Pan American Health Organization


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

Flag of UruguayUruguay is located to the east of Argentina and to the south of Brazil; its territory extends for 176,215 km2 and it has a maritime area of 205,057 km2. The country has a rolling topography and subtropical climate; its ecosystems include grasslands, coastal environments, wetlands, mountain areas, and forests. Uruguay is a unitary state and is divided into 19 departments. It has a democratic republican form of government, with three independent branches (executive, legislative, and judicial). The departmental governments are composed of an Administrator (Intendente) and a Departmental Board.


In 2016 Uruguay had an estimated population of 3,444,000 (). Afro-descendents were the main ethnic-racial minority (8.1%), followed by those citing indigenous ancestry (5.1%) (); 95.3% of the population lives in urban areas, concentrated in Montevideo’s greater metropolitan area.

The aging of the population is characterized by a low birth rate (13.5 births per 1,000 population) and increased life expectancy at birth (80.2 years for women and 73 years for men for the 2011-2015 period) (Table 1). The over-65 age group grew from 7.6% of the total population at the time of the 1963 census to 14.1% in the 2011 census, while the proportion of those under age 15 declined from 28.2% to 21.8%. Uruguay is at the end of its “demographic bonus,” and within a few years the dependency rate will be rising toward a new balance more challenging than the current one (). Annual population growth for 2016 was 0.4%, while the total fertility rate was 2.0 children per woman. In 2014, the economically active population (EAP) was 51.9% of the total population (). Figure 1 shows the evolution of Uruguay’s population structure between 1990 and 2015.

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

Between 1990 and 2015, Uruguay’s population increased by 10.3%. In 1990, the demographic structure was that of a relatively narrow pyramid, with an age distribution reflecting increased life expectancy and an aging population. By 2015, the structure had become regressive, as there had been a marked increase, in the fertility rate in the intervening 25 years, while the mortality rate had declined.

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

Table 1. Demographic indicators, by sex, Uruguay, 1996 2015

  1996—2000 2001—2005 2006—2010 2011—2015
Indicator Men Women Men Women Men Women Men Women
Total population 1,605,210 1,702,992 1,619,497 1,726,570 1,628,894 1,742,035 1,662,837 1,777,164
Children under 15 (%) 25.90 23.60 25.40 22.90 24.30 21.80 22.70 20.30
Adults over 65 (%) 10.00 13.90 10.30 14.50 10.50 14.90 10.70 15.20
Life expectancy at birth 70.40 78.40 71.50 78.90 72.30 79.70 73.20 80.20
  Both sexes
Annual growth (%) 0.64 0.01 0.26 0.39
Natural growth (%) 0.78 0.59 0.47 0.39a
Total fertility rate (children/woman) 2.30 2.10 2.00 1.90
Birth rate (per 1,000 inhabitants) 17.10 15.40 14.10 13.50
Mortality (per 1,000 inhabitants) 9.30 9.40 9.40 9.60

Note: Based on data of from the National Statistics Institute (INE) of Uruguay. Estimates and Projections, 1996-2050. 2013 Revision.
a The INE does not show migratory data for this period. Thus, the annual growth rate coincides with the natural rate.
Source: Levcovitz E, Fernández Galeano M, Benia W. Perfil del Sistema de salud. Monitoreo y análisis de los procesos de cambio. Montevideo: PAHO; 2016.

Social Determinants of Health

Uruguay ranks 52nd in the 2015 Human Development Index (HDI) (). Since 2005, laws have been passed to ensure rights such as same-sex marriage and legal abortion, while providing for quotas and positive discrimination in the civil service for people of African descent. That year also marked the beginning of a process of transforming the health system, leading to the creation of the country’s Integrated National Health System (SNIS) (). In 2005-2015, the population’s quality of life improved steadily, as reflected in indicators of access to goods and social services, distribution of wealth, employment, infant mortality, and poverty, among other factors.

The creation of the National Institution of Human Rights and Office of the Ombudsman (INDDHH), through Law 18,446 of 2008, represents substantive progress with regard to human rights. The National Institute of Women (INMUJERES) is the principal agency responsible for gender equality policy. However, there continue to be disparities. Based on the gender distribution in the 2015-2020 legislature, women have a 17.69% representation in the country’s political life. This represents an increase from 14.1% in 2010-2015 and from 10.77% in 2005-2010 (), demonstrating a gradual narrowing of the gap. Young women have a disproportionately small role in decision-making activities (approximately 30%) ().

In 2004, social spending represented 19.5% of gross domestic product (GDP), while the figure was 24.1% in 2011, reflecting a sustained increase in funding for social projects. In urban areas, poverty, as measured by income, declined from 39.9% in 2004 to 9.7% in 2014, while extreme poverty took a similar course, decreasing from 4.7% to 0.3% in the same period. The national minimum wage rose from US$80 in 2005 to US$334 in 2015 (). Major inequalities continue to exist between different geographic areas. Notably, poverty in Montevideo is 13.4%, compared with 7.3% in the rest of the country. The infantilization of poverty is notable, with poverty continuing to most sharply affect the youngest age groups—particularly the under-13 group. While the incidence of poverty is 7.8% in the 18- to 64-year-old population, it is 20.6% among children under the age of 6. And although it has narrowed, the gap persists, especially in the population of African descent. In 2014, the incidence of poverty for this group was 23.1%, while the incidence in the rest of the population was 9.0%. In 2006, the respective figures were 55% and 30% ().

With regard to income quintiles, 50.7% of income went to the wealthiest 20% of households in 2006 and 4.9% to the poorest 20%. As of 2014, income in the first quintile had risen by 1.4%, while that of the wealthiest quintile had fallen by 6% (). Although gender gaps are not significant in this indicator (9.9% for women versus 9.4% for men in 2014), they are higher in the 18-49 age bracket, where women of reproductive age are concentrated.

In 2015, the labor force participation rate for people above the poverty line was 64.2%, while the rate for those below the poverty line was 58.3%, with the gap greatest in rural areas, where there is a difference of 10.8 percentage points (65.9% versus 55.1%) (). The greatest concentration of households below the poverty line (more than 8%) is in the departments on the northeastern coast of the country and in the capital, while the lowest levels are in the southern departments (Colonia, Flores, Florida, Lavalleja, Maldonado, San José, and Soriano) ().

Between 2005 and 2013, the State’s education budget rose from 3.2% to 4.8% of GDP, allowing for an expansion of early childhood care and education. Among children 3 to 5 years old, attendance at educational facilities was 85.4%, while the figure was 99.3% in the 6-11 age bracket. The national illiteracy rate was 1.6% (). Although the net secondary school enrollment rate rose by 7.4 percentage points between 2006 and 2014, the 78.5% figure for the latter year shows that over 20% of the country’s adolescents are still not attending secondary school.

There has been progress in the creation of a digital society. The Ceibal Plan, which provided computers for all of the country’s primary school students, was extended to high school and technology-education institutions in 2010. In 2015, the Ibirapitá Plan was implemented to promote the digital inclusion of older persons, and 2016 saw the delivery of 100,000 tablets to retirees.

In 2011, unemployment declined to a historical low of barely 6.5%. High indices of informality persist, above all in the youngest and poorest segments of the population. In 2014, female unemployment continued to be higher than for males (8.4% versus 5.1%) (). Moreover, women received 20% less income than men with equal amounts of schooling.

Although the population living in irregular settlements has dropped, 165,000 people still live in these conditions. With regard to unmet basic needs (UBN) in housing, the population of African descent is at a greater than 12 percentage point disadvantage with respect to the rest of the population ().

The Health System

Management and care changed from a curative social welfare model to a preventive model based on the principles of primary health care (PHC). Funding incentives have not been sufficient to produce significant movement toward a care model that provides uniform quality of care for the entire covered population. Moreover, progress has been slow in assigning users to providers, and in ensuring that users choose a physician assigned to their respective population groups—goals set by the SNIS institutions. Interinstitutional and intersectoral coordination have benefited from the creation of the Social Cabinet and the Council for the Coordination of Social Policy, as well as from mechanisms for achieving the Sustainable Development Goals (SDGs) agreed to by the country.

The structural transformation of Uruguay’s health system began in 2007 with the passage of Law 18,211, which established the SNIS. In order to move toward achieving the regional objective of universal access and coverage, innovative forms of organization and operation were developed, with substantive changes in funding, management, and care models. These changes were accompanied by tax reform and the development of a new social protection matrix designed to redistribute income. Along with the structural reforms were: (i) an extensive social protection network using noncontributory transfers conditional on meeting obligations in health and education (guaranteed minimum income [salario ciudadano] and family allowances); (ii) provision of a food card for basic nutritional needs; (iii) promotion of jobs for young people and women; and (iv) universalization of early education and physical education.

The SNIS constitutes the organizational and functional structure for a care network encompassing all public and nonprofit private services (mutual associations and medical cooperatives). The National Health Fund (FONASA) is a central part of the funding model. As a mandatory pooled public fund, it involves a tripartite mechanism whereby those insured contribute based on income, employers contribute in proportion to wages paid, and the State’s general fund supplements these, in order to bring to reality the benefits package for the entire population provided for in the Comprehensive Health Care Plan (PIAS).

The collective nature of the insurance is reflected in the system of risk-adjusted reimbursement to SNIS providers. In June 2016, coverage reached 73% of the country’s population. Lastly, the strategy for creation of the SNIS emphasized gradually moving toward guaranteed and unrestricted universal coverage.

Leading Health Challenges

Critical Health Problems

The Ministry of Public Health established National Health Objectives for 2020. In defining the objectives, it began by identifying an initial list of critical problems that affect health, including unwanted pregnancy in adolescents, premature birth and low birthweight, high rates of cesarean section, vertical transmission of syphilis and HIV, and early childhood developmental impairments and nutritional problems.

Human Resources

In 2010, the Ministry created a human resources division to prioritize the development and training of health workers. The model features a dual component of education and training for health workers, along with management of human resources in health, with a view to orienting services toward primary care.

In 2012, the density of human resources in health was 63 per 10,000 population, well above the 25 per 10,000 figure proposed in the Regional Goals for Human Resources for Health 2007-2015 of the Pan American Health Organization (PAHO). Nurses and midwives were underrepresented, with the proportion of providers distributed as follows: 73.2% physicians, 23.8% nurses, and 3.0% midwives (). The priority lines of work were: harmonizing remunerations and addressing conflict management; establishing a human resources information system; developing the nursing field; and working to meet the regional goals for human resources in health. The principal components include: (i) the Uruguay node of the Virtual Public Health Campus (VPHC); (ii) curriculum reform at the undergraduate and graduate levels to adapt to changes in the care model, (iii) training in health system management at the national and departmental levels and in integrated health services networks; and (iv) new profiles for primary care professionals and certain key specialties.

Health Knowledge, Technology, and Information

The University of the Republic (UDELAR), through its medical school, as well as the National Agency for Research and Innovation (ANII), orients its scientific output to the sector’s needs and demands. The ANII has a National Strategic Plan for Science, Technology, and Innovation (PENCTI), which established the National System of Researchers and created the Timbó website, providing free nationwide access to Uruguayan and foreign scientific publications.

For years, health technologies have been evaluated, with a view to enhancing the technical capacity for introducing new technologies, such as diagnostic and therapeutic techniques and high-cost drugs. Skills have also been developed to facilitate technology transfer, innovation, and proper management of intellectual property, encouraging networked collaboration to bring together different agencies, technical cooperation opportunities, and the ANII, including various generations of sectoral funds.

There is very high penetration of telecommunications in Uruguay. There is extensive internet access (wired and mobile), as well as widespread cable television; the entire country receives radio station signals; and over 90% of the population has access to broadcast TV. The quality of the country’s vital statistics is excellent, and electronic certificates have been in place for live births since 2010, and for deaths since 2016.

The Environment and Human Security

Deforestation and Soil Degradation

Native natural forest formations (mountains) cover 3.7% of the national territory. Forest Law 15,939 protects forests from clearcutting and lays the foundations for industrial forestation and its management. Nearly one million hectares are planted with pine and eucalyptus for cellulose production. Responsible Soil Use and Management Plans must be prepared, submitted, and approved before certain actions or activities are carried out. Moderate erosion affects 6.8% of the Uruguayan territory, and 2% of the territory is subject to severe erosion.

Air Pollution

Uruguay has generally good air quality, due to geographic, climatic, and technological factors, and to the effects of public policy. Nevertheless, rural areas continue to have problems related to roads with loose material, industrial complexes, and waste-burning in landfills and dumps.

Among the strategic measures designed to improve air quality are surveillance and monitoring of the air quality baseline, as well as permanent monitoring of significant sources, along with promotion of renewable energy sources, as called for in Energy Policy 2030. Wind energy, which had not exceeded 1% of the energy supply up to February 2014, provided 16% of generated electricity in 2015. At the same time, the implementation of a desulphurization plant at the oil refinery made it possible to considerably reduce the level of sulfur in the fuels being produced ().

Persistent Organic Pollutants

Law 17,732 ratified the Stockholm Convention. The Ministry of Housing, Land Management, and Environment (MVOTMA), with participation by ministries and other public and private entities and social organizations, developed the National Plan for Implementation of the Stockholm Convention; by 2016, the first action plan and the inclusion of new persistent organic pollutants were already being reviewed.

Natural and Manmade Disasters

The National Emergency and Disaster System (SINAE) coordinates various institutions and sectors, along with a network of coordination centers dealing with departmental emergencies (CECOED), linking various aspects of emergency and disaster risk management, principally involving seasonal fluvial flooding, droughts, forest fires, and, recently, tornados ().

Solid Waste

Management and handling of urban solid waste is overseen by the departmental administrations. As of 2005, the Montevideo and Metropolitan Area Solid Waste Master Plan (PDRS) covers waste generated in the country’s metropolitan area, including urban solid waste and specialized solid wastes. It is estimated that, in Montevideo alone, the informal sector collects 40% of the waste ().

Food Security

Problems of malnutrition, due to both deficits and excesses, persist in Uruguay. Food intake typically features excessive salt, saturated fats, trans fats, refined sugars, and limited fiber. The diet tends to be poor in essential micronutrients, bioactive substances from fruits, vegetables and grains, and minerals. The “Uruguay Grows with You” office of the Ministry of Social Development (MIDES) works throughout the country’s population to promote a comprehensive system for protection in early childhood. Various programs of the Ministry (MIDES) and of the National Food Institute (INDA) address these health problems. The incidence of foodborne diseases is low. Work requiring cooperative effort is facilitated by coordination between various institutions: the Ministry of Public Health; the Ministry of Livestock, Agriculture, and Fisheries; the departmental administrations; and the Technological Laboratory of Uruguay (LATU). As a result of extensive vaccination, Uruguay is free of foot-and-mouth disease, as certified by the World Organization for Animal Health (OIE).


Along with economic growth and declining unemployment, there are signs of increased immigration and an uptick in the flow of returning Uruguayan emigrants. In 2014, a total of 3,755 residence permits were granted, of which 2,785 were for immigrants from other countries in the Region, 783 for immigrants from Europe, and the remainder for immigrants from other continents (). With regard to internal migration, the migratory flow has historically been toward Montevideo. Beginning in the 1960s, there was growing migration to the department of Canelones, which includes the metropolitan area. Currently, the country’s fastest growing department is Maldonado, where the population tends to be concentrated on the banks of the river Río de la Plata.

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

The SNIS was created through five laws, between 2005 and 2007. Law 17,930, the National Budget legislation for 2005-2010, establishes the entity’s broad programmatic lines; Law 18,131 created FONASA; Law 18,161 decentralized the State Health Services Administration (ASSE); Law 18,335 guarantees the rights and defines the duties of users; and Law 18,211 provides a comprehensive definition of the principles and organizational and functional configuration of the SNIS, establishing the new funding model.

Since 2008, implementation of the SNIS has improved the country’s health outlook, reducing the segmentation that created sharp inequities, and making the system more stable. Within this framework, the National Health Objectives (OSN) 2020 were defined, in order to: (i) improve the population’s health status; (ii) reduce unequal exercise of the right to health; (iii) improve the quality of the processes involved in providing care; and (iv) create the conditions needed for the health care experience to be a positive one for users.

The Ministry of Public Health has nondelegable leadership responsibilities for oversight, essential public health functions, regulation, and the authorizing and accreditation of health services and professionals. The National Health Board (JUNASA)—composed of the Ministry of Public Health as chair, the Ministry of Economy and Finance (MEF), the Social Security Bank (BPS), provider institutions, worker representatives, and representatives of the SNIS’s users—monitors coverage, coordinates funding, and regulates compliance with standards on the delivery of services. At the departmental level, governance is supplemented by departmental health boards whose decisions are non-binding. The legislation delegated FONASA’s administrative management and accounting to the BPS, while the Ministry’s leadership functions were separated from its health services provision function, so as to clearly delimit its areas of authority.

In addition, the State Health Services Administration (ASSE) was created as a decentralized entity, under a management model that includes participatory instruments and societal control over management by workers and users. Transformation of the health system significantly reduced inequality as measured by the Gini coefficient (which dropped from 0.4628 to 0.4526), while building consensus and guaranteeing extensive governance control, as measured by all public opinion studies carried out since 2008, which showed approval ratings of between 65% and 80%.

Between 2007 and 2014, health spending grew 53%, reaching nearly US$4.9 billion in the latter year, or 8.6% of the GDP and 45% of per capita expenditure on health. In 2007, 53% of spending was financed by public funds; by 2014, the figure had reached approximately 70%. Moreover, social protection for health expanded to cover the entire family unit and the full life cycle. At the same time, the mechanism for payments to comprehensive health providers was changed to a risk-adjusted capitation system, with additional payments to reward meeting care objectives. This supplementary payment for achieving goals constitutes 8% of the “health premium.” It is paid when the relevant achievement is verified. The public subsector—essentially the ASSE—was also strengthened; its annual budget rose from US$190 million in 2005 to approximately US$1.1 billion in 2014. In 2005, monthly spending per user in the private sector was US$50, versus US$14 in ASSE—a 3 to 1 ratio). In 2016, expenditure per user was nearly the same in the two sectors. Further, FONASA’s National Resource Fund (FNR) has become an important mechanism for centralized, supplementary, and (financially and institutionally) independent insurance, providing coverage for an extensive package of highly specialized medical services.


As mentioned earlier, the Ministry of Health has established National Health Objectives for the year 2020. The first objective aims to improve the health status of the population by promoting healthy lifestyles and environments, and by diminishing risk factors. The second aims to reduce the burden of premature and avoidable morbidity and mortality by reducing early mortality from cancer and cardiovascular disease, the prevalence of hypertension, chronic complications from diabetes, and mortality from chronic obstructive pulmonary disease (COPD) and HIV/AIDS. It also aims to reduce neonatal infant mortality and morbidity by affecting the determinants of prematurity, as well by reducing the incidence of suicide and the morbidity and mortality associated with gender violence. The third objective aims to improve the quality of health care throughout the life cycle through actions to reduce adolescent pregnancy, provide adequate support for parenthood in that group, humanize institutional childbirth, and reduce the rate of cesarean sections. In regard to the care of persons with disabilities and their access to health services and programs, it aims to improve access to health services, including rehabilitation services, at the three care levels and at the various stages of the life cycle. The National Care System will be responsible for ensuring the health care required by people with dependencies in everyday life (those with disabilities, and vulnerable older persons).

The safety and quality of health care, as part of the institutional culture, is the target of the fourth strategic objective. Progress in this regard will require developing standards and best practices by area, and by implementing a policy on safe behavior, with strategies to measure and evaluate the quality of care so that improvements can be ongoing. Lastly, efforts are under way to develop a patient-centered health care system (fifth objective), so that people have a positive experience of health care. This will strengthen and deepen the connection between doctor and patient, and between the health team and users, increasing response capacity at the primary care level, which is to be conceived as an integrated network of health services.

Major achievements and challenges

Implementation of the Integrated National Health System constituted progress toward universal access to health care. To a large extent, social segmentation has been overcome with regard to exercising the right to health, and there have been advances, though still insufficient, in reducing fragmentation and in promoting the completion of a broad network of public and private health services. One of the achievements of the SNIS is that the reform has generated multiple areas of social participation (by users, workers, and providers). Nevertheless, this process is at a crucial juncture in terms of sustainability and the extent to which it effectively addresses the various facets of access and coverage, and the outcome will depend on how issues of funding, provision, care model, quality, leadership, and overall regulation of the system are resolved.

The incorporation of groups that were not part of FONASA in 2016 (the military, police officers, municipal personnel, and people without formal employment covered by the ASSE) constitutes a fundamental challenge, both for the financial sustainability of the insurance and for realizing the guiding principles of the Integrated National Health System.


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1. Growth retardation, defined as values less than two standard deviations (SDs) of the height distribution in children of the same age, according to the standard set by the World Health Organization (WHO, 2006).

2. The DMFT index reflects both present and past cases, since it takes account of teeth with injuries from caries as well as previously treated cases. The figure is derived from the sum of decayed, missing, and filled permanent teeth, including prescribed extractions, among all examined individuals.

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