities of the country’s public human resources for health.

Information management tools for health care and epidemiological surveillance have been and are increasingly being incorporated, the main tools being electronic medical files (SEIS-MINSA/SIS-CSS) and the Epidemiological Surveillance System (SISVIG). In their initial stages, there are also laboratory information systems that provide information for the Health Statistics and Information System, which began operation in 2016 (). The National Cancer Registry () is being strengthened, and is integrated with the Global Initiative for Cancer Registry Development of the World Health Organization (WHO) ().

The Environment and Human Security

In 2016, Panama’s Law Ratifying the Paris Agreement was passed. The Paris Agreement is the first global agreement to combat climate change, replacing the Kyoto Protocol when the latter expires in 2020 (). The National Policy on Climate Change was updated in 2015, and a National Climate Change Strategy has been drafted (). The Ministry of Health, which regulates the water and sanitation sector, has a draft national policy. The National Institute for Water Supply and Sewerage Systems (IDAAN) is the principal provider of water and sanitation services, serving nearly 75% of the nation’s population, while the country’s Administrative Boards of Rural Water Supply Systems also provide these services, mostly in rural areas.

As of 2015, improved-water coverage was 84% nationally (98% in urban areas) (), although there were rural and indigenous communities in which 50% of the population lacked such service. Average access to improved sanitation services was 75%, with marked differences between urban and rural areas (84% versus 58%), and with indigenous regions being particularly disadvantaged in this respect (). The country’s 100/0 Basic Health Program aims to strengthen the supply of potable water for all homes, and to eliminate unimproved sanitation. The Panama City and Bay Sanitation Project is being implemented in the framework of the Panamanian Sanitation Program, with 93% coverage at present () and expansion to other districts under way.

The quality of river water is deteriorating, due to urban effluents, deforestation, and soil erosion (). These problems are to be addressed by the recently established National Water Council, which is responsible for promoting and implementing the new National Water Security Plan (). The Panama Canal Basin supplies drinking water to 55% of the population (). In 2016, the new set of Panama Canal locks was put into operation. This creates a need for significant additional amounts of water. Although the project to expand the canal took account of that need, the project will have to be reviewed as part of planning for the country’s water supply, with the main challenge being that of addressing the problems that arise in the dry season.

On a daily basis, Panama generates 1.2 kg of waste per inhabitant. The capital has a sanitary landfill that takes in 2,000 tons/day of waste (). In 2013, waste generation in the metropolitan area was 40% above the figure for 2004-2009, which averaged 1,400 tons/day. Approximately 26.3% of the waste generated is not appropriately deposited in sanitary landfills. In 2013, only 2% of waste was recycled (). This situation represents a significant challenge for the country. Panama has a National Comprehensive Waste Management Plan 2014-2019 that addresses the recovery and treatment of materials, as well as adequate final disposal of waste.

In Panama, an estimated 560,936 metric tons of gases were released into the atmosphere in 2014, including 406,886 tons of carbon monoxide, 78,441 tons of nitrous oxide, 53,004 tons of hydrocarbons, and an additional amount of other substances. Mobile sources accounted for 97.5% of air pollutant emissions, with the energy sector and industry accounting for the remainder ().

Between 2000 and 2013, domestic consumption of petroleum derivatives in Panama rose 146% (). The country has major potential for hydroelectric resources, which could generate 65% of the nation’s electricity. The National Energy Plan 2015-2050 () calls for promoting alternative energy sources, which at present are used to only a small degree.

Aging

Demographic projections indicate that the over-60 age group will increase from 10% of the population in 2010 to 25% by 2050 (), posing a challenge for the CSS social security programs and for the country’s health services. In 2016, a debate was held regarding the sustainability of programs to protect the CSS and, specifically, to protect the Program on Risk of Disability, Old Age, and Death, which is associated with the increase in the elderly population.

Migration

Recent years have seen an increase in immigration. Between 2011 and 2014 (), the number of entries to the country increased by 40%, with a similar increase in the number of residence permits granted, primarily to immigrants from Colombia, Venezuela, Spain, and the United States. The principal sources of informal migration were identified as Colombia, Nicaragua, the Dominican Republic, and Venezuela, with men accounting for the majority of immigrants. Migration from outside the Americas also increased. For migrants from Africa and Asia, Panama and other countries in the Region serve as a step toward their final destination (the United States). There are no exact figures on these movements.

Panama continues to have a relatively open migratory policy, with frequent and extensive regulatory changes (). Foreigners account for 4.7% of Panama’s total population (). In this regard, the health system faces a major challenge, in that basic capacities must be strengthened at Darién and Guna Yala on the Colombian border, and at Chiriquí and Bocas del Toro on the Costa Rican border, in terms of both infrastructure and human resources,. In addition to migration to countries to the north, Panama experiences seasonal migrations. These principally involve indigenous people from the Ngäbe Buglé region and from the province of Bocas del Toro moving to and from Costa Rica during the coffee harvest season. This presents a challenge for basic services, including health services. The country’s internal migration consists essentially of rural to urban migration by young people, with the province of Panamá accounting for nearly 70% of these migrations ().

There is a national plan outlining an intersector approach to the problem of human trafficking, which has gained visibility in recent years. Measures include crime detection and prosecution, protection of victims, and international cooperation.

Monitoring the Health System’s Organization, Provision of Care, and Performance

The health system’s design and how resources are allocated give way to inequities in access, primarily affecting indigenous and rural populations, adolescents, disabled persons, and the lesbian, gay, bisexual, and transgender (LGBT) population, since the services do not include options designed to serve these groups.

In 2014, Panama evaluated the performance of its Essential Public Health Functions (EPHF). The overall analysis indicated that EPHF 1 (monitoring, evaluation, and analysis of the population’s health status) was the only one of the 11 functions that was operating optimally. Although no EPHF received the lowest possible score (0 to 0.50), the human resources development and public health training function scored a mere 0.52. The findings of this latest evaluation, carried out in 2001, indicate that performance had worsened ().

According to Cabinet Decree No. 1 of 15 January 1969 and the Organic Statute on Health, the Ministry of Health is responsible for determining, regulating, and executing the government’s health policy and essential public health policies. The delivery and funding of services, as well as the associated insurance, are responsibilities shared by the CSS and the Ministry of Economy and Finance. The Ministry of Health also shares functions with other agencies: ICGES and SENACYT (for health research); the Technical Health Council of the Ministry of Health (for advice on regulation of the medical profession); the Ministry of the Environment and the Institute of National Aqueducts and Sewage Treatment, or IDAAN (for environmental regulation); and the Panamanian Food Safety Authority (AUPSA) and Urban and Domestic Cleaning Authority (AAUD) ().

Panama devotes 7.6% of its GDP to public health. During the last decade, health spending rose more than GDP. However, while expenditure by the Ministry of Health increased more than GDP over the last decade, spending by the CSS rose proportionately with GDP (). Private health spending represents 23.2% of total health spending ().

The public health sector, composed of the Ministry of Health and the CSS, covers 100% of the population. The CSS is the largest provider of health services (84.4% coverage) (), while the Ministry of Health serves 47% of the population, overlapping with the CSS population. Although the Ministry of Health and CSS have plans to strengthen primary health care (), the majority of their resources are allocated for hospital care.

The fragmentation of the health system is reflected, as well, in the management dynamics of the national referral hospitals (Hospital Santo Tomás, Hospital del Niño, Hospital José Domingo de Obaldía, and the National Oncology Institute), which are financed by the State but have legal autonomy and employ mixed management models (with boards of trustees).

A diagnostic assessment exercise aimed at guaranteeing the universal right to health as an indispensable condition for sustainable development identified over 500 critical points (). This initiative calls for a comprehensive public health system with universal coverage and access, and timely, effective care, to meet the population’s needs and expectations and reduce inequities of access to health services. The proposal for this initiative was submitted to the President of the Republic in November 2015, and a High-level Commission to Transform the National Public Health System was created in response in May 2016 ().

Prospects

In accordance with approved sectoral policies, the country will continue the process of transforming the health system, aiming to strengthen the leadership role of the Ministry of Health, improve the efficiency of services, and guarantee access to services of better quality, with special attention to the most vulnerable populations. One of the foundations of this process of change consists of strengthening intra- and intersectoral coordination for management of the health system, and orienting actions to achieve functional integration of services provided by the two institutions, including support services for diagnosis and treatment. Thus, the framework of standards regulating the health sector needs to be reviewed, harmonized, and updated, beginning with the Health Code. The standards should promote better coordination, so as to address the determinants of health in an intersectoral manner.

In some cases, policies should be supplemented by subsector guidelines, as in the water and sanitation sector, the end goal being to move toward guaranteeing the right to health for all people and populations equitably, starting with access to basic health services.

Transformation of the system requires creating mechanisms to more thoroughly measure the effectiveness and efficiency of health spending, as well as the quality of services the system provides. Lastly, the management of health personnel needs to be modernized to meet appropriate standards.

References

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24. Law Nº 56 of 12 December 2007, Creating the National Research System and establishing incentives for scientific and technological research and development. Consulted: 8 July 2011. Panama: National Assembly of Deputies; 2007. Available from: http://www.asamblea.gob.pa/APPS/LEGISPAN/PDF_NORMAS/2000/2007/2007_557_0099.pdf.

25. National Secretariat of Science and Technology. National Policy on Science, Technology, and Innovation in Panama and National Plan 2015-2019. Panama City, 2015. Available from: http://www.senacyt.gob.pa/wp-content/uploads/2016/03/Resolucion_Plan-y-Politicas.pdf.

26. National Secretariat of Science and Technology. ABC Platform. Available from: http://abc.senacyt.gob.pa/?page_id=69.

27. Resolution 697 of 8 June 2016, by which the Ministry provides legal support for standards of the Health Information System. Panama: Ministry of Health of Panama, 2016. Available from: http://www.minsa.gob.pa/sites/default/files/programas/seis_-_resolucion_697_del_8_de_junio_de_2016.pdf.

28. Ministry of Health of Panama. National Cancer Registry. Panama City. Available from: http://190.34.154.93/rncp/.

29. World Health Organization. Global Initiative for Cancer Registry Development (GICR). Geneva. Available from: http://gicr.iarc.fr.

30. National Assembly of Panama, Ratification of the Paris Agreement. Panama City, 2016. Available from: http://www.asamblea.gob.pa/legislativo-y-ejecutivo-juntos-en-ratificacion-del-acuerdo-de-paris/.

31. Ministry of Environment of Panama. National Climate Change Strategy of Panama. Panama City, 2015. Available from: http://www.miambiente.gob.pa/images/stories/documentos_CC/Esp_Info_V.1_ENCCP_15.12.2015.pdf.

32. UNICEF database. Available from: http://data.unicef.org/water-sanitation/sanitation.html.

33. CONADES. Noticias. Moradores de La Pintada visitan el Proyecto-de-Saneamiento-de-la-Ciudad-y-la-Bahía-de-Panama. Panama City, 2016. Available from: http://www.conades.gob.pa/Noticias.

34. National Environmental Authority. http://www.miambiente.gob.pa.

35. La Estrella de Panamá. El mercado de los hidrocarburos en Panamá. 2016. Available from: http://laestrella.com.pa/economia/mercado-hidrocarburos-panama/23887533.

36. National Secretariat of Energy. National Energy Plan 2015-2050: “Panama, the Future We Want.” Panama City, 2016. Available from: http://www.energia.gob.pa/tmp/file/277/plan%20energetico%20nacional%20-edicion%20ira%20-julio%202016.pdf.

37. Government of the Republic of Panama. National Migration Service. http://www.migracion.gob.pa.

38. Executive Decree 167 of 3 June 2016, establishing the general procedure for regularizing migration. National Migration Service: 2016. Available from: http://200.46.254.138/APPS/LEGISPAN/PDF_GACETAS/2010/2016/28045-C_2016.pdf.

39. World Bank and Kaiser Family Foundation. Indicators. 2015.

40. Ministry of Health of Panama. Model for Individual, Family, Community, and Environmental Care. Panama City, 2012.

41. Social Security Fund of Panama. Plan for Modernizing Primary Health Care. Panama City, 2012.

42. Executive Decree N° 213, designating the members of the high-level commission created through Executive Decree N° 1 of 8 January 2016. Panama: Ministry of Health of Panama; 2016. Available from: https://www.gacetaoficial.gob.pa/pdfTemp/28034_B/GacetaNo_28034b_20160519.pdf.

43. United Nations System (2014). Millennium Development Goals. IV Report. Panama City.

44. Instituto Conmemorativo Gorgas de Estudios de la Salud. National epidemiological study of HIV. Panama City, 2013.

45. Ministry of Health of Panama. Department of Epidemiology. National Consolidated Monitoring of Cases of SARI and Deaths from Influenza. Panama City, 2016.

46. Ministry of Health of Panama. Estimates and Projections of HIV 2014. Panama City, 2015.

47. WHO. Global Tuberculosis Report. Geneva; 2015.

48. Ministry of Health of Panama. Information provided by the Tuberculosis Program.

49. Ministry of Health of Panama. Department of Vector Control.

50. Ministry of Health of Panama. Department of Epidemiology of MINSA. Boletín Epidemiológico N° 36: Zika. Panama City.

51. Instituto Conmemorativo Gorgas de Estudios de la Salud. Prevalence of Risk Factors Associated with Cardiovascular Disease. Panama City, 2013. Available from: http://www.gorgas.gob.pa/atlas%20interactivo/prefrec.html.

52. Ministry of Education/Ministry of Health. VII Census of first-grade schoolchildren, 2013. Panama City, 2014. Available from: http://190.34.154.88/procedimientos/ProgramaNutricion/Estudios%20e%20Investigaciones%20en%20Nutrici%C3%B3n/Censo%20de%20Talla%202014.pdf.

53. Transit Authority and Land Transportation. National Plan for the Decade of Action for Road Safety 2011-2020 of the Republic of Panama. Panama City, 2011. Available from: http://www.who.int/roadsafety/decade_of_action/plan/panama.pdf.

54. Ministry of Health of Panama. Operational Plan for Mental Health 2016-2017. Panama City; 2015. Available from: https://www.paho.org/pan/index.php?option=com_docman&task=doc_view&gid=378&Itemid=224.

55. PAHO/WHO. Results of survey on tobacco use in Panama. Panama City, 2013. Available from: https://www.paho.org/pan/index.php?option=com_content&view=article&id=766:presentan-resultados-encuesta-sobre-consumo-tabaco-panama&catid=673:pan.04-reduccin-de-riesgos-para-la-salud.

56. Ministry of Health of Panama. Survey on the Use of Tobacco by Young People. Panama City, 2013.

57. WHO database. http://apps.who.int/gho/data/node.home.

58. Ministry of Health of Panama. Nutritional Monitoring at MINSA Health Facilities. Moninut, 2014. Panama City, 2015. Available from: http://190.34.154.88/procedimientos/ProgramaNutricion/Estudios%20e%20Investigaciones%20en%20Nutrici%C3%B3n/Informe%20Monitoreo%20Nutricional%202014.pdf.

59. INCAP. Marked increase in obesity in Panama in the last three decades. Guatemala City. Available from: http://www.incap.ops-oms.org/index.php/en/news/948-in-the-last-3-decades-has-been-a-marked-increase-in-obesity-in-panama-study-divulge.

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Reference/Note:

1. The multidimensional poverty data by province are from the UNDP analysis that appears in that organization’s Atlas of Local Human Development: Panama 2015, since such information was not available from Panamanian sources.

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