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Country Visit to Paraguay, 23 September to 6 October 2015 by the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health Mr. Dainius Pūras

Preliminary observations

Asunción, 6 October 2015

Members of the press,
Ladies and gentlemen,

I would like to begin by warmly thanking the Government of Paraguay for inviting me to visit the country to assess, in a spirit of dialogue and cooperation, the realisation of the right to health in the country.

During my visit, I have met with high-ranking Government officials, members of the Judicial and Legislative branches, as well as with representatives of international organizations, and a wide range of civil society actors. I have visited different health facilities and schools in Asunción, including in various neighbourhoods in situation of poverty (bañados), in Itagua, in Coronel Oviedo, and in Ciudad del Este. I have also visited the Psychiatric Hospital in Asunción, one prison, and one educational centre for adolescents. I take this opportunity to thank the Adviser on Human Rights of the Office of the High Commissioner for Human Rights and the UN Country Team for their crucial support to my visit. 

You will find in this room a short document that explains my responsibilities in the framework of the UN mandate as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health). I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realisation of the right to health.

After two weeks in the country, I have gathered a wealth of information and testimony, which will help me assess the realisation of the right to health in Paraguay.  Today, I will confine myself to presenting some of my preliminary observations, which will be elaborated in more detail in a report that will be considered by the UN Human Rights Council in Geneva in June 2016.

Context and achievements

Paraguay emerged in 1989 after three decades of dictatorship, and it is still a young democracy. The country has made improvements in the life expectancy of certain sectors of the population, it has reduced maternal and child mortality rates over the past decades, and has introduced successful vaccination campaigns nationwide. 

Recent social reforms include free access to primary health care and the expansion of conditional cash transfer programmes. The first National Development Plan for the period 2014-2030 was prepared with the goal to eliminate extreme poverty and promote income growth of the more disadvantaged sectors of the population, and there is a component to improve access and quality of social services, including health.

Paraguay is a founding member of the United Nations, is a member of the UN Human Rights Council, and it has ratified almost all international human rights treaties, only the Optional Protocol of the Covenant on Economic, Social and Cultural Rights, and the Optional Protocol of the Convention of the Rights of the Child on a communications procedure are pending ratification.  Of the regional human rights system, Paraguay has ratified all treaties and conventions, except for the Inter-American Convention against all forms of Discrimination and Intolerance, and Inter-American Convention against racism, racial discrimination and related forms of intolerance.

The constitutional and normative framework recognises the right to health and other related rights, and there are a number of public policies, programs and initiatives that stem from this framework, including relevant work on human rights indicators and the right to health which should be continued.  The Government has developed a system to monitor the implementation of the recommendations from human rights mechanisms (SIMORE) which is considered as a good practice and is being replicated by other countries.

It is also worth noting the existence of a National Plan for Human Rights, which should be implemented following the recommendations made by the UN Human Rights Committee, the National Plan on Education for Human Rights, and the recently approved National Action Plan for the Rights of Persons with Disabilities. 

Challenges and groups in vulnerable situation

Many of the challenges identified during my visit relate to structural and systemic factors that obstruct progress in many areas, including in the realisation of the right to health. Main factors include deep inequalities and widespread discrimination associated with a regressive tax structure that does not allow for the necessary public investment; lack of effective decentralisation; endemic institutional weaknesses, and corruption at all levels. 

The effective implementation of the existing normative framework is often hampered by a lack of a human rights based approach to health, including to public budgets and information. This, combined with a non-inclusive model of rapid economic growth, seriously undermines efforts undertaken since the inception of democracy to promote and protect the right to health and related rights. In my report I will illustrate and elaborate on some of these structural factors. 

I have observed stark disparities and discrimination regarding the enjoyment of the right to health in Paraguay and some retrogressive tendencies related to certain prior achievements.  This has been mostly related to barriers of availability, accessibility, acceptability and quality, as well as the underlying determinants of health such as poverty, food and nutrition, safe and potable water and adequate sanitation, healthy occupational and environmental conditions, and access to health-related education and information.

The right to equality and the prohibition of discrimination is guaranteed by the Constitution of Paraguay.  I therefore urge the Government to expedite the approval of the Law against all forms of Discrimination, which has been a project for the last 7 years.  Paraguay is amongst the few countries in the region which do not have such law and this represents a historical debt to Paraguayan society. 

Moreover, the lack of essential services in rural and remote areas of the country disproportionally affects groups who are in situation of poverty as well as campesino and indigenous communities. Additional specific groups also face serious challenges in realizing their right to health, including women and girls; children and adolescents; lesbian, gay, bisexual and transgender persons; as well as people living with HIV/ AIDs and drug users.

Right to health of women and girls: maternal mortality and morbidity

While overall rates of maternal and child mortality have improved, Paraguay still faces important challenges in reducing preventable maternal and neo-natal mortality. It continues to be one of the countries with the highest maternal and neo-natal mortality rates in the region. Positive initiatives to improve access to the right to health include the National Plan for Sexual and Reproductive Health (2014-2018), the national mobilisation for reducing maternal and neonatal mortality, which has already helped reduce the number of maternal deaths by 30% since 2014, and the campaign to reduce preventable maternal and neo-natal deaths (“Cero muertes evitables”).

Women and girls face numerous barriers in their enjoyment of their right to health, in particular those from groups in situations of poverty and vulnerability such as indigenous women and those deprived of liberty. 

Evidence and information gathered during my visit has led me to conclude that violence against women and girls can be considered as an epidemic in Paraguay. There is widespread prevalence of sexual abuse and other forms of violence, including domestic violence. I welcome the draft law on Integral Protection of women against all forms of Violence, which is currently being considered by Parliament and trust it will be passed and implemented swiftly.

Maternal mortality remains very high mostly due to the large number of early pregnancies, many of which affect 10 to 14 years old girls as a result of sexual abuse and violence.  The situation is aggravated by an extremely restrictive law about the interruption of pregnancies, which only allows abortion when the life of the women is at risk. In addition health-care professionals who perform abortions and the mothers of these girls are criminalized. As a result pregnant girls are confined to homes, isolated from their families and close relatives until they give birth. 

The current legal and policy system is failing to protect very young girls as they are forced to continue high-risk pregnancies with long-lasting impact on their physical and mental health. The case of the Mainumby girl, widely reported and discussed in the media, is an example of a systemic challenge. But her case is just one of the hundreds of cases of 10 to 14 year old girls who are forced into unwanted pregnancies and motherhoods every year.  

This is a particularly worrying phenomenon and a public health concern that must be addressed without delay and in a serious and comprehensive way through changes in legislation, policies and practices based on scientific evidence and a human rights-based approach. Existing legislation should be reviewed to decriminalize abortion and allow the therapeutic interruption of pregnancies when the life of the mother is in danger, when the pregnancy is the result or rape and incest, and when life of the foetus is not viable.

Evidence shows that criminalising abortion only leads to clandestine and unsafe practices and exposes women and girls to additional dangers, violence, and stigma that negatively impact on their health.  Many girls and young women die from complications related to clandestine abortions every year in Paraguay.

During my visit, I received reports of acts of intimidation and harassment of individuals, NGOs, human rights defenders, and lawyers working on cases related to gender and gender-based violence. This is not acceptable.  These are crucial actors in a democratic society who work to promote and protect the right to health, and should be able to do so in a safe and enabling environment.

The right to health of children and adolescents

Children and adolescents comprise a large sector of population of Paraguay and should be accepted by authorities, society, and by health service providers, as holders of rights.

In this respect, their meaningful participation in all decisions affecting them should be promoted, including in the area of sexual and reproductive rights. Respect for children and adolescents’ rights, including sexual and reproductive health and rights, as well as their participation are the main precondition for investments in their health to be effective.

There have been some positive initiatives trying to address the needs of children and adolescents in the health system, such as the national plans for the promotion of quality of life and health with equity for children and adolescents.  However, serious threats and barriers to the right to holistic development of children remain, including corporal punishment in public and private setting, and a lack of comprehensive approach to address bullying and other forms of violence in schools.

The high rate of early pregnancies reflects serious protection gap of children’s rights including of their right to physical and mental health and integrity, their right to be free from all forms of violence, their right to receive adequate information and health education. The fact that comprehensive sexuality education is not integrated in school curricula prevents girls and boys from having access to the necessary information to make informed decisions about their sexual and reproductive health. There is a strong influence of religious groups and ideas in the school system where students are being provided with un-scientific and inaccurate information about their health. This contributes to the high prevalence of unintended pregnancies amongst young girls; as well as the high risk of the spreading of sexually-transmitted diseases, including HIV/AIDS.  

I recommend the implementation of the National Plan on Human Rights Education at the school level, with emphasis on sexuality education.  In this connection, the Pedagogical Guiding Framework for Comprehensive Sexual Education (Marco Rector Pedagógico para la Educación Integral de la Sexualidad), prepared in 2010, was a commendable initiative but unfortunately it was never implemented.  This Framework could serve as an inspiration for the development of new measures in this area.

On the other hand, violence against children and adolescents is a prevailing challenge in Paraguay. Six out of ten children suffer from some form of violence in their families.

Also, six out of ten deaths of adolescents are due to external causes, such as traffic accidents, homicides and suicides. There is a need to address this violence and self-destructive behaviour as a priority. I have observed that good practices and recommendations brought forward by international organizations and other relevant actors are not implemented in a sustainable way in Paraguay since significant barriers in different levels of policy formulation and implementation still remain. 

Amongst other issues of concern, I have identified a lack of adolescent friendly health services and confidential counselling; poor access to effective services for adolescent using drugs, including in detention; lack of comprehensive health education and information in schools, including comprehensive sexuality education; and a lack of sustainable investments in promoting holistic development of children, including emotional and social development.

The way that authorities are addressing the health and protection of children and adolescents in vulnerable situations, who are exposed to multiple adversities, is an example of ineffective policies and practices. Children and adolescent who use drugs and have committed, usually, minor offences are deprived of liberty and confined for years in so called “educational centres” where they are  deprived of their liberty. I have visited one of these centres in Ciudad del Este and my preliminary observation is that all efforts made to improve the situation in these centres are compromised by the fact that the majority of these adolescents should not be deprived of liberty. Punitive measures such as this are a form of institutional violence and only reinforce the cycle of injustice, exclusion and hopelessness in society.

The right to health of lesbian, gay, bisexual, and transgender persons

The situation and rights of lesbian, gay, bisexual, and transgender people (LGBT) has become more visible in Paraguay over the past few years. The National Plan on Sexual and Reproductive Health includes non-discrimination on the basis of sexual orientation and gender identity. During my visit, the Senate held a debate about the situation of transgender women, and I met with a number of high-ranking Government officials who are quite aware of the specificities of this group.

However, LGBT persons face important barriers in their full enjoyment of their right to physical and mental health mostly due to deeply entrenched discriminatory attitudes in society at large, which generate stigma, violence and abuse.  The situation of those living outside main urban areas is of particular concern as they are isolated from the main networks of support and live and work in very difficult environments. 

LGBT persons face discrimination from healthcare personnel and lack of integral health services tailored to their needs.  Moreover, confidentiality in health services is not always guaranteed.  I could asses that many of them do not use health services for fear of stigma and rejection which can drive many health issues underground with negative consequences for their health and that of society at large.

People living with HIV/AIDS and drug users

On average, there are three new cases of infection with HIV/AIDS every day in Paraguay.  Most of the cases are concentrated in Asunción and the Central department, and the most affected group are men who have sex with men, but also sex workers.

However, in recent years, Paraguay has seen a surge in HIV/AIDS infections due to sexual transmission, increasingly affecting young people, including women.  The Government of Paraguay has taken effective measures to reduce the spread of HIV/AIDS through an evidence-based approach, including access to free testing, distribution of condoms and free provision of antiretroviral treatment.

The normative and institutional framework includes a Law on the Rights, Obligations and Preventive Measures in relation to the effects produced by HIV/AIDS (Law 3.940), and a National Programme for AIDS Control (PRONASIDA).  The Law 3.940 contains some provisions with a strong moralistic approach that does not correspond to human rights standards and should be updated (arts. 8.1 and 8.2), but the real challenge lies in the operationalization of this framework.

People with HIV/AIDS face stigma and discrimination in society and, in general, there is little information, dialogue and training on this. Compulsory HIV testing in the workplace is not allowed but I received reliable reports that it is common practice.  In addition, there are established practices in the health sector that violate the right to privacy of users and should be reviewed.

The National Centre for the Treatment of Addictions cannot cope with the existing demand and it should be expanded adapting its programmes to the needs of those in most vulnerable situations, including those with less resources and adolescents. 

The right to mental health and persons with developmental and psycho-social disabilities

Paraguay has ratified the Convention on the Rights of Persons with Disabilities (CRPD), and it is currently considering a Mental Health Bill. However, I am concerned that certain public policies and services are not in line with the Convention’s standards. 

Moreover, the recommendations made by the Committee are not known in the country and therefore not implemented.   

So far, good initiatives have been fragmented and lacked sustainability and adequate support with human and financial resources. During my visit to the Psychiatric Hospital in Asunción and in different meetings in relation to mental health, I have observed that the mental health care system remains strongly dependent on the model based on long-term institutionalization and medicalization and continues to be poorly integrated in the community and the general healthcare system.  An illustration of this is the plan to construct a new building within the premises of the Psychiatric Hospital, for which an investment of 2,500 million Guaranies is foreseen.  I urge the authorities to reconsider this decision and use the opportunity to invest these resources to expand and reinforce community-based services to move away from institutionalization.

There have been important positive initiatives regarding community-based services for persons with mental health conditions, including developmental and psychosocial disabilities. The experience with the “substitute homes” (hogares sustitutos) was a positive initiative but it has not been expanded further, and this has led to systemic violations of the rights of these group, such as the right to enjoy living in community.  

The development of a full spectrum of community-based services for children and adults with psychosocial and intellectual disabilities should be a strong priority. I envisage that a comprehensive reform of the mental health care system, based on principles of non-discrimination and respect to dignity and all rights of users of mental health services, could be successful in Paraguay.  Political will and broad support is necessary to seriously implement recommendations of the CRPD Committee.

National health care system

Paraguay is facing complex challenges for the sustainability of the healthcare system. It has one of the lowest health expenditures per capita in the region, high out-of-pocket payments among the poorest quintiles of the population, and scarcity of qualified health care personnel. 

To address effectively many of the challenges which I have raised, the performance of the healthcare system needs to be improved, for instance, by continuing the work on human rights indicators, in particular on the right to health.  I will elaborate more on this in my report. But I will outline some of my preliminary observations on what could be some priorities for strengthening the healthcare system in Paraguay.

The excessive fragmentation of the current healthcare system is obvious and needs to be addressed with a view to integrate existing elements which are key to reduce inequalities and contribute to social cohesion.  Initiatives such as the Integrated Network of Health Services (Red Integrada de Servicios de Salud, RISS), have tried to tackle this but more should be done and this requires the political commitment from the highest levels of governance.

The development of family health units (unidades de salud familiar) since 2009 is a good example of such efforts in the direction of universal health coverage through the primary care system. However, after an initial and very promising stage of establishing these units, I have observed that the network requires more resources, and very few new units have been created over the past two years. It is of utmost importance to use this momentum and reinforce the expansion and quality of this network, by increasing the number of units, health personnel available, including health promoters, and improve infrastructure.

I have learned that the National Health Code (Código Sanitario) is in the process of being reviewed with the technical assistance of the Pan-American Health Organisation.  I welcome this and hope that this important document will be updated to include all relevant issues from a human rights perspective.

The active involvement of all participants in the functioning of the health system, including users of services and the healthcare workforce, is crucial to ensure trust, transparency and accountability. For this, the self-regulation of professional health groups should be promoted, and the role of health councils at all levels should be reinforced. The quality of medical education and the education of related professions need to be strengthened so that beyond clinical skills other knowledge and skills are promoted, including human rights, ethics, health management, and communication skills.

Members of the press,
Ladies and gentlemen,

There are good opportunities to achieve the progressive realisation of right to health in Paraguay, but public policy should address structural factors that hamper the way forward.

Individuals, families, communities and the civil society have a strong potential to promote and protect the right to health and can play a key role in strengthening the national health system.

It is essential to advance the meaningful participation of all groups and stakeholders, including the United Nations, NGOs, and professional associations, without exceptions, and with particular attention to those who are in the most vulnerable situations. This would reinforce accountability and transparency mechanisms, which are crucial for the realization of the right to health and related rights. Only a sustained commitment to promote and protect human rights and the right to health would make this possible.

Let me conclude by reiterating that I am very grateful to the Government of Paraguay for inviting me to visit the country, enabling me to deepen my understanding of the right to health and related rights. This invitation – and what I have learnt during my visit – indicates that there is a commitment to ensure and guarantee the enjoyment of the right to health. I hope that my visit and my report will assist the country in moving forward. 
Thank you.