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PAHO Basic Health Indicator Data Base This is a multidimensional query tool that offers a collection of 108 indicators from 1995 to 2005. The system presents data and indicators on:
- demography
- socioeconomic
- mortality by cause indicators
- morbidity and risk factors
- access, resources and health services coverage.
Selected indicators are disaggregated into age groups, sex and/or urban/rural region. Generated tables can be exported and printed.
The data presented is updated annually with the latest country information.
GENERAL SITUATION AND TRENDS The Republic of Paraguay has an area of 406,752 sq km; its territory is divided by the Paraguay River in two well-differentiated regions. The western region or Chaco represents more than 60% of the Paraguayan territory; 2.7% of the Paraguayan population lives there. The eastern region is populated by almost 98% of the population. From an administrative point of view, the country is divided, besides the national capital, Asunción, in 17 departments and 237 districts.
In its 15 years of democratic life, Paraguay has had to solve the system’s structural crises, and of its institutions. The current government was democratically elected on April and took control of the office on August, 2003. Paraguay has a multiethnic society, about 20 ethnic groups, with numerous multicultural immigrant enclaves. Economic recession has deteriorated the quality of life. The social investment in education and health is low and there is a slow advance in the implementation of structural and institutional reforms. The agricultural production has fallen, increasing the unemployment, the delinquency and the citizen lack of safety.
On August, 2004, a tragedy affected the national capital when a fire caused about 370 deaths and 700 injured people. The Executive Power declared the state of emergency and the estate of sanitary emergency in Asunción for 30 days. About 138 health workers from nine different countries, mostly of the Americas Region, collaborated immediately to help the victims.
Demography: The Population and Households National Census was carried out in 2002. Not all data are available. According to the Census in that year, the Paraguay population was composed by 5,163,198 inhabitants; 56.7% lived in urban areas and 43.3% in rural zones. Men and women represented 50.4% and 43.3% respectively, of the total population. Children under15 years of age and people above 65 constitute 37.1% and 4.9% of Paraguayan population, respectively. According to projections, in the near future Asunción, along with the Central and Alto Paraná departments will concentrate most of the urban population, causing high pressure on employment, and a growing demand of housing and public services.
Ethnically, Paraguay has one of the most homogenous populations in South America. About 91% of its population is composed by Mestizos, Spaniards and Guaranies. Paraguayans are bilingual and there are two official languages in the country: Spanish and Guarani. According to the 2002 Census, 59% of the population speaks more frequently Guarani at home; 36% speaks Spanish and the rest speaks other languages. Six percent of the population only speaks Spanish.
The estimated crude birth rate for the 1995-2000 quinquennia was 31.3 newborns per 1,000 inhabitants, while in the 2000-2005 period; it was of 29.6 newborns per 1,000 inhabitants. In 2002, the crude mortality rate was 3.6 per 1,000 inhabitants. In the same quinquennia, life expectancy at birth rose from 67.5 to 68.6 years in men and from 72.0 to 73.1 years in women. In general terms, estimated life expectancy at birth was 69.7 years for the 1995-2000 period and 70.8 years for the 2000-2005 quinquennia.
For the 1995-2000 quinquennia, the general fertility rate (GFR) was estimated in 4.2 children per woman. In a 10% sample of the 2002 National Census, the GFR was estimated in 3.9 children per woman (3.2 in urban areas and 5.1 in rural zones).
Economy: The economically active population (EAP) has grown about a 3.2% rate, which agrees with the population growth rate. In 2000-2001 the EAP was 44.8%, and in 2003 it was 59.8% of the total population. The unemployment rate rose from 6.8% (1999) to 7.6% (2000-2001), in 2002 it reached 10.8% and 8.1% in 2003 (11.2% in urban areas and 3.8% in rural zones). The underemployment rate passed from 17.6% to 22.2%, and then to 24.1% during the same years. The female participation in the work force rose from 41.3% in 1999 to 45.7% in 2003. It is important to remark, that two out of five employed workers do not earn the minimum wage. Of the entire workforce, 63.4% is in the informal sector, and only 25% of the employees pay taxes for the social security.
Between 2000 and 2001, the Gross domestic Product (GDP) grew 2.7% due to a recovery of the agricultural sector. In 2003, the GDP grew 2.6% and reverted the contraction that occurred in 2002 (-2.3%). The GDP grew an annual average of 0.76% between 1997 and 2003, according to the 2003-2004 Economical Study for Latin America and the Caribbean. Economical sectors having more weight on the GDP are agriculture and cattle raising (25%), commerce and financial services (21%), manufacture industry (14%), building, transportation and communications (11%). Due to the prolific informal economic activities the estimated tax evasion is 40%.
In relation to the income distribution, the bottom 40% of the population spends 8% of the total income, while the top 20% spends 61% of the total income (DGEEC, EIH, 2002). The percentage of Paraguayan population living in poverty is estimated in 46.4% (CNPV-Modelo de ingreso) with significant differences between urban and rural areas; about 1,198,000 Paraguayans live in abject poverty (21.7%). In 2002, the illiteracy rate in 15-64 year population was 7.1% (230,800 people).
Mortality: The crude mortality rate for the 1995-2000 period was 5.4 deaths per 1,000 habitants, in 2002, that rate was 3.7 per 1,000. It is estimated that every year occurred 28,000 deaths; only 18,000 of them are registered, 11,000 are certified and 10,000 are due to a defined underlying cause of death. In 2002, 18,394 deaths were registered: 4,003 (21.1%) had ill-defined causes of death. Among deaths due to defined causes, 27.8% were caused by circulatory system diseases, 17.6% to cancer and 14.1% to external causes
SPECIFIC HEALTH PROBLEMS Analysis by age group Children: Infant mortality is a problem in Paraguay, as it has a great underregistration. It has been estimated that of the 170,000 babies that are born every year, only 80,000 to 90,000 are registered. On the other side, it has been estimated that every year 7,000 deaths occur among children less than 1 year of age; only 1,600 to 1,800 of these deaths are registered. Thus, the registered infant mortality rate is about 20 per 1,000 live newborns while the estimated one would be about 38-40 per 1,000 live newborns.
The estimated live newborns for 2002, were 172,000, only 90,085 were registered. Infantile deaths registered in 2001, were 1,652 and 1,767 in 2002. Sixty percent of the registered deaths occurred in the neonatal period, 38.5% of them were due to delivery injuries. Among deaths occurring in the postneonatal period, 16.2% were caused by pneumonia and influenza, and 15.8% to diarrheic diseases. Taking into account the underregistration (above 70%), it is irresponsible to provide explanations on the moment or cause of infantile death.
The national percentage of children under five years of age suffering acute malnutrition (-2 SD) is 5% (in rural areas it rises to 6.3%). It is estimated that the percentage of children suffering mild malnutrition or in risk of being undernourished (-1 SD below the mean) is 20.5% (23.6% in rural areas and 17.1% in urban zones). The national percentage of children under 5 years of age suffering chronic malnutrition (height/age index –2 DS) is 10.99% (14% in rural areas and 7.4 in urban zones).
In 2002, the mortality rate in children between 1 and 4 years of age was 69.4% per 100,000. The main causes of death were communicable diseases, especially pneumonia and diarrheic diseases (30.7 per 100,000) and external causes (14.9 per 100,000). Mortality rate in the 5-9 year age group was 22.3 per 100,000. 28.9% of these registered deaths were due to external causes.
Adolescents: In 2002, the mortality rate in this group was 39.8 per 100,000. External causes were the most common in both sexes (58% of all deaths in this group, rate of 23.1 per 100,000).
Adults: In 2002, the number of 10-49 year women was estimated in 1,777,663. In that year and in that age group 1,386 deaths were registered (specific rate, 78.1 per 100,000 women of that age group). One hundred and sixty four deaths were related to pregnancy, delivery and birth. In 1999, the registered maternal mortality rate in Paraguay was 114.4 per 100,000 live newborns; that figure was 23.8% lower to the registered in 1990, and corresponded to 20% of adolescent mortality. In 2000, 2001 and 2002 and with the implementation of the maternal death surveillance, registered rates were 154, 160.7 and 182.1 per 100,000 live newborns, respectively. Maternal mortality rates present great variation among regions. According to MSP and BS, maternal deaths in Paraguay are related to access barriers to health services: delayed arrival to service was registered in 46% of deaths; in 23% the lack of skills of the health services’ staff was registered and 31% of all maternal deaths occurred at home without medical assistance.
Elders (60 years of age and above): In 2002, the population above 60 years of age was estimated in 313,703. Fifty seven percent of all deaths were observed among this age group. Circulatory system diseases are the most frequent causes of death among this group.
Indigenous population: In 2002, the Second National Indigenous Census was carried out. Data are still being adjusted to the data of the National Census. As the former differs in its methods from previous Census, comparisons should be done carefully. Indigenous population constitutes an ethnic minority of scarce demographic representativity –87,099 people represent 1.7% of total Paraguayan population. In the last 21 years, it has been considered that indigenous population grew at a faster cumulative annual rate (3.9%) than general population (2.7%).
Contrary to observations made by the 1981 Census (32.8%) and the 1992 National Census (44.2%) in 2002, 50.7% of the registered indigenous population lives in the eastern region of the country. For Census purposes, indigenous population was classified in 20 ethnic groups and five linguistic families (Guarani, Maskoy language, Mataco-Mataguayo, Zamuco and Guaycuru). Indigenous people are mostly located in rural areas (91.5%). However, five ethnic groups have a significant presence in urban areas: Maka (77.4%); Maskoy (32.7%); Western Guarani (29.4%), Nivaclé (25.2%), and Enlhet Norte (24.4%). According to the Census, 51.7% of the indigenous populations are men and 48.3% are women. The 0-14 year age group constitutes 47.1% of indigenous population, while just 2.6% are above 65 years of age.
The total fertility rate in indigenous populations is almost two-fold the national one: 6.3 children per woman (4.8 in urban areas and 6.5 in rural ones). There are enormous differences among ethnic groups: from 3.4 and 3.5 children per woman among the Enhlet Norte and Toba respectively, to 8.8 and 8.9 children per woman in the Guanás and Manajui, respectively.
Illiteracy rates point to a tremendous disadvantage for indigenous people: illiteracy rate is 7.1% among general population and 51% among indigenous people. The average of school years in 2.2 in indigenous population (in comparison, it is 7 years among general population). Western Guarani have an schooling average of five years while the Manjui have only 0.7 years.
The most common kind of housing is the rancho which is characterized by the lack of basic hygienic services. Only 2.5% of indigenous population has access to drinking water and 9.5% to electricity. Another significant issue of indigenous extreme poverty is land possession: 185 (45%) of 412 indigenous communities living in Paraguay do not have a definite and legal settlement.
Analysis by type of disease Vector-borne diseases: During 1999-2000 there was a significant malaria epidemic; 9,946 cases were notified in 1999, and 6,852 in 2000 in the Alto Paraná, Caaguazú and Canindeyú departments. Malaria returned to endemic levels in 2002, though by establishing well-defined zones of total coverage where control actions were taken, made possible to reduce the scope of the problem. In 2000, the country suffered an important Dengue Fever epidemic due to Dengue virus–1; cases were confirmed in the 18 Sanitary regions and were concentrated in the capital city, Central and Alto Paraná departments. In 2001, an outbreak due to Denguevirus-2 was rapidly controlled; between 2002 and 2004 only isolated cases were registered. From 2000 until September, 2004, thirty six cases of human Visceral Leishmaniasis (VL) were diagnosed. Most of human VL cases came from the Central Department due to the establishing of the transmission cycle, because of the convergence of high proportion of VL-infected dogs and the parasite vector. After 13 years of the South Cone Initiative to eliminate the vectorial transmission of Chagas Disease and especially in the last five years, Paraguay has made significant progress in the control of the transmission making possible to eliminate the transmission of the disease in great areas of the country; the surveillance of the deisease remains as a challenge.
Vaccine-preventable Diseases: In September, 2001, a diphtheria case was detected in the Alto Paraná department; six months later (during the 7th-43rd epidemiological weeks, 2002) there was an outbreak (174 confirmed cases), which were mostly concentrated in nine districts of the Central Department. Most of the cases occurred in the 1-5 years of age group, the highest incidence occurred in children under 1 year of age. The low vaccine coverage of the regular immunization program, throughout the years, was the identified risk factor responsible for the occurrence and spread of the outbreak.
Chronic communicable diseases: TB is still an important public health problem; in 2003 the incidence rate (all forms) was 37.8 per 100,000, and the pulmonary TB incidence rate was 20.8. Moreover, there is a significant underregistration. The most vulnerable population is located in urban shantytowns, as well as in the Chaco department; incidence rate among indigenous communities reaches 150 per 100,000 inhabitants.
Zoonoses: Despite significant reduction of canine and human cases since 1999, rabies is still a public health problem; every year canine rabies foci and human cases are registered.
HIV/AIDS: Since the notification of the first case of HIV/AIDS in 1985, 1,023 cases of AIDS have been registered. Currently, it is estimated that 18,000 people live with HIV/AIDS. 36.1% of AIDS cases (370/1,023) have died. The epidemic shows a trend to spread to smaller cities, to heterosexual transmission and to affect progressively the poorest communities. 65% of all registered AIDS cases are in the 20-39 year age group. Sexual transmission was notified in 80% of cases; 7% of cases is due to blood-borne transmission, with a majority presence of UDI’s with cases caused by transfusional accidents which were notified at the beginning of the epidemic; vertical transmission contributes to 5% of all cases and in 8% the infection route is unknown. Most of the cases are reported in urban areas, although the notification from the interior of the country is rising. The highest prevalence rates occur in the capital city, followed by the Central Depatment and the border departments with Argentina and Brazil (Itapúa, Alto Paraná and Amambay).
The growing border exchange with vulnerable Argentinian and Brazilian communities is another risk factor that foresees a possible spread of the epidemic in the next years unless suitable surveillance and control actions will be provided on time. 3.7% of health bugdet is assigned to HIV/AIDS prevention and control.
RESPONSE OF THE HEALTH SYSTEM The national government, through the Public Health and Social Welfare Ministry (Ministerio de Salud Pública y Bienestar Social, in Spanish), has defined a policy directed to rise social protection with equity, vitalizing the continuity of the National Health System. This means to strengthen at an institutional level the directive duties, the organization, provision and insurance of the avaible resources of the sector, as well as its movility to other areas and social actors to improve the quality of life, and the productive life years to contribute efectively to the country development.
Health care is responsabilty of two subsectors: public, which is integrated by the PHSWM, the Social Pension Institute, the Army Health Services and the Police, and the National University of Asunción, along with townships and department governments and a group of autonomous agencies and decentralized state enterprises; private, which is integrated by universities, non-profit organizations, clinics and hospitals and the Paraguayan Red Cross (a mixed institution).
Most of health services coverage is provided by public institutions, especially the PHSWM that along the Health Services of the Army and the Police, looks after half of the Paraguayan population. PHSWM operates in 18 sanitary regions corresponding to 17 Departments and the Asunción region which constitutes an independent sanitary region because of its populational density, and the fact that the capital city is there.
National Health Policies and Plans: The National Constitution declares that “The State will protect and promote the health as a right of the individual and for the own good of the community”. It indicates that a National Health System will be promoted to execute integral sanitary actions with policies that facilitate the concentration, coordination and complement of programs and resources of public and private sectors. The Mission of the National Health Policy for the the 2003-2008 period has been defined as “the health improvement of the target community, which is the Paraguayan population”. In this context, it is attempted to develop and to strenghten the National Health System through the following atrategies: reorganizing the health services, vitalizing the directive role of the Health Ministry, decentralizing of the health sector, promoting and financing health.
Health Sector Reform: The reform of Health Sector in Paraguay begins with the passing of Law 1,032, that creates the National Health System which is based on the principles of equity, quality, efficiency and social participation. According to Law 1,032, the National Health Council, which is constituted by key institutions of the sector and its Chairman is the Health Minister, is responsible for the coordination of the sector and has the legal responsibility to coordinate and control the plans, programs and activities of public and private institutions. Currently, the National Council is not running the coordination role which has been assumed by the Public Health and Social Welfare Ministry.
Institutional organization of the Health System: Health care is responsabilty of two subsectors: public, which is integrated by the PHSWM, the Social Pension Institute, the Health Services of the Army , the Police and the National University of Asunción, along with townships and department governments and a group of autonomous agencies and decentralized state enterprises; private, which is integrated by universities, non-profit organizations, clinics and hospitals and the Paraguayan Red Cross (a mixed institution).
In the PHSWM there is not a separation of functions. Direction is exerted by PHSWM which also concentrates health care provision through hospitals, health centers and health posts, and health financing through internal and external and Treasury resources. On the other side, the Social Pension Institute and the private subsector do the securing, provision and financing functions. The Health Superintendence is the authority responsible for the control of the country’s health service providers. Its main functions are the approval and classification of health service providers, the enforcement of sanitary laws and regulations, and the passing of standards to which pre-paid health services providers must adjust their services.
The prevention and control of diseases is in charge of the PHSWM through the Surveillance and Health Programs General Directorates.
The Health Analysis, the Epidemiologic Surveillance Systems and the Public Health Laboratories are a shared responsibility between the Planning and Evaluation Directorate and the Health Surveillance Directorate
Drinking Water and Sewer Systems: The country has a great deficit in the drinking water and sewer systems infraestructure. According to data of 2002 Census (DGEEC), 63.42% of all population had access to piped water; 22.2% had piped water out of the house, and 40.6% had piped water inside the house. Greater differences are found between urban and rural areas, and are more related to the urbanization condition than to poverty. 84.5% of urban households have piped water (55.4% inside the house and 29% outside the house but within household’s ground), while 35.5% of rural households has piped water (15.9% outside the house but within household’s ground and 19.6% inside the house).
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In relation to the water source, 52.7% of households have piped drinking water, 14.7% obtain water through pumped-wells, 26.1% get water through artesian wells, and 6.5% through other sources. In urban areas, 73.9% of households have piped drinking water; 12.9% get water through pumped-wells, 10.4% through artesian wells, and 2.7% through other water sources. In rural areas, 22.4% of households have piped drinking water, 17.3% obtain water through pumped-wells, 48.2% through artesian wells and 11.9% use other water sources.
In relation to basic sanitation and according to data of 2002 Census (DGEEC), only 9.4% of all households (all in urban area) are connected to a sewerage system; this percentage represents a 16% coverage. 53.6% of households have latrines (77.8% of urban households and 23.2% of rural households). 34.9% of households dispose excreta through pits (12% of urban housholds and 67.5% of rural households). 1.1% of all households have no approved form of sewerage disposal (1% of urban households and 0.8% of rural ones).
Organization and functioning of health care services: Public subsector.- PHSWM provides services to 18 sanitary regions in the three health care levels. It develops promotion, prevention, recovery and rehabilitation actions. It provides medicines in its facilities or in community clinics at subsidizied prices. It also provides emergency care and ambulance service. The Social Pension Institute (IPS, in Spanish) covers disease, disability, survival and death insurances of wage earning employees in a share-out system; the financing comes from the income tax (14% is paid by the employer, 9% by the worker, and 1.5% by the government). The Army Health Services provide care to active and retired military personnel, their relatives and to civil population in regions where no public or private care facilities exist. The Police Health Services provide care to active and retired members of the police force, their relatives and prison inmates. The National University of Asunción offers low-cost services in the Clinics Hospital and in the Neuropschyatric Hospital, both located in Asunción. In the department governments, the Health Secretary of the Departament is by law, the highest authority of the Health Regional Council and he/she works in coordination with the department’s townships and with the Central Government. Among the autonomous agencies and decentralized state enterprises, Itaipú Binacional and Yayreta offer health services and medical insurance to officers, exofficers and their relatives in their own health facilities, mostly for ambulatory care. They offer preventive and health care programs to the populaton living in the influence areas of the dams.
Public subsector.-Non-profit organizations: Non Govermental Organizations (NGO’s) provide services, though most of them do not offer medical care but complementary services. They have 30 facilities; among them, medical clinics, social help, rehabilitation and investigation installations. Private Profit Institutions: Pre-paid and insurance companies, hospitals and sanatoria (145 facilities of second and third levels); clinics, centers and institutes (363 facilities of third level and specialized care); medical offices (474 facilities of first level, 342 laboratories, 15 emergency services and 1,965 drugstores. On June, 2001, there were 99 organizations registered in the National Registry of the Health Superintendence: 47 are private hospitals and sanatoria, 46 are pre-paid medicine and six of prehospital care. Some of the 46 pre-paid medicine organizations provide care through their own infrastructure.
Human resources: Despite the existence of a policy in this area, structural problems persist that have not been tackled yet. The most prominent are the existence of personnel formation models, which are not linked to the requirements of the services; the poor development of health personnel with public health background, the early development of regulative process of professional practice and the insufficient sectorial development of the human resources process management. According to the Integral Census of Public Officers (2003), Paraguay has 3,276 doctors, 6.3 per 10,000 inhabitants. There are significant regional diferences (Asunción has 31.4 doctors per 10,000 inhabitants, the Central Region has 5.7 per 10,000 and there are less than two per 10,000 in Caaguazú, Caazapá and Boquerón departments). The country has 1,452 nurses, 2.8 per 10,000 inhabitants). Again this personnel is concentrated in Asunción and Central Region (11.3 and 3.3 nurses per 10,000 inhabitants, respectively) and less than one per 10,000 in six regions.
Financing and Sectorial Expenditure: Public social expenditure has increased from levels below 4% of the GDP in the past decade, to about 8% in 1998, 8.1% in 2003 and 8.3% of the approved budget for 2004. The rise has been significant in Education and Culture, Social Security and Assistance followed by Public Health.
Public social expenditure as a part of the central government expenditure passed from 27.6% in 1990 to 44.2% in 1998 and to 43% in 2004. Annual average social expenditure in Paraguay is 140 USD per habitant.
The funding sources of public subsector are mixed (General Budget of the Nation, taxes paid by the employer and worker, premium insurances, out-of-pocket payments, taxes and external aid); their processes and results are poorly controlled. Public facilities charge fees that do not correspond to real costs and their income is transferred to National Treasury.
Technical and financial external cooperation: Paraguay receives financial help from USAID in reproductive health, adolescence, HIV/AIDS and sector reform programs. It also receives aid from GTZ in adolescence, reproductive health, HIV/AIDS programs, and JICA provides aid in nursery training. Currently, the country has resources provided by PAHO for priority diseases; at the end of 2004 it received funds from the Global Fund for Tuberculosis and it began to use them in 2005. Paraguay receives some funds from UNFPA for reproductive health.
In relation to loans, the country has finished the execution of a maternal-infant health project with the World Bank (infraestructure), and it is negociating a five-year new project directed to nine departments in maternal-infant health, information and surveillance programs. It is also negociating the execution of the remaining funds of a decentralization project financed by IDB, for five regions of the country and with a strategic reorientation to make it coincidence with the package negotiated with the World Bank to widen the coverage of maternal-infant insurance.
