- Overall Context
- Leading Health Challenges
- Health Situation and Trends
- Full Article
Paraguay (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.
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 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
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 ().
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 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).
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.
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.
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) ().
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.
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).
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.
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.
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.
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.
Health Situation and Trends
Health of Population Groups
Maternal and Reproductive Health
In 2013, 80.6% of pregnant women had at least four prenatal checkups and 96.2% of deliveries took place in health facilities.
Mortality in children under the age of five declined 59% between 1990 and 2104, from 40.0 to 16.8 per 1,000 live births. Infant mortality (children under one year) fell 53.3% during the same period, from 30.4 to 14.2 per 1,000 live births. Despite this progress, the MDG 4 target of reducing child mortality by 66.6% was not achieved. This decline was fundamentally influenced by the low post-neonatal mortality rate, since the neonatal mortality rate fell by only 32.6% during that period (), which was undoubtedly affected by the increase in health-related investments (which increased from 0.4% of GDP in 1990 to 3.6% in 2013), the momentum provided to primary health care through the creation and development of USFs starting in 2008 (in the public sector, healthcare visits increased from 3 million in 2007 to more than 14 million in 2013), and the introduction of new vaccines (pneumococcal, rotavirus, smallpox, and influenza), with high vaccination coverage rates.
The infant mortality rate recorded in 2015 was considerably higher than the national average in the following three departments: Alto Paraguay (23.6%), Boquerón (22.9%), and Presidente Hayes (19.9%). Similarly, neonatal mortality was much higher than the national average in the departments of Alto Paraguay (20.3%), Concepción (13.6%), and Boquerón (13.2%). The leading causes of neonatal death were childbirth injuries, congenital malformations, newborn infections, and prematurity. In the case of infant mortality, the most frequent causes were pneumonia, influenza, and diarrhea (). According to national administrative data, vaccination coverage in 2015, based on population projections from the 2002 census, was 89% for the pentavalent vaccine (DPT-3) and 66% for the measles vaccine. However, the systematic monitoring of vaccine recipients and WHO/UNICEF coverage estimates for the same year are 93% and 83%, respectively.
Health of Schoolchildren (5–9 Years Old)
According to estimates, children aged 5 to 9 years represent 10.6% of the nation’s population, increasing 3.7% in the last 10 years. In 2014, 124 deaths were reported in this age bracket, 40% of them from external causes and 28% from tumors, congenital malformations, and respiratory and circulatory system diseases ().
Health of Adolescents (10–19 Years Old)
The population aged 10 to 19 years makes up 21% of the Paraguayan population. In 2014, according to the vital statistics provided by the Ministry, traffic accidents and homicides were the leading causes of death in this group ().
Health of Adults
Adults aged 30 to 59 represent 31.3% of the population, growing 27.8 in the last 10 years. Of the 26,975 deaths recorded in 2014, 22.9% were in this group (64% men and 36% women) (). The three leading causes of death in this age group that year were tumors and neoplasms (21.0%), external causes (19.5%), and circulatory system diseases (19.4%) ().
Health of the Elderly
According to estimates, in 2014 the elderly (60 years and older) made up 8.4% of the total population, growing 42.2% in the last 10 years. According to vital statistics, 63% of the deaths recorded in the country were in older adults (52% men and 48% women). Of all causes of death that year, 65% were due to circulatory system diseases, tumors, diabetes mellitus, cerebrovascular diseases, hypertension, external causes, pneumonia, and influenza ().
Health of the Disabled
It is estimated that 514,635 people with disabilities are living in the country (10.7% of the population). Of them, 53.5% are women and 46.5% are men. According to a study conducted in the Eastern Region, the prevalence of disability in 2008 was 19.4%, with the most frequent forms being multi body system disorders (28%), body system disorders (28%), physical disability (19%), and vision disorders (18%), while 7% had other forms of disability (). Paraguay ratified the Inter-American Convention on the Elimination of All Forms of Discrimination Against Persons With Disabilities (Law N.º 1925/02) and the Convention on the Rights of Persons With Disabilities and its protocol (Law N.° 3.540/08); in 2012 the National Secretariat for the Human Rights of Persons With Disabilities was created through Law N.°4720/12.
General mortality trends from all the causes remained stable up to the year 2014, with a profile similar to what was observed in 2009. Of the 26,975 deaths that occurred in 2014, 56% were in men, rising to 78% in young adults (aged 15 to 35). In that period, the rate of under-reported deaths remained at about 29%, although it should be noted that ill-defined causes of death declined from 13% in 2009 to 11% in 2014. In 2014, diseases of the circulatory system were responsible for 17.8% of all deaths recorded in the country, followed by tumors, diabetes mellitus, cerebrovascular diseases, accidents, and respiratory system diseases, among other causes (Table 1). However, in the indigenous population, the distribution of deaths by cause was determined by the vulnerability conditions in which these people lived, with respiratory system diseases the leading cause of death (11.3%), followed by accidents, tuberculosis, nutritional disorders and anemia, and homicides (Table 2) ().
By the end of 2001, Paraguay succeeded in reducing the national prevalence of leprosy to less than 1 per 10,000 population, so practically speaking, these diseases were eliminated in the country. An average of 440 new cases were reported annually between 2011 and 2015, and the multibacillary form was identified in 80% of these cases. Of the 421 new cases detected in 2015, 371 (88.1%) were multibacillary, 14 (3.3%) were in children under the age of 15, and 44 (10.4%) had Grade II disability. In 2015, 454 people were receiving treatment. Leprosy has not been eliminated as a public health problem in seven departments of Paraguay ().
Regarding HIV/AIDS and other sexually transmitted infections, in 2015 1,430 new cases of HIV were detected, 907 of them (63.4%) in men. Of the total number, 423 (29.6%) were diagnosed as AIDS. In both 2014 and 2015, more than 100 new cases of HIV were recorded each month. According to calculations, of the 17,564 people living in the country with the HIV infection as of December 2015, 5,505 (31.3%) had antiretroviral therapy, an increase with respect to the 18.3% who received treatment in 2010. This was due in part to the progress made in the decentralization of comprehensive health care facilities where antiretroviral therapy is offered, which increased from six in 2010 to 10 in 2015. Of the people diagnosed with HIV in 2015, the majority (56.5%) were between 15 and 34 years old, and the male-female ratio of newly diagnosed cases of HIV increased from 1.6 to 1.7.
In terms of the Program for the Prevention of Mother-to-Child Transmission, testing to confirm HIV infection and syphilis in Paraguay is guaranteed in 1,137 health services (78% of the Ministry’s health facilities). Of the approximately 160,000 women who were pregnant in 2015, 52.5% were tested for HIV and informed of their results, resulting in the detection of HIV in 131 pregnant women, 87% of them between the ages of 15 and 34. The estimated percentage of pregnant women who received antiretroviral drugs to prevent the vertical transmission of HIV was 55.7%, a 22.9% increase with respect to 2010 (45.3%). Sixty-nine percent (69%) of the women who went to Ministry health facilities were tested for syphilis at one of their visits. The test was was positive for 4.3% of them, and 57% of those women were treated with penicillin. Despite the progress made in Paraguay over the five-year period analyzed, the country was not able to achieve target 6A of the MDGs related to halting and beginning to reverse the spread of HIV/AIDS, or target 6B, which proposes to achieve by 2015 universal access to treatment of HIV/AIDS for all those that need it.
In Paraguay, the incidence of all forms of tuberculosis (TB) estimated by WHO for 2014 was 43 per 100,000 population. National data reflect an incidence of 38 per 100,000 population in 2011 and 35 per 100,000 population in 2015, which could indicate a 17% underreporting of cases if the figure estimated by WHO is used as reference. The highest incidence rates are in the states of Boquerón, Presidente Hayes, and Alto Paraguay, with 116, 88, and 54 per 100,000 population, respectively. The incidence of TB is nearly 10 times higher in the indigenous population than in the general population, i.e., 429 and 272 per 100,000 population in 2011 and 2015, respectively. The situation regarding individuals in prison is particularly concerning, where the incidence of TB was 2,085 per 100,000 population in 2015. The penitentiary in Paraná reported an incidence of 4,748 per 100,000 that year. The number of new cases and relapses detected in the penal population remained nearly constant over the five-year period studied, with roughly 2,358 cases per 100,000 population and a peak of 2,476 per 100,000 in 2012. The cure rate for patients with TB and positive sputum-smear microscopy declined from 70% in 2011 to 61% in 2015. In 2012, the country had seven reported cases of rifampicin–resistant tuberculosis (RR-TB) and multi-drug resistant (MDR) tuberculosis, which includes rifampicin and isoniazid, with a 57% therapeutic success rate. This low treatment success rate in patients with drug-resistant tuberculosis as well as in those with no resistance increases the likelihood of a growing number of cases of MDR-TB.
Vector-borne diseases are important health issues in Paraguay. Dengue virus, for example, is characterized by epidemic cycles that occur approximately every two years, caused by environmental, social, and behavioral factors that encouragethe continued presence of vector breeding sites. From 2011 to 2015, Paraguay faced one of the worst dengue epidemics in its history, with 133,718 cases and 251 deaths in 2013. During this epidemic, the viral serotypes GIVE-1, GIVE-2 and GIVE-4 were in circulation.
The introduction of chikungunya was reported in June 2014, with eight imported cases and one indigenous case. In 2015 a concomitant epidemic of dengue broke out in the central part of the country, with 4,294 cases.
Zika virus was detected in Paraguay for the first time in October 2015, and in 2016 up to epidemiological week 38, eight laboratory-confirmed cases had been recorded along with another 1,243 cases with compatible clinical manifestations; of them 535 were unconfirmed and 702 were ruled out. Furthermore, in that same period 57 cases of congenital syndrome that were possibly associated with Zika virus infection were reported to the surveillance system; of them, two cases were laboratory confirmed, 11 cases were ruled out, and 44 cases had inconclusive results. In addition, 39 cases of Guillain-Barré syndrome were reported, which were under investigation.
Chagas disease is a public health problem in Paraguay, with more than 165,000 estimated new cases. Congenital transmission is the most common. In 2015, 2,831 chronic cases of this disease were identified in the country, 825 of which (29.1%) were diagnosed in health facilities and 2,006 (70.9%) diagnosed in blood banks (positivity of 2.3% of total samples processed). Vector control has made considerable progress as a result of the actions taken over more than a decade, which made it possible to be certified for interruption of Triatoma infestans vector-borne transmission in 17 of the country’s 18 departments. Presidente Hayes is the only department where transmission still needs to be eliminated in order for the entire country to be certified ().
Indigenous malaria transmission has been successfully eliminated In Paraguay and WHO certification was requested, which means that MDG 6B has been achieved. Epidemiological surveillance of acute febrile diseases continues, notably yellow fever, dengue, chikungunya, and Zika.
Efforts to control vaccine-preventable diseases in Paraguay have been successful overall. During the five-year period studied, Paraguay had no indigenous cases of measles, rubella, poliomyelitis, or neonatal tetanus, and in 2014 WHO formally declared the country free of the endemic transmission of measles, rubella, and congenital rubella syndrome. Planning began in 2015 for the final polio eradication phase with the introduction of the inactivated polio vaccine. During that time, six new vaccines were added to the national vaccination schedule to prevent chickenpox, influenza, hepatitis A, whooping cough (acellular vaccine), and the human papillomavirus and pneumococcus infections.
In terms of zoonoses, no cases of rabies in humans and only four cases of canine rabies were reported in 2011-2015. The number of snake bites recorded annually remained at an average of 188 cases (). In 2015, 126 cases of cutaneous leishmaniasis were reported, for an incidence rate of 1.9 per 100,000 population. The departments with highest number of cases were Caaguazú (22.2%), San Pedro (20.6%), Amambay (14.3%), and Canindeyú (12.7%). There has been a downward trend over the last 15 years, from 1,251 in 2002 to 126 cases in 2015. However, an increase in cases of visceral leishmaniasis occurred between 2004 and 2013, averaging 60 cases per year, and in the last two years, the number of recorded annual cases fell from 113 to 93. The incidence of visceral leishmaniasis in 2015 was 1.4 per 100,000 population, and the department with the most cases was Central (63%) ().
Chronic, Noncommunicable Diseases
Mortality from ischemic cardiopathy in 2013 was 22.1 deaths per 100,000 population, while the rate for cerebrovascular diseases was 16.2 per 100,000 population (). The results of the 2011 ENFR revealed that 84.2% of the population studied reported having had their blood pressure taken by a physician or health professional; 32.3% said they were diagnosed with hypertension by a health professional in the last 12 months (38.0% women and 25.3% men), and 45.8% had high blood pressure when it was checked during the survey. In addition, the prevalence of diabetes mellitus in the country was 9.7% (11.0% in women and 7.9% in men). Mortality from diabetes in people under the age of 70 in 2013 was 24 per 100,000 women and 18.8 per 100,000 men (). Following the enactment of Law N.º 5372/2014 on the prevention and comprehensive treatment of diabetes, all health centers gradually started to provide comprehensive care for people with diabetes. Starting in 2014 a chronic care model for treating diabetes and hypertension was implemented in several departments, and efforts are being made to extend the model throughout the country.
Cancer is the second leading cause of death in Paraguay, after cardiovascular disease. In 2013, the primary cause of death in men was cancer of the lung, trachea, and bronchus —code 401 according to the 2010 International Statistical Classification of Diseases and Related Health Problems (ICD-10)— while in women, it was breast cancer (code 324) and cervical and uterine cancer (code 278), which both increased significantly between 2009 and 2013 (). The National Program for Cancer Control was created in 2013 (General Secretariat Resolution N.º 93/2013), and creation of the Population-based Cancer Registry has been in the works since 2015.
In 2009 there were 199 recorded deaths from chronic obstructive pulmonary disease (COPD), which increased to 492 in 2014 (). That year the National Chronic Respiratory Disease Program was created, in order to help reduce morbidity and mortality from these types of diseases in Paraguay’s adult population, especially from COPD and its principal risk factor, tobacco use.
The national prevalence of malnutrition (low weight for age) was 5.2% in 2011, while the rate of chronic malnutrition (low height for age) was 12.9%, both of which occurred in children under the age of five. This may be due to the high prevalence of low-weight pregnant women (27.1%) and obese pregnant women (weight/height for gestational age) (30%). In addition, 26% of schoolchildren and adolescents were overweight or obese, based on their Body Mass Index. As for those over the age of 20, in 2001 there was a 57% increase in the frequency of overweight and obesity, mostly among women, which has been associated with unhealthy lifestyles practices.
Accidents and Violence
From 2009 to 2013, there was a 2.1 percentage point increase in traffic accident deaths, and the percentage of motorcycle traffic accident increased from 44.4% to 55.8% (), followed by a relative decline in the next two years. As part of the 2011-2020 National Road Safety Plan, the National Transit and Road Safety Agency was created (Law N.º 5016/2014), which is responsible for developing lines of action aimed at improving road safety. It is important to mention that homicides are the 9th leading cause of mortality, with 537 deaths in 2013 ().
According to the 2011 ENFR, 33.6% of respondents (42.1% of women and 25.2% of men) reported a history of some symptom or sign of depression. The age-adjusted suicide rate in 2014 was 5.6 deaths per 100,000 population (two times higher among men than women), which is one of the lowest rates in the Region (). Although progress has been made in the decentralization of mental health care, coverage is still largely insufficient. In 2016 the Mental Health Action Plan (2015-2020) was validated, which falls within the framework of the Mental Health Policy.
Other Health Problems
From 2008 to 2012 there was an 87% increase in the number of facilities with dental services in the country, in addition to the care provided by mobile clinics, which in 2012 treated 23,000 patients in 217 indigenous communities. A total of 1,137,503 odontological procedures were performed that year.
In 2013, the total prevalence of avoidable blindness in people 50 years or older in Paraguay was 1.1%, with no significant differences between men and women. The leading reported causes of blindness in this group were untreated cataracts (43.8%), glaucoma (15.6%), and age-related macular degeneration (9.4%) (). The country has 219 ophthalmologists (38 in training), 60 of whom work in the public services of the Ministry of Public Health and Social Welfare. In 2015, around 13,119 cataract surgeries were performed, 56.2% in the public sector, 11.4% in the private sector, and the rest in other institutions such as the Vision Foundation (Fundación Visión) and the Eye Bank Foundation (Fundación Banco de Ojos) or through the Cuban medical collaboration program ().
Risk and Protective Factors
According to data from the 2011 ENFR, 14.5% of adults in Paraguay use tobacco. The Global Youth Tobacco Survey conducted in 2014 showed a decline in the percentage of smokers in this population group, from 8.3% in 2008 to 5.8% in 2014 (), even more so among men. The biggest decline was seen in the frequency of passive smokers, with passive exposure to tobacco in public places falling from 55.8% in 2008 to 27.9% in 2014 (). Law N.o 5538/2015 was enacted at the end of 2015, which established and regulated the fight against tobacco, in keeping with the Framework Convention on Tobacco Control, although the regulations for enforcing it are still pending.
According to the 2011 ENFR, 50.9% of the surveyed adults had consumed alcohol in the 30 days prior to the interview, and 75.2% of them reported excessive consumption in last 12 months. According to a study conducted in 2013, episodic excessive consumption was 32.5% among men and 14.2% among women (). With regard to young adults, the Second Departmental Study on the Prevalence of Drug Use, Risk Factors, and Prevention among In-school Youth 12 Years or Older conducted in 2015 revealed that 58.9% of these young adults consumed alcohol at some point in their lives and 1 out of every 4 had consumed it in the 30 days prior to the study.
Marijuana was the illegal substance used the most in Paraguay: 5.7% of the respondents admitted having tried it at least once in their lives (7.1% of men and 4.5% of women). Cocaine was the second illegal drug most frequently consumed by the young adults participating in that study (2.0%), with 2.7% of men and 1.4% of women stating that they had used cocaine at some point in their lives. In general, 10.3% of the respondents admitted having used some illegal drugs at least once in their lives (11.4% of men and 9.4 of women).
Insufficient levels of physical activity and sedentary lifestyles in Paraguay are similar to what is reported by other countries in the Region: one out of four Paraguayan adults does not engage in enough physical activity. In 2013 the National Policy on the Promotion of Physical Activity that includes a life course approach was approved, and a Manual on the Promotion of Physical Activity has been available since 2014. The Ministry has entered into agreements with universities and private enterprises on the implementation of healthy environments, active breaks, and healthy trails, among other initiatives.
The prevalence of obesity in Paraguay is 23.2%, with a significant increase in two groups of people: schoolchildren and adolescents, and pregnant women. In 2014, the prevalence of obesity was 8.5% in the first group and 29.9% in the second, a considerable increase since 2007, when it was 4.8% and 18.9%, respectively. Given these circumstances, in 2013 guidelines for the prevention and the treatment of eating disorders and their harmful effects on health were established (Law N.º 4599/2013), and in 2015 the National Strategy for the Prevention and Control of Obesity was implemented, aimed at promoting multisectoral integration for the prevention of overweight and obesity.
Accidents and Occupational Diseases
A total of 3,492,514 people are economically active in Paraguay. Of them, 3,306,124 are working. The occupational hazard management system is monitored by the Ministry of Labor, Employment, and Social Security, and only private sector workers (approximately 520,000 people) are covered by social security and have access to occupational hazard insurance. There is significant underreporting of occupational accidents, but one study reports that there are 1,000 to 1,300 work-related accidents per year among workers covered by social security, while another study mentions an accident rate of 37% among waste collectors in the formal sector and 30% among the self-employed.
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
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.
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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/.
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