Country Report: Uruguay
The Oriental Republic of Uruguay is located east of Argentina and south of Brazil and has a land area of 176,215 km2. Uruguay is a unitary state and is territorially divided into 19 departments.
Between 1990 and 2015, the population increased by 10.7%, reaching 3.4 million in 2015 and 2016. In 2016, 95.3% of the population resided in urban areas and was concentrated in greater metropolitan Montevideo.
The population pyramid was expansive in 1990 but became regressive by 2015. The proportion of the population over 65 was 14.1% in the 2011 Census.
Afro-descendants are the principal ethnic-racial minority in the country (8.1%), followed by those who claim indigenous ancestry (5.1%).
In 2011-2015, life expectancy at birth was 80.2 years in women and 73.2 in men.
- The transformation of the health system began in 2005, leading to the establishment of the Integrated National Health System (SNIS).
- Throughout the decade of 2005 to 2015, Uruguay witnessed a steady improvement in the quality of life of its population. This was reflected in such indicators as poverty, employment, distribution of wealth, access to goods and social services, infant mortality, recognition and formalization of civil rights, and the reversal of migration flows.
- Since 2008, implementation of the SNIS has improved the country’s health situation, reducing the segmentation that created sharp inequities and making the system more stable.
- The National Health Fund (FONASA) is a centerpiece of the financing model, based on a tripartite mechanism whereby the insured contribute based on their income.
- In June 2016, coverage reached 73% of the country’s total population.
- The purposes of the National Health Objectives for 2020 are to improve the population’s health status, reduce inequities in the exercise of the right to health, improve the quality of health care, and create the conditions for users to have a positive health care experience.
Figure 1. Distribution of the population by age and sex, Uruguay, 1990 and 2015
Proportional mortality (% of all deaths, all ages, both sexes), 2014
Source: Pan American Health Organization and PAHO Health Information Platform (PHIP).
SELECT BASIC INDICATORS
Source: UN Population and Statistics Divisions, 1990; PAHO Health Information Platform (PHIP), 2013, 2014, and 2015.
SOCIAL DETERMINANTS OF HEALTH
- The Gini coefficient was 0.453 in 2014. In urban areas, poverty, as measured by income, declined from 39.9% in 2004 to 9.7% in 2014, while extreme poverty fell from 4.7% to 0.3% in the same period.
- In 2014, female unemployment continued to be higher than male unemployment (8.4% versus 5.1%). Women earned 20% less than men with equal schooling. High rates of informality persist, particularly in the youngest and poorest segments of the population.
- Literacy among young people aged 15-24 reached 98.4% in 2015 (99.0 in women and 98.0 in men). In 2014, 78.5% of adolescents in the country attended secondary school.
- Along with economic growth and declining unemployment, there are signs of increased immigration and an uptick in the flow of returning Uruguayan emigrants.
- Between 2005 and 2013, the State education budget rose from 3.2% to 4.8% of the gross domestic product (GDP), making it possible to expand early childhood education.
- The principal environmental disasters are seasonal river flooding, droughts, forest fires, and, recently, tornados.
- The strategic measures to improve air quality include the monitoring of baseline air quality, continuous monitoring of pollution sources, and promotion of renewable energy sources, as stipulated in the National Energy Policy 2005 2030.
HEALTH SITUATION AND THE HEALTH SYSTEM
- In 2014, the maternal mortality ratio was 18.6 deaths per 100,000 live births. That same year, vertical transmission of HIV/AIDS represented 1.6% of reported cases, less than the regional elimination goal (< 2%).
- The prevalence of contraceptive use in the period 2011-2014 was 77%.
- In 2015, hospital delivery coverage reached 97.0%.
- In 2014, premature births represented 9% of total births, and 1% of all newborns had low birthweight (less than 1,500 g).
- In 2015, the infant mortality rate was 7.5 per 1,000 live births, while neonatal mortality was 5 per 1,000 live births. Thus, the goal of reducing infant mortality by two-thirds by 2015, as proposed in the Millennium Development Goals (MDGs), has been met. The leading causes are conditions originating in the perinatal period linked to prematurity (52.1%) and congenital malformations (28.7%). Some 60% of neonatal deaths occurred in the early neonatal period.
- Mortality in children under 5 was 23.4 per 1,000 live births in 1990, decreasing to 8.7 in 2015.
- The current immunization schedule in Uruguay includes 13 vaccines for the prevention of 15 diseases. Immunization is universal, free, and compulsory, with close to 96% coverage.
- The total death rate in 2014 was 9.5 per 1,000 population. Mortality from diseases of the circulatory system shows a sustained decline, as does mortality from ischemic heart disease, which fell from 75.2 deaths per 100,000 population in 2010 to 66.0 in 2014. Furthermore, mortality from cerebrovascular disease declined from 83.60 per 100,000 to 71.41 in the same period.
- There is no under-reporting of deaths; ill-defined or unknown causes represented 8.8% of deaths in 2014.
- There are no reported cases of measles and rubella. In 2014, a single tetanus case was reported; diphtheria has been absent since 1975.
- There were 213 reported cases of whooping cough in 2014, for a rate of 6.2 per 100,000 population.
- Hantavirus and leptospirosis were endemic in 2014, with an incidence of 0.6 and 4.9 cases per 100,000 population, respectively.
- The last reported case of human rabies was in 1966 and of canine rabies, in 1983.
- Three cases of brucellosis were reported in 2014, with an incidence of 0.1 per 100,000 population. Cystic echinococcosis is endemic in rural areas but is subject to a very high level of control.
- Leprosy was successfully eliminated in 2002 at both the national and subnational levels. In 2015, the prevalence was five cases.
- Suicide is a significant problem in adolescents, 10.1% of whom reported having attempted suicide at least once in the past 12 months.
- In 2015, the prevalence of risk factors in the adult urban population (aged 25-64) was 64.9% for overweight or obesity, 36.6% for hypertension, and 21.5% for elevated cholesterol.
- In 2011, 17% of the population reported suffering from at least one disability, which was mild in 70.5% of cases, moderate in 25%, and severe in 4.5%.
- In 2014, motor vehicle accidents were the leading cause of death among young people aged 15-24 (20.17 deaths per 100,000), with a significant difference between the sexes (33.21 in men versus 6.65 in women).
- There were 601 suicides in 2014. The suicide rate was 26.0 per 100,000 in men and 6.8 in women.
- The prevalence of diabetes in the population aged 25-64 was 7.6% in 2015.
- Between 2007 and 2011, the cancers with highest incidence in women were breast (73.1 cases per 100,000 population), colorectal (27.3), and cervical (15.7) cancer, and in men, prostate (61.7), lung (47.9), and colorectal (38.1) cancer.
- The prevalence of overweight and obesity in the population aged 25-64 was 64.9% in 2013.
- In 2013, 5% of children aged 0-3 years had low height for age; 9.6% of children under 2 were overweight or obese, with a prevalence of 11.3% in children aged 2-4.
- In 2010-2011, the prevalence of dental caries, measured as an average on the DMFT (decayed, missing, and filled teeth) index, was 4.15 in young people, 15.2 in adults, and 24.1 in older persons.
- In the population aged 25-64, the percentage who were daily smokers declined from 32.7% in 2006 to 28.8% in 2013. Among adolescents aged 13-17 who were in school, the percentage dropped to 9.2% in 2014.
- The average age for the start of alcohol consumption is 12.8 years. It is estimated that only 10% of problem drinkers have sought professional help at specialized centers.
- The most commonly used drug is cannabis. In 2014, annual prevalence of cannabis use in the population aged 13-17 exceeded that of tobacco use (17% and 15.5%, respectively). In 2013, Uruguay began efforts to establish a regulated market for cannabis.
- Some 22.8% of the population aged 25-64 does not engage in physical activity. Among students aged 13-15, 42.6% of males and 17.1% of females had an acceptable level of physical activity.
- Entry and exit of the insecticide endosulfan has been prohibited by decree since 2012.
- The Ministry of Public Health has nondelegable leadership responsibilities for oversight, essential public health functions, regulation, and the qualification and accreditation of health services and health professionals. The General Health Directorate coordinates and oversees public health policies, while the General Administrative Directorate oversees administration, finances, and human resources management.
- The National Health Board (JUNASA) administers the national health insurance, the General Coordination Directorate coordinates public-private integration, and the National Health Fund (FONASA) is a mandatory public fund that finances the system.
- Health expenditure grew by 53% between 2007 and 2014, reaching 8.6% of gross domestic product in 2014 (public, 6.5%; private, 2.1%).
- Per capita health expenditure grew by 45% in that same period (2007-2014). In 2007, 53% of expenditure was financed with public funds, rising to approximately 70% by 2014.
- The density of human resources for health was 63 professionals per 10,000 population in 2012, of whom 73.2% were physicians, 23.8% nurses, and 3.0% midwives.
- The management and care model has shifted from a curative to a preventive model, based on the principles of primary health care.
- Funding incentives have not been sufficient to produce significant movement toward a health care model that provides uniform quality of care for the entire
- There has been modest progress in assigning users to providers and ensuring that users choose a physician assigned to their respective population—goals set for the institutions of the Integrated National Health System (SNIS).
ACHIEVEMENTS, CHALLENGES AND PERSPECTIVES
- Between 1990 and 2015, the country made great progress in health and other areas. Uruguay ranks 52nd on the human development index, with an HDI of 0.793.
- Life expectancy at birth has increased and the population has aged, with a greater burden of chronic noncommunicable diseases.
- Strengthening the health system through the reform process has contributed to better health conditions and better care. However, there are continuing challenges associated with the health care system itself and the demands imposed by an aging population and changing epidemiological profile.
- Among the most important challenges are climate change and human security, especially violence and food security.
- Despite the availability of antiretroviral therapy, complications of and mortality from HIV/AIDS remain a significant problem. A project launched in 2012 aims to achieve social inclusion and universal access to prevention and comprehensive care for HIV/AIDS in Uruguay’s most vulnerable populations.
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