“The public health system is failing everyone in the country, but particularly groups that usually face discrimination, like transgender women and Indigenous people, who have to overcome multiple barriers when trying to receive care. The Paraguayan authorities urgently need to strengthen the system and make it more humane through more and better investment"

• Severe and unequal gaps in access to Paraguay’s public health system – caused by under-investment and inefficient use of resources – put people’s lives and health at risk and seriously affect their income, Amnesty International said today in a new report.

Paraguay’s Bill of Health report analyses the right to health in Paraguay from the perspective of the status of its public health system. Following international standards for access to health services, the report examines the gaps in access to health services. It focuses on the dimensions of availability, accessibility, acceptability, and quality, with special emphasis on primary health care. Primary health care is a basic and mandatory element for all state parties to the International Covenant on Economic, Social and Cultural Rights. Paraguay is a party to this treaty.

“The public health system is failing everyone in the country, but particularly groups that usually face discrimination, like transgender women and Indigenous people, who have to overcome multiple barriers when trying to receive care. The Paraguayan authorities urgently need to strengthen the system and make it more humane through more and better investment. The well-being of over 5 million people depends on it,” said Ana Piquer, Americas director at Amnesty International.

The public health system is failing everyone in the country, but particularly groups that usually face discrimination, like transgender women and Indigenous people, who have to overcome multiple barriers when trying to receive care. The Paraguayan authorities urgently need to strengthen the system and make it more humane through more and better investment. The well-being of over 5 million people depends on it.

Ana Piquer, Americas director at Amnesty International

The report’s methodology combines quantitative and qualitative tools. On one hand, it uses the government’s own statistics and records, along with international indicators on health and economic development. It supplements these sources with information from 18 focus groups involving 200 participants, as well as four in-depth interviews with people impacted by the precarious state of the health system.

In short, Paraguay does not invest the minimum of 6% of GDP that the Pan American Health Organization recommends in order to ensure healthcare for all. In fact, the country ranks close to last in the region for investment in health. This underfunding is a serious problem in a country where seven out of 10 people have no health insurance at all and generally rely on the Ministry of Public Health and Social Welfare to shield them from life-shattering illness-related expenses.

Severe and unequal gaps in access to health care in Paraguay

The right to health is a human right recognized under international law and must be guaranteed without discrimination. The Paraguayan government must therefore do everything required to progressively ensure access to health services for all.

Meanwhile, the state’s failure to provide the healthcare that it owes the people of Paraguay takes different forms and patterns of inequality. Spatially, most infrastructure and resources are clustered in the capital and urban areas rather than spread across the rest of the country. In terms of population, the institution that serves the most people – the Ministry of Public Health and Social Welfare (MSPBS) – receives less money per person served than other public institutions.

These gaps are exacerbated by the status of other related rights. The report identified that households with children under five experience higher food insecurity, and that people without health insurance are less likely to have access to water and sanitation, increasing their exposure to disease. There is also a direct relationship between employment status and access to health insurance. Informal workers are often more vulnerable when medical emergencies occur. Informal work tends to be feminized – i.e., a higher percentage of women than men work under these conditions – and most informal workers are in the lowest income bracket.

“I didn’t get cancer treatment because I had to feed my children and I couldn’t stop working. Now if I have to choose between my treatment and feeding them, I will stop treatment,” said Felipa, whose name we changed for her protection. She lives in an outlying area of Asunción and earns money by selling farm animals. She uses this income to fight her advanced cervical cancer.

I didn’t get cancer treatment because I had to feed my children and I couldn’t stop working. Now if I have to choose between my treatment and feeding them, I will stop treatment.

Felipa*

These gaps in access to health care are aggravated by the discrimination that women and Indigenous people often experience. Inadequate prenatal and obstetric care or no care of this kind at all is a form of violence that directly affects pregnant women. Transgender women also reported to Amnesty International that they suffer transphobic violence at healthcare centres due to the lack of recognition of their gender identity. This violence is so severe that some prefer not to use the services of these public institutions, even when they have degenerative diseases.

Meanwhile, figures from the National Institute of Statistics show that a large proportion of Indigenous people also stop seeking medical care because of the lack of infrastructure in their geographical areas or because of the costs associated with care, whether due to the physical distance to health centres or the frequent shortages of medicines and supplies in public health centres. Amnesty International also heard accounts of people who received substandard care because they spoke a language other than Spanish. 

“Indigenous people are always made to suffer before receiving care; we only ask to receive proper care,” said Silvio, a member of the Enxet people, whose name we have changed for his protection. When Silvio’s partner Lilia received negligent and untimely care for a broken leg, it brought their family’s life and income to a halt for months.

Indigenous people are always made to suffer before receiving care; we only ask to receive proper care.

Silvio*

Funding that is inefficient, insufficient and unfair

Under international law, the Paraguayan state is obligated to maximize public resources to guarantee human rights, including the right to health, by investing in relevant programmes and budgets. These interventions must be designed to meet the criteria of equity and non-discrimination in accessing this human right.

But Paraguay is one of the most expensive places in the world to fall ill. Nearly four out of every 10 dollars in annual health spending comes directly out of people’s pockets because of shortages of medicines or supplies or a general lack of healthcare. To pay these bills, people often go into debt or rely on family or community networks to rally together and help cover the cost. However, for several years running the authorities have not spent the entire budget earmarked for procuring medicines, despite the fact that 40% of people report not having received the free medication they are entitled to under Paraguayan law.

According to the Pan American Health Organization, at least one third of a country’s annual health budget should be allocated to primary health care. This level of care is key to detecting diseases early and consequently to increasing the population’s well-being and keeping the other levels of healthcare from being overwhelmed. But Paraguay invests less than half of the amount recommended by international organizations. At the same time, it paradoxically sets aside 4% of the public budget to cover private health insurance for government employees.

Finally, the trends in how Paraguay funds its public health care system are unsustainable. In recent years, one-third of health investments were funded with public debt. According to Amnesty International’s analysis, Paraguay needs to implement progressive fiscal policies that allow it to fairly collect more tax revenue so it can take the urgent step of strengthening the public health system’s funding scheme. One such policy could be raising the corporate income tax rate and cracking down harder on tax evasion. The report highlights that tax revenues from products that directly undermine people’s health – such as tobacco, alcohol, foods with low nutritional value or sugary drinks – are currently marginal. In addition to providing the government with more revenue, taxes on these products could curtail their consumption and help people stay healthier.

Keys to strengthening Paraguay’s public healthcare system

Amnesty International urges the Paraguayan state to build its health policy on five pillars of action:

• Strengthen primary care and all levels of the hospital network.
• Guarantee free medicines, supplies and transport in health services.
• Reduce discrimination and promote equity in the health system.
• Fund the public health system better through fair tax reforms instead of adding to the public debt.
• Spend current public resources more efficiently.

Amnesty International sent this analysis to the Paraguayan authorities to learn their position on the organization’s findings. In response, the Ministry of Public Health and Social Welfare shared a report presented in November 2023 on the first 100 days of the current administration. This report describes seven areas where the ministry has taken multiple actions: 1) shorter waiting times for consultations and appointments, 2) mental health, 3) a health information system, 4) optimized financial resources and fewer administrative steps, 5) precautions for cardiac arrest at institutions and in cities, 6) remote cardiovascular diagnosis, and 7) clinical practice guidelines for cardiovascular or cerebrovascular diseases. Amnesty International takes notice of these contributions and stands behind the findings of its analysis, reiterating how important it is for the Paraguayan state to take the structural action that Amnesty International outlines in the conclusions of its report to improve access to the right to health.

*Name we changed for their protection.

For more information or to request an interview, please contact press@amnesty.org