ESSAY

PARAGUAY, ON THE WAY TO ACHIEVING THE UNIVERSAL HEALTH COVERAGE.

Prepared by:

MARIA CAMILA MONTÚFAR PANTOJA

UNIVERSITY OF BONN

MASTER IN GLOBAL HEALTH RISK MANAGEMENT & HYGIENE POLICIES

BONN- GERMANY
AUGUST 2023.
 CONTENT

1. Essay: Paraguay in the way to achieve the Universal Health Coverage.

2. Conclusions
3. References
 1. Paraguay on the way to achieving the Universal Health Coverage.

Paraguay has made great efforts in the achievement of some of the priorities in health, such
as the reduction of the maternal mortality rate (in 2016 - 86,4 deaths per 100.000 births and
in 2018 - 70.8 deaths per 100.000 births ). It was also certified by the WHO as Malaria and
Chagas disease free in 2018. In fact, the pandemic caused by COVID 19 sped up the Health
System changes in the country with the support of the OPS/WHO. Thus, enhancing the
Governance, proposing an efficient health service delivery, and strengthening the
epidemiologic surveillance and the Health Information System. (1)

However, there remain so many objectives to achieve, which have been affected by the
economic situation that the Paraguayan government is facing nowadays. Currently, the GDP
shows a decrease over the past decade. In fact, from 2003 to 2018 the average increase
was 4.4% and from 2019 to 2022 , it was only 0.7%, with a total increase of -0.3% for the
2022.(2) As a result, the economic situation has a direct impact on the socio demographic
health determinants, the health access, and the availability of resources to deliver high
quality health care.

The World Bank, as one of the main sources of worldwide data, shows that the economic
perspective of the country is impacting the poverty level, which accounts for 26.9% of the
population, and also generating some problems in the Health System: public investment on
health from the GDP for 2022 was 3.3% (in the past decade, it had achieved an 8.4%) and
the out of pocket health expenditure was 41.6% for the same year, a dramatic scenario that
ends in a catastrophic health expenditure by the population, which should not be the case,
as it is the government’s responsibility to protect them.

The Paraguayan Health System was created by Law N 1032/1996. Currently, it is considered
a fragmented system because of the division and categories inside it and the little coherence
and alignment among the parties that must coordinate joint strategies to support the main
goal from the National Health Policy. Its goal of achieving a “Universal Health Coverage” is
set to be reached by 2030, which is aligned with the Sustainable Development Goals.

The structure of the health system is divided into two principal subsystems, the public one
and the private one. Regarding the Public subsystem , this is responsible for 90% of the
population and it has 5 entities : The Ministry of Health and Social Wellness (MSPBS) with
65% of the population (often the poorest and the ones who live in rural and neglected areas)
– The Army and Police health system with 2% of the population- The Social Prevision
Institute (IPS) with 15% of the population (including formal workers) – The National
University, and the Hydroelectric Companies.(3) Despite all the entities mentioned before ,
73% of the population do not have any kind of health insurance, a surprising fact for a
country that started to plan some strategies around this goal 15 years ago. (4)

The budget and resources are obtained through different actors and government structures:
The MSPBS gets them through the country’s general budget, the donors such as the World
Bank or the OPS/WHO, and the taxes ; the Army and Police health system get them through
the Ministry of Defense; the IPS gets them through the salary of the workers, distributed as
follows: employers 14%, employees 9% and the government 1.5%. Finally, the National
University obtains its resources trough the Country’s General Budget.(4)

The MSPBS has the main role in the health system, performing functions such as direction,
provision, and financing. It is also supported by the Superintendence of Health, which is in
charge of the surveilling and guaranteeing the quality of health care centers. Then comes
the National Health Council with the Regional and Local Health Councils, which integrate
the policies and reach agreements between the parties involved in the health care activities.
The IPS and private health systems are in charge of insurance, provision and financing.
Some of the functions of the subsystems overlap, creating difficulties in health system
alignment and central decision-making. (4)

Regarding the financing issue, it is necessary to increase the investment in health and
emphasize the need of a central/national budget to avoid the separation of resource
management. Currently, there exists a tax reform to increase the taxes on cigarettes, alcohol
and sugary drinks that could give extra support to the health financing system. Moreover,
increasing the taxes is one the most cost- effective strategies to prevent and take control of
consumption.

Sometimes, talking about universal health coverage seems like a distant and often utopian
concept, however, the primary health care model that the Paraguayan Government
proposed becomes a realistic approach to reach that target. Since 2008, the Health System
has been oriented to achieving Universal Health Coverage (UHC) through the Primary
Health Care (PHC) Model. Its objective is to guarantee equity in health access and to make
sure that no one will be left behind. As it is now, the health service delivery suffers of a
centralization of the attention in the Capital City and central areas of the country, creating a
barrier for access to medical services in the rural and neglected areas (where 37.5% of the
inhabitants lives according to the last 2020 PAHO data reports) and on top of that, with social
determinants that worsen the situation.

That's the reason why the Health Family Units (USF / Unidades de Salud Familiar) exist.
Their purpose is to increase the PHC coverage in the mentioned areas. These Units are
meant to be the first step for health access in the population, including indigenous
communities, who live far away from district hospitals or central regions of the country. The
USF are in charge of activities such as promotion, prevention, treatment, palliative care and
rehabilitation and surveillance of health in the different stages of life which seems to be a
great strategy to increase the health service coverage. (4) Until 2019, there were 804 USFs
distributed along the country and with a full estimate of 1400 USFs to cover all the
population.(5)

The Primary Health Care model fits into the National Health Policy considering that the first
5 causes of general mortality in the country are related to non-communicable and
preventable diseases. Therefore, promotion and prevention programs, risk stratification of
the population and the guarantee of closer access to health services become important
actors in health management.

Nevertheless, the information available and one interesting study about the USF, describes
that the units are not well prepared to respond to the population’s needs, nor are they to
solve the basic health problems that they should. The article by Giménez E, Amarilla MG,
González-de Mestral C et al from 2022, evaluates the availability and preparation of health
services in the first level of attention, the USF in this case. The results showed that just
13.89% of the units had sufficient preparation and that, in the rural areas, the performance
was lower than in the urban areas(6). That means that even if the strategy to cover the
neglected population is good to achieve the UHC, there must be stronger support in all of
the following areas: infrastructure, financing, availability of Health human resources ,
medicines, and supplies. In this scenario, the essential medicines play an important role.
The National Policy of Medicines was developed in 2001 and its last review, made in 2011,
added 441 medicines to the list. The challenge is that 52% of the out of pocket expenditure
is due to the purchase of said medicines and that people usually pay 12.9 times more than
the public sector for each medicine. (7)
The National Health System Information has advanced since 2017, when Paraguay adopted
the automatized/electronic health information system, which has improved the quality of
statistics and national data. Until 2023 , 205 health centers had adopted the system. (8).
According to the recent data from the Observatory of Human Health Resources (HHR) in
Paraguay, the country has not achieved the WHO target for nurses and physicians per 1.000
people. Currently, the last indicators reported by the World Banks show that Paraguay has
1.1 physicians per 10.000 people (2020 report) and 0.7 nurses per 10.000 people (2017
report) . Paraguay has a lack of human health resources, maldistribution of the health
workforce and inequity in the work conditions, making the USF unprepared to respond to
both the population’s needs and to the National Health Policy.

To face the current situation in the health workforce, Paraguay developed The National
Policy of Human Health Resources in 2021. To advance in the goal of reaching the Universal
Health Coverage, they thought of 6 strategies : 1. Planning of the HHR. , 2. Strengthening
of stewardship and management, 3. National System of information in HHR, 4.
Implementation of the Health Career, 5. Management and equitable development , 6.
Training and qualification. (9) These actions allow for a better development and
management of human resources for health and guarantee conditions of equity in terms of
working conditions, training, distribution and capacity building. Ultimately, the health
workforce is essential to achieving the objectives towards UHC; without it, it is not possible
to serve the population, mobilize health workers in remote areas or even cover the Family
Health Units distributed in the most vulnerable regions.

The actual proposed Health Care Model, based on Primary Health Care, is completely
aligned with the health objectives set out in governmental policies. It must be enhanced and
supported by the Government and the different stakeholders to increase the access to health
services with high quality and equitable and universal health coverage without barriers.
 2. Conclusions

• Focusing efforts on the PHC model is the better way to achieve UHC through the USFs
as the main structures of health care and the first point of outreach for vulnerable
communities. It becomes extremely important to have units totally prepared in terms of
health workforce, medicines, supplies, and financial support to respond to the needs of the
population according to the segmented risks and priorities.

• The health workforce is one of the main targets to be strengthened for the proper
functioning of the USF. The country needs to continue implementing the National Policy of
Human Health Resources to address the inequalities in the health workforce and encourage
to be capable, available and prepared to support the country’s needs, thereby raising the
health workforce indicators and the WHO target for physicians and nurses available to
deliver health care.

• Paraguay has a fragmented health system that requires coherence between the parties
in order to achieve the proposed objectives. The integration and coordination between the
subsystems will allow for the optimization of the resources already available and will allow
for projection and planning in accordance with real needs.
 3. Reference List

1. Informe anual 2020: La salud universal y la pandemia, Sistemas de salud resilientes.

Paraguay. OPS/OMS; 2020.

2. Paraguay: panorama general [Internet]. World Bank. [citado el 22 de agosto de 2023].

Disponible en: https://www.bancomundial.org/es/country/paraguay/overview

3. Mancuello. J and Bejarano M. Sistema de Salud de Paraguay. Revista de Salud Pública

Paraguay. 2011;1:13–25.

4. Manual de Organización de los Servicios de Salud en el Marco de las RIISS. Paraguay.

Ministerio de Salud Pública y Bienestar Social- OPS/OMS; 2019.

5. Política Nacional de Salud 2015- 2030 : “Avanzando hacia el Acceso y Cobertura

Universal de la Salud en Paraguay”. Gobierno Nacional del Paraguay- OPS/OMS;
2015.

6. Giménez-Caballero E, Amarilla MG, González-De Mestral C, Araújo-Quevedo JM.

Evaluación de disponibilidad y preparación de servicios de salud en el primer nivel de
atención de cinco regiones sanitarias del Paraguay durante el 2022. Mem Inst Investig
Cienc Salud. el 10 de diciembre de 2022;20(3):13–26.

7. Política Nacional de Medicamentos. Gobierno Nacional del Paraguay- OPS/OMS.;

2015.

8. Available in : https://www.mspbs.gov.py/portal/26737/el-his-llego-a-161 -
establecimientos-de-salud-en-el-2022.html

9. Política Nacional de Recursos Humanos en Salud del Paraguay 2020-2030. Ministerio

de Salud Pública y Bienestar Socia Paraguayl- OPS/OMS; 2021.