Pan American Health Organization

Paraguay

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

Flag of ParaguayParaguay (Paraguái in the Guaraní language), officially the Republic of Paraguay, has a total land area of 406,752 km2, divided by the Paraguay River into two regions: the eastern region, where the largest cities are located, and the western region, which is part of the northern Chaco area. The country borders Argentina to the southeast, south, and southwest; Bolivia to the north; and Brazil to the east. It is subdivided into 17 departments plus a capital district, Asunción, which for purposes of this report is counted as another department.

Demographics

As stated in its National Constitution enacted on 20 June 1992, Paraguay is a multicultural and bilingual country. It has two official languages, Spanish and Guaraní, with Guaraní spoken or understood by 87% of the population. Paraguay is defined as a democratic, unitary, and representative republic, which has three branches of government: the legislative, the executive, and the judicial. The legislative branch resides in the National Congress, which has two chambers: the Senate with 45 members, and the House of Representatives with 80.

In 2015, Paraguay had a population of 6,755,756 inhabitants (50.5% males), with 31% of the population under the age of 15, 63% between the ages of 15 and 64, and 6% aged 65 years or older (). Figure 1 shows the evolution of Paraguay’s population structure between 1990 and 2015.

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

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

The 2012 indigenous population census revealed that there were 112,848 indigenous peoples in the country (1.8% of the total population), 51.7% of them men (). In 2015, 60.5% of Paraguayans lived in urban areas, the vast majority in the two largest cities in the eastern region: Greater Asunción and Ciudad del Este. In the western region, the population is predominately rural, and is distributed across small towns.

Life expectancy of the Paraguayan population increased from 69.3 years in 2011 to 70.7 in 2015. The average annual growth of the population in 2015 was 1.5% and is expected to slightly decline to 1.3% by 2024, with the median age increasing from 25 years in 2015 to 27.9 in 2024, reflecting an aging population and growing health care needs for the elderly. The general fertility rate in 2015 was 2.6 and is expected to decline to 2.3 by 2024 (); in the indigenous population, this rate fell in the last decade from 6.3 children per woman to 4.5.

The Economy

The Paraguayan economy is growing. It is the largest exporter of electricity in the Americas, and is the fourth largest exporter of soybeans and the sixth largest exporter of beef in the world. In the last decade, the domestic economy grew an average of 5% per year, which is more than its neighbors, although there are wide variations due to the country’s dependency on natural resources. The per capita gross domestic product (GDP) in 2014 was US$8,911, and in 2015 the GDP increased 3.0%. The electricity generated by the Itaipú and Yacyretá binational hydroelectric power plants, along with the highly productive and modern agriculture and livestock sectors, are leading economic activities, accounting for more than 60% of Paraguayan exports in 2015. Sustained economic growth helped reduce poverty and promote shared prosperity: the income of the bottom 40% of the population increased 8% annually between 2009 and 2014, and the proportion of Paraguayans living on less than US$ 4.0 a day (poverty line) fell from 32.5% to 18.8%. However, poverty and income inequality remain a major challenge. With regard to labor, the predominant group is comprised of self-employed workers (33.5%), followed by househusbands and housewives (26.2%). In the period 2010-2015, the employment rate ranged from 90% to 92% among the 3,492,514 economically active people.

The Health System

The National Health System created by Law 1032/96 is comprised of the public, private, and mixed sectors, and is characterized by a lack of integration as well as asymmetrical territorial coverage. Although by law the health authority is the Ministry of Public Health and Social Welfare, leadership is weak and in actual practice, the National Health System operates in an uncoordinated and fragmented manner, with different financing, regulation, enrollment, and service delivery modalities.

The public sector consists of the Ministry of Public Health and Social Welfare; the Military, Police, and Navy Health Services; the Institute of Social Welfare (IPS); the Clinics Hospital, which is part of the National University of Asunción; and the Maternal and Children’s Health Center. The private sector includes nonprofits (such as nongovernmental organizations and cooperatives) and other for-profit organizations (prepaid medicine institutions and private providers). The Paraguayan Red Cross is a mixed entity that receives funds from the Ministry as well as from a private nonprofit foundation ().

The Ministry and the IPS are the two most important health institutions in Paraguay and together cover approximately 95% of the country’s population. In 2014 it was reported that the IPS covered 19% of the population (25.4% in urban areas and 12.6% in rural settings), primarily workers in the formal sector and their families; 7.6% of the population has another type of health insurance, and 73.4% has no insurance and is covered by the Ministry, which must therefore meet most of the demand for health services ().

According to the Health Accounts System, in 2014 the total expenditure allocated to health, which is understood as the sum of public and private healthcare resources, was approximately US$ 1,800,000,000 (54.3% financed by the public sector and 45.7% by the private sector), which accounted for 7.7% of GDP that year. Public health expenditure in 2012 was 4.1% of GDP, which fell to 3.6% in 2013, and then increased to 4.2% of GDP in 2014; private health expenditure remained at an average of roughly 3.5% of GDP for the last years analyzed. Current public health expenditure per capita (US$ 155.25) was higher than private (US$ 130.00). The overall per capita figure for the year 2014 was the highest in the years analyzed, i.e. US$ 285.25.

As a part of the efforts made to achieve universal coverage and access to health, in December 2008 the Ministry started to create family health units (USFs for their Spanish acronym) and set them up in the health regions (). The USFs are physical structures where many of the activities included in the primary health care strategy are carried out in a coordinated, comprehensive, and ongoing manner. By creating a basic family health team responsible for the health of the population assigned to it, these units provide consultation, home care, community integration, territorialization, ongoing medical evaluation, and vulnerability assessment services, through activities such as disease prevention and health promotion, medical care and habilitation, rehabilitation, and social inclusion. Moreover, each USF conducts activities related to sanitation, education, research, and social organization.

Primary care only exists in the Ministry of Public Health and Social Welfare network, which is comprised of 1,028 health services delivery facilities with different levels of complexity, with potential hospitalization available at 354 of these facilities; in turn, the IPS has 78 facilities, 41 of them with hospitalization (). Together, both institutions have 6,156 beds, for a coverage of approximately one hospital bed per 1,000 population ().

The number of USFs has continually increased. While in 2010 there were only 503 of these units serving approximately 2,012,000 people, or 22.8% of the population (), in 2011 the number of USFs climbed to 704, spread out in 234 districts in 18 departments of the country, covering a total of 2,467,000 people. In 2013 the number of USFs increased to 743 () and 2015 and 2016 ended the year with 754 and 796 USFs, respectively (). Despite these increases, coverage is still insufficient and only reaches, for example, 50% of the population in the health region of Alto Paraguay, which has a low population density of residents who are widely geographically dispersed. The regions with the highest poverty levels, such as Caaguazú, Also Paraná, and Boquerón, have the lowest coverage. Although the intent was for USFs to be located on the basis of population density, the areas with the highest poverty rates where the USFs are needed the most, is where there is the greatest shortage. An analysis of the behavior of other basic health indicators such as the maternal mortality ratio (MMR) reveals that this ratio is highest in the departments with low USF coverage, such as Alto Paraná and Boquerón, where coverage is below 30%. In general, these indicators reveal enormous territorial inequity, i.e. the situation is much worse in rural and marginalized urban areas, which have the least access to quality health services (Figure 2).

Figure 2. Population covered by the family health units (USFs), by health region, Paraguay, 2013

Source: Author elaboration with data from the General Directorate of Primary Health Care, Ministry of Public Health and Social Welfare, Paraguay, 2013.

Between the years 2010 and 2011, three USFs were evaluated and received very favorable assessments with regard to the free nature of care and supply of drugs, the satisfactory treatment provided by the family health team, medical instructions, efficacy of treatment, hours open to the public, census modalities, and home visits, among other aspects of their work, although it was concluded that they should continue to make progress to ensure a regular supply of drugs, adequate infrastructure, and sufficient equipment ().

In general, the delivery of health services has been concentrated in urban areas; more than 90% of health facilities are located in the Eastern Region, which is justified since more than 95% of the country’s population lives there. However, the department of Caaguazú, which is also located in the Eastern Region and has a large population density but one of the highest levels of poverty, has only 85 public health facilities and 259 hospital beds, which is one of the lowest local rates in the country (0.9 beds per 1,000 population). This is in contrast to what is found in other departments with lower poverty levels, such as Alto Paraguay and Asunción, which have more than 4 beds per 1,000 population.

Articles 4, 6, 7, 68, and 69 of the National Constitution of the Republic establish the right to health with regard to the rights to life, physical and mental integrity, and quality of life; Article 68 in particular establishes the State’s responsibility to protect and promote health as a fundamental right. In Paraguay, the Indigenous Health Act, prepared in consultation with indigenous populations, was passed in September 2015.

Leading Health Challenges

Critical Health Problems

Emerging Diseases

A yellow fever outbreak in Paraguay was reported in 2008, with a total of 28 confirmed cases. The introduction of the chikungunya virus was detected in June 2014, and in 2015 a chikungunya and dengue epidemic was recorded in the central part of the country. In addition, the Zika virus was detected for the first time in October 2015.

HIV/AIDS and other Sexually Transmitted Infections

It is estimated that in 2015 there were 17,564 people living with the human immunodeficiency virus (HIV) infection in the country (), primarily men who have sex with men, female sex workers, and transgender people. According to an epidemiological report prepared by the Ministry in 2015, of the total number of people diagnosed with HIV, 54.3% were between 20 and 34 years old, and the trend over recent years among young people between 20 and 24 years shows an increase from 33.4% in 2001 to 39.7% in 2015. Between 2010 and 2015 the HIV-positive incidence rate in all ages increased from 18.1 cases in 2010 to 21.2 cases per 100,000 population in 2015 (). Congenital syphilis continues to be a serious health problem in the country, with four newborns infected for every 1,000 live births ().

Tuberculosis

According to World Health Organization (WHO) data, between 1990 and 2014, the incidence of tuberculosis in Paraguay declined from 91 to 55 cases per 100,000 population (39.6%) and mortality fell from 4.7 to 2.9 cases per 100,000 population (38.3%). According to that source, the estimated number of annual cases expected in the country is 2,700 to 3,000, although the national detection rate is only 75% to 83% of that figure, which means that the disease is not detected in 17% to 25% of infected individuals. Paraguay did not achieve Millennium Development Goal (MDG) 6 calling for a 50% reduction in the prevalence and mortality from tuberculosis in 2015 with respect to 1990.

Maternal Mortality

Maternal mortality is another challenge to public health in Paraguay. According to the UN Maternal Mortality Estimation Inter-Agency Group, between 1990 and 2015 the MMR declined from 150 to 132 per 100,000 live births (12.0%), which means that MDG 5 calling for a 75% reduction in maternal mortality was not achieved. According to data reported by Paraguay to the Pan American Organization (PAHO), between 1990 and 2014 there was a 57.4% reduction in the maternal mortality rate, and in 2014, there were 72 maternal deaths, 59 of which were classified as direct deaths and 13 as indirect. The leading causes of maternal deaths were toxemia, postpartum hemorrhage, and complications following abortion (). However, after conducting a deliberate search and reclassification of deaths occurring in 2015, 95 maternal deaths were recorded, which raises the MMR to 81.8 per 100,000 live births, and if the 19 late deaths are added, that rate would increase to 98.2 per 100,000 live births. At least 86% of those deaths were in-hospital. The four departments with the highest MMR were Boquerón, Amambay, Canindeyú, and Concepción, with rates of 347, 190, 167, and 153, respectively (2015 data not yet published).

Adolescent Pregnancy

Of the total number of births recorded in 2013, 18.3% were to teenage mothers (between 15 and 19 years old) and this was not the first pregnancy for 2 out of 10 of them. Nonetheless, the increase in the number of pregnancies in early adolescence (between 10 and 14 years) is even more troubling: between 2004 and 2013 there was a 62.6% increase in the number of live births to mothers in this age group.

Malnutrition

Paraguay is in epidemiological transition, characterized by a sharp increase in the risk factors for noncommunicable diseases (NCDs). This transition is accompanied by changes in the dietary habits of the population, with an increase in the consumption of fats, sugar, and processed food, which leads to the coexistence of nutritional deficiencies and obesity. This situation is in turn aggravated by the concomitant presence of communicable diseases.

Chronic Conditions

NCDs continue to be the leading cause of death in Paraguay. In 2013, the most frequent causes of death were diseases of the circulatory system (18.7%), neoplasms (14.6%), diabetes mellitus (8.0%), cerebrovascular diseases (7.8%), accidents (7.4%), diseases of the respiratory system (6.1%), renal disease (2.7%), and homicides (1.9%). In 2014, of the 10 leading causes of death, 8 were NCDs. Cancer is the main cause of premature death, with a rate of 43.8 per 100,000 population (42.6 in women and 45.0 in men) ().

Human Resources

Efforts have been made to strengthen the leadership of the health authority, through the creation of the Directorate of Health Human Resources in the Ministry of Public Health and Social Welfare. Although there are 55.2 health workers for every 10,000 people in Paraguay according to data provided by that directorate for 2015, based on an estimated population of 6,755,756 inhabitants, 70% of those health workers are in the metropolitan area of Asunción, where 30% of the population resides. The proposed regional human resource target of 25 professionals per 10,000 in 2013 was met, since there were 34.4 health workers per 10,000 people. However, only 8.2% of the work force is covered by primary health care. The equity gap between urban and rural areas in terms of the distribution of health workers is still too wide, with a maximum of 69.3 workers per 10,000 population in the capital and a minimum of 7.9 per 10,000 in the Department of Alto Paraná. This indicator can be related to a higher rate of maternal and child mortality: in 2013 the department of Alto Paraná reported an infant mortality rate of 20.4 per 1,000 live births and a MMR of 151.6 per 100,000 live births. Other challenges that should be taken into account are the migration of health professionals to neighboring countries, the absence of research on health human resources, healthcare education that does not sufficiently meet professional development needs and the needs of the new primary health care system, and the lack of standards and solid oversight of professional practice.

The data contributed by the Ministry’s Directorate of Registries and Oversight of Professionals show a continuous increase in the number of professionals between 2006 and 2016, with 7,005 more physicians, 3,703 more dentists, 18,907 more nursing graduates, and 1,188 more biochemists during this period. Furthermore, in 2016 the country had 3,248 graduates in obstetrics, 6,482 psychologists, 3,633 pharmaceutical chemists, 977 social workers, and 5,378 graduates with other health-related degrees, such as nutrition, kinesiology, speech pathology, and anesthesia.

With regard to health worker training, the regional target is for 80% of health science schools to refocus their training on primary health care and community health needs, and incorporate strategies for interprofessional training; however, as of 2013 only 42.3% of that target had been met.

The Ministry has organized a rural internship program coordinated by the National Institute of Health. The School of Medicine of the National University of Asunción and the Ministry signed an agreement that will govern internships for doctors who graduate from that institution, as well as the enforcement of Resolution No. 844/2010.

Health Knowledge, Technology, and Information

Paraguay has made progress in the implementation of initiatives related to the georeferencing of pregnant women and infants through the use of an ad hoc computer program, the implementation of an electronic drug prescription system, an electronic triage system for hospital emergencies, the automation of primary data collection in service delivery units at all levels, and the implementation of a national remote diagnosis network, all within the public system. This network serves remote populations and ensures three types of diagnosis: CT scans, electrocardiograms, and sonographies; between 2014 and 2016, 46,809 CT scans, 19 sonographies and 82,947 electrocardiograms were performed, for a total of 129,775 remote diagnoses (). Users have shown a high degree of satisfaction with this system and the observed trend is toward increased demand. The addition of electroencephalography is in the testing phase.

Scientific and technological research on health is growing but output is still low and fragmented. Paraguay has educators who are not involved in research, which may indicate that research has not yet become as widespread or achieved the level of priority that one would expect in the health sector. Public spending on research and development in the country is primarily concentrated in the agricultural sciences (36.9% of the budget), engineering and technology (29.6%), health sciences (15.8%).

The National University of Asunción is the institution that produces the most scientific publications and has the most international visibility. Using its own funds, it finances projects submitted by work groups in the university’s 12 faculties and research centers, including the Health Sciences Research Institute, whose mission is to generate, conduct, and promote scientific research in the area of health sciences. The PAHO/WHO Data Management Center (DMC), as a specialized public health information unit, supports the strengthening of Paraguay’s National Coordinating Center for the Virtual Health Library (VHL), which is in turn coordinated by the National Institute of Health, which is comprised of 40 libraries and documentation centers of public and private institutions in the health sector. Over the last five years, health and health-related institutions in four departments of the country were added to the Health Information Network (REDISAL).

The National Health Information System (SINAIS) that belongs to the Ministry of Public Health and Social Welfare consists of four subsystems that operate at the national level: the epidemiological information system, economic, financial, and administrative information system, sociodemographic information system, and the clinical information system (). The vital statistics subsystem is used in all public and private facilities, and provides information used to develop indicators on maternal, fetal, neonatal, and under-five mortality, among others; these data are published annually as part of the basic health indicators. However, when compared to the data of the General Directorate of Statistics, Surveys, and Censuses, these data under-report 29.4% of deaths and 26.3% of births ().

In addition, the Ministry has other information subsystems that can be simultaneously used by several users in a web-based environment: Outpatient Health Information Services Information, Health Services and Hospital Activity Information Subsystem, Hospital Discharge System, Paraguayan Automated Inventory Information and Control System, Uterine Cancer Registry, Information System of the General Directorate of Health Surveillance, Registry of Obstetric Emergencies, Health Facility Geographic Information System, Paraguayan Health Professionals Registry System, and subsystems for tuberculosis (TB) and HIV control, as well as the Expanded Program on Immunization Information System. The Access to Information Act was passed in September 2015, and in 2016 the Ministry created an open data portal and the Akuerapp application for the Web and mobile devices. These tools give citizens access to the 72 most requested health facilities and have data referenced through a geographic information system. Users can also check the availability of drugs in as well as what services are offered.

The Environment and Human Security

Deforestation and Soil Degradation

In the last 50 years, Paraguay lost nearly 90% of its original forest cover. Between 2002 and 2015, deforestation averaged 366,180.47 hectares annually. Deforestation due to changes in land use from 2000 to 2015 affected 63,383.36 hectares in the Eastern Region and 302,797.10 hectares in the Western Region. The use of biomass as solid fuel in the country averaged 30.4%, with 57.0% in rural areas and 13.1% in urban areas.

Air Pollution

Progress has been made on the legal and regulatory framework for outdoor air quality, through the enactment of Law No. 5211 in July 2014. The government disseminated the WHO Guidelines for Indoor Air Quality and its effects on health (http://www.who.int/indoorair/publications/household-fuel-combustion/en/), and obtained data through a survey conducted in two districts on the use of fossil fuels for food preparation and lighting, which included a measurement of contaminants in the surveyed households. Cooking fuels used in the J. A. Saldívar district were liquefied petroleum gas (46.5% of all households), charcoal (37.0%), firewood (11.0%), and electricity (5.5%), while in El Salado, they were liquefied petroleum gas (32.4%), firewood (29.7%), charcoal (28.8%), and electricity (9.1%). These results demonstrate the continued wide use of coal and firewood (unpublished data).

Pesticides

According to data for the 2014-2015 season, 3,264,480 hectares in Paraguay were planted with soybeans. If we take into account that each hectare of soybeans requires the use of at least 8 liters of glyphosate, a product classified as probable carcinogen by the International Agency for Research on Cancer (IARC), we can get an idea of the volume of this pesticide that is poured into the environment in the country. From 2011 to 2013, more than 38,000,000 liters (or kg) of agrochemicals were imported into the country (), mostly herbicides. Reported acute cases of pesticide poisoning ranged from 204 in 2013 to 235 in 2014, and 199 in 2015.

Natural and Manmade Disasters

The worst disasters and emergencies in Paraguay over the five-year period from 2011 to 2015 were mainly related to floods and droughts in some areas of the Paraguayan Chaco region. Floods were recorded in 2012, 2014, 2015, and 2016, while the drought in the first quarter of 2012 affected all departments of the country and led to a state of emergency being declared through Decree N.°8,282 of 2012 (http://www.presidencia.gov.py/v1/wp-content/uploads/2012/01/decreto8282.pdf), due to the serious impact on family crop production. In 2014, floods recorded in 10 departments isolated rural areas in the Chaco region, affecting 46,272 families (231,360 people) according to data of the Secretariat of National Emergencies (). In December 2015, the overflowing of the Paraguay and Paraná rivers due to El Niño affected river districts in eight departments and caused damage to 23,262 families (106,021 people), which led to the establishment of 154 shelters in seven health regions, according to reports of the General Directorate of Primary Health Care. At that time, the damage was similar to what occurred during El Niño storms in 1982-1983, but surpassed the damage from the emergency in 1997-1998.

Diseases that affect food security

The main disease that can affect food security in Paraguay and neighboring countries is foot-and-mouth disease. Under the provisions of Chapter 8.8 of the Terrestrial Code, 2015 Edition, of the World Organization for Animal Health (OIE), Paraguay has areas that are free of foot-and-mouth disease as a result of vaccination.

Food safety

In the last five years, several cases and outbreaks of food-borne diseases have been recorded in the country. In 2011, there were 255 cases and six outbreaks, and although the number of cases declined in the 2012-2014 period (116 affected people), the number of outbreaks increased in 2015 (nine outbreaks) ().

Water and Sanitation

At the end of 2015, 71.0% of the population had drinking water —87.5% in urban areas and 71.1% in rural— provided through 3,754 public and private operators, primarily the Health Services Company of Paraguay, which services 20.1% of the population, mostly urban; the National Environmental Sanitation Service (SENASA/Ministry of Public Health and Social Welfare) that supports the services provided through Sanitation Boards, which cover 31.5% of the population, primarily rural; the Local Commissions, with 8.2% coverage; private services, with 9.0% coverage; and others that service 2.2% of the population (). This made it possible for the country to achieve MDG 7 related to water.

In 2015, 12.3% of the population had sewer systems in Paraguay; 42.8% had a septic tank and drainage well; only 26.7% had a pour-flush pit latrine; 8.5% had common latrines with no roof or door; 7.2% had common dry pit latrines; 1.1% had a ventilated latrine; and 0.4% had a latrine that directly discharges into waterways. This enabled the country to achieve MDG 7 related to sanitation.

Solid waste

Approximately 1 kg per person per day of solid waste is generated in Paraguay, which means that nearly 7,000 tons of waste is produced each day. According to the Permanent Household Survey, barely half population (52%) has household garbage collection (76% of urban households and only 16.3% rural). With regard to the final disposal of waste in urban landfills, only 36 (15.1%) of the country’s 238 municipalities have an authorized dump.

Aging

In 2015, life expectancy at birth was 76.5 years for women (compared to 72.1 in 2009) and 70.8 for men (70.0 in 2009). According to estimates, in the last 10 years the adult population between the ages of 30 and 59 increased 27.8% and children in the under-15 bracket increased 3.7%, while the proportion of the elderly (60 years or older) increased 42.2% ().

For several years now, the four leading causes of death in Paraguay have been NCDs, which primarily affect the older population. The prevalence of these diseases has been increasing in recent years, as has the frequency of their principal risk factors: poor dietary habits and a sedentary lifestyle. According to the 2011 National Survey of Risk Factors (ENFR 2011), people ate fruit an average of 4.4 days in a typical week, regardless of age bracket and gender. The high rate of obesity in Paraguay mandates the adoption of measures aimed at the prevention and reduction of risk factors, as well as intervention in environments that are conducive to obesity. Based on estimates of metabolic equivalents, according to the results of the Global Physical Activity Questionnaire (GPAQ), it was estimated that physical activity levels were low in 59.7% of the population, intense in 25.1%, and moderate in 15.2%. On average, the population engages in physical activity for 18.8 minutes in their free time, significantly more among men (31.3 minutes) than women (6.0 minutes). When questioned about the time spent engaging in sedentary activities, the average was 264.5 minutes.

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

Laws and decrees have been enacted in Paraguay aimed at improving the food and nutritional security of the population, notably Decree 3000/2015 on the Promotion of Family Farming, Law N.° 5210/2014 on School Meals, Law 4698/2012 on Early Childhood Nutritional Guarantees, and Law 5508/2015 on Breastfeeding. In addition, the Plan for the Prevention and Control of Noncommunicable Chronic Diseases was approved for the period 2014-2024, and there is a Health Promotion Policy for the period 2015-2019, which was adopted in 2015 by means of Resolution 995 of the Ministry of Public Health and Social Welfare.

The mission of the Management Audit Directorate, a unit within the Ministry’s General Internal Audit Directorate, is to help efficiently and effectively achieve institutional objectives by making recommendations and promoting the collaboration of human talent, quality in management activities, and continuous improvement. To this end, an Organizational Chart and Manual of Functions were adopted by means of Resolution S.G. N.°390 of 17 May 2002, and a Procedures Manual for the Ministry’s General Internal Audit Directorate was adopted by means of Resolution S.G. N.°429 of 2008. Along these lines, a national monitoring and evaluation system was defined that will help monitor and learn about the performance of the health system. In addition, a culture for evaluating the implemented policies and programs, including the USFs described in previous sections, has been promoted.

Prospects

In the five-year period 2011-2015, significant progress was made in Paraguay in terms of health care coverage and access, with 66% of the population in the poorest quintile covered in 2015. Box 1 shows the leading achievements and challenges in health in Paraguay during the reporting period. The key milestones during the period were:

  • free access to services
  • 796 USFs established and in operation
  • progress in the coordination and decision-making capacity of the Integrated Health Services Network
  • elimination of malaria, measles, and congenital rubella, with potential elimination of rabies and Chagas disease
  • development and incorporation, for the first time ever, of information and communication technologies, particularly eHealth, with advances in telemedicine and information system applications, among other areas.

Box 1. Achievements and Challenges in Health, Paraguay

The country has made significant progress toward the objective of guaranteeing the full right to health for all Paraguayan people. In this regard, health care for the population in the poorest quintile was significantly expanded, from 29% in 2000 to 66% in 2015. Despite this progress, there are still significant limitations to the optimal functioning of the National Health System. In addition, there are social determinants of health such as certain basic services that are not yet universal and primarily affect indigenous populations, people living in rural areas, low-income people, and in some cases, women and children. Faced with these challenges, Paraguay identified strategies that are heading in the right direction and should be extended to the entire nation, while increasing local decision-making capacity until a substantial transformation is attained that will guarantee the right to health for the entire population. In order to achieve the targets set out in the health-related Sustainable Development Goals, the active, coordinated participation of other sectors, local governments, community organizations, including indigenous peoples, and the population in general, is crucial. Furthermore, an adequate tax structure and appropriate health financing should be ensured in order to facilitate a sustained increase in public investments to be used to make the structural changes required to maintain and improve the health of the Paraguayan people.

Despite this progress, there are still significant problems that need to be solved to achieve full operation of the National Health System, including inattentiveness to health promotion and disease prevention, as well as insufficient coverage of national territory, with the primary health care system covering less than 30% of the population. Other important limitations are the significant segmentation of the Ministry of Public Health and Social Welfare, which undermines its leadership, guidance and control capacity, the fragmentation of services, and the lack of a solid human resources policy that would facilitate improvements in the training, distribution, and management of health workers in the country. Furthermore, public resources allocated to health, which are currently negligible and much lower than national averages in other South American countries, lead to increasing direct out-of-pocket payments (60%) made by the population, which is one of the highest in the world. However, the strategies of the 2015-2030 National Health Policy are heading in the right direction and should be extended to the entire country, until a substantial transformation is achieved that guarantees the right to health for all citizens.

In terms of communicable diseases, the vector-borne transmission of Chagas disease has been successfully eliminated in 17 of the country’s 18 health regions, and the process of achieving certification of the elimination of dog-transmitted human rabies and malaria began in 2016. Despite this progress, greater investments are required to improve prevention and treatment for patients with HIV/AIDS, tuberculosis and leishmaniasis, as well as to prevent the vertical transmission of HIV, syphilis and Chagas disease. To this end there must be greater and better integration of these programs in health services.

Paraguay is periodically affected by droughts and floods, so it is urgent to update contingency plans with a local approach and build capacities at the district level with greater community participation. There have been successful experiences such as those in the towns of Pilar and Alberdi in the department of Ñeembucú during the floods of 2015-2016, which could serve as a model to be replicated in other parts of the country. The emerging and reemerging disease epidemics that have affected the Paraguayan population in recent years (such as influenza, dengue, and diseases caused by the chikungunya and Zika viruses) and the threat of others (such as Ebola) necessitate the development of basic skills to detect, report, and respond to events of this nature, in the context of enforcement of the International Health Regulations.

Policies, legal instruments, and strategic plans have been created to prevent risk factors and treat the principal NCDs that affect the Paraguayan population. Efforts should seek to ensure an intersectoral and integrated national response with strong citizen participation.

There is an unfinished agenda in the areas of maternal and neonatal mortality, malnutrition, and anemia, so more efforts must be made to increase investments and implement a family, human rights, gender and intercultural approach.

References

1. DGEEC. Proyección de la Población Nacional, Áreas Urbana y Rural por Sexo y Edad, 2000-2025. Revisión 2015, Paraguay. Available from: http://dgeec.gov.py/Publicaciones/Biblioteca/proyeccion%20nacional/Estimacion%20y%20proyeccion%20Nacional.pdf.

2. DGEEC. III Censo de Comunidades de los Pueblos Indígenas. Resultados Finales 2012. Paraguay. Available from: http://www.dgeec.gov.py/Publicaciones/Biblioteca/triptico%20comunitario/Triptico%20censo%20comunitario_Castellano.pdf.

3. Ministry of Public Health and Social Welfare. Plan Nacional Integrado de las EID 2016-2020. Paraguay. In press.

4. United Nations- 2015 Spectrum estimates. Paraguay.

5. Ministry of Public Health and Social Welfare. DGVS: Informe epidemiológico 2015. Paraguay (Unpublished).

6. United Nations. Global AIDS Response Progress Reporting (GARPR) 2015. Paraguay.

7. Resumen Objetivos de Desarrollo del Milenio, Segundo Informe de Gobierno. Paraguay, September 2015.

8. Ministry of Public Health and Social Welfare. Indicadores de Mortalidad (INDIMOR) Año 2014. Available from: http://www.mspbs.gov.py/digies/indicadores-de-mortalidad/.

9. Ministry of Public Health and Social Welfare. Boletín Epidemiológico de ENT 2015. Paraguay. Available from: http://www.mspbs.gov.py/dvent/boletin-epidemiologico-ent-2015.

10. Ministry of Public Health and Social Welfare. Informe Ejecutivo Nro. 123 – Resumen General – Periodo: 01.01 del 2014 al 27.06 del 2016. Total de Estudios realizados por Hospital Regional, Asunción – 2016.

11. Ministry of Public Health and Social Welfare – [Internet]. Dirección General de Información Estratégica en Salud. [citado 25 de julio de 2016]. Available from: http://www.mspbs.gov.py/digies/.

12. Dirección General de Estadísticas y Censos. Compendio Estadístico Ambiental 2002-2012. Paraguay, 2013. Available from: http://www.dgeec.gov.py/Publicaciones/Biblioteca/ambiental2012/compendio%20ambiental%202012.pdf.

13. Ministry of Public Health and Social Welfare – DGVS. CNE. Boletín Especial 06/2014.

14. Empresa Reguladora de los Servicios Sanitarios, ERSSAN, Informes acumulados del 2002 a Dic/2015. Paraguay, 2015.

15. JICA. Estudio de prevalencia de discapacidad en la Región Oriental del Paraguay. 2008.

16. Ministry of Finance-UES, Informe de Evaluación de Programa Emblemático Gubernamental Unidades de salud de la Familia. Asunción. December 2011. Available from: http://www.mspbs.gov.py/planificacion/wp-content/uploads/2012/04/APS_Programa_emblematico_Caballero2010.pdf.

17. Ministry of Public Health and Social Welfare – APS. Manual de funciones de las unidades de salud de la familia. Paraguay – 2016.

18. Cristina Guillen María. Paraguay. Sistemas de salud en Sudamérica: Desafíos hacia la integralidad y equidad. 2011. Available from: http://www.mspbs.gov.py/planificacion/wp-content/uploads/2012/07/SSS-PARAGUAY-2011.pdf.

19. Ministry of Finance-UES, Informe de Evaluación de Programa Emblemático Gubernamental Unidades de Salud de la Familia. Asunción. December 2011.

20. Ministry of Public Health and Social Welfare. Información sobre APS en Paraguay. Portal Web. 2015. Available from: http://www.mspbs.gov.py/aps/informacion-aps/.

21. Universidad Nacional de Asunción-IICS, Actualización de línea de Base 2008-2010 y aplicación de encuestas año 2010 “Hábitos para la Prevención de la Diarrea y Percepción de la Calidad de Atención que brindan las USF“. Asunción. March 2011.

22. Ministry of Public Health and Social Welfare. Programa Nacional de Salud Ocular. Asunción, Paraguay-2015.

23. Ministry of Public Health and Social Welfare. Formato de Datos: Año Calendario 2015. Programa Nacional de Salud Ocular. Paraguay, 2016.

24. Ministry of Public Health and Social Welfare – PAHO/WHO. Encuesta de Tabaco en Escolares. Paraguay, 2014. Available from: http://www.mspbs.gov.py/dvent/tabaco-en-jovenes/.

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Reference/Note:

1. 1 USD = 0.00018000 PYG.

2. Ministry of Public Health and Social Welfare, General Directorate of Planning and Evaluation, Directorate of Health Economics. Health Accounts. Paraguay; 2017.

3. Action whereby a responsibility, action, etc. is assigned to a specific teritory.

4. Dynamic, organized and ongoing evaluation of a person’s state of health within his or her family and social environment.

5. Paredes A, González C. La pasantía rural en Paraguay [Rural Internships in Paraguay]. Rev Salud Pública Paraguay. 2013; 6(2):6-16.

6. For more information on the work of the Management Audit Directorate, please visit: http://www.mspbs.gov.py/controldeprofesiones/wp-content/uploads/2014/04/Memoria-2013.pdf

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