In Paraguay, mental, neurological, and substance use conditions contribute to 18 percent of all the country’s disability-adjusted life years (DALYs) and 36 percent of all years lived with disability (YLDs).[1] Historically, individuals with these conditions have faced human rights violations within the mental health care system. In response, significant reforms are being undertaken to transform the previously centralized approach. Key among these reforms is the enactment of a new Mental Health Law in 2022and the creation of a National Mental Health Directorate and Observatory.[2]  This marks a pivotal shift towards community-based services, with a focus on integrating mental health care into the first level of care through family health units and the establishment of community-based mental health centres for the first time in Paraguay's history. The World Health Organization’s (WHO) Special Initiative for Mental Health has played a key role in this transformation by advocating for legal reforms, supporting the development of a national policy and plan, and supporting the transformation of the country’s main psychiatric hospital in favour of decentralized and community-based services.[3] These developments aim to improve the quality of life for those formerly reliant on long-term hospitalization, enhancing mental health outcomes, reducing human rights abuses, and fostering better physical and social well-being. This represents significant advancements towards the programme’s main strategic actions at global level, particularly that of “advancing mental health policies, advocacy and human rights” as well as contributing to the completion of the country workplan, specifically around Outcome 1 relating to strengthening governance and leadership structures for the development and implementation of  human rights based laws and policies.

How did Paraguay, with the support PAHO/WHO, achieve this?

Since 2001, Paraguay's Ministry of Public Health and Social Welfare has committed to enhancing access to mental health care. The National Mental Health Policy for 2011-2020 outlined a comprehensive strategy aimed at improving mental health services, with a particular focus on integrating these services into the first level of care. In 2019, Paraguay was selected to join the Special Initiative for Mental Health, which launched in the country in August 2021.[4] This initiative aims to advance towards universal mental health coverage by ensuring access to quality and affordable care. It encompasses a commitment from participating nations to promote mental health policies, improve the quality of interventions, and expand services for individuals with mental health conditions, including substance use and neurological disorders.

“The management of mental health conditions in all its forms is a priority for the national government, particularly through the training of frontline workers in the Family Health Units.”

Dr Miguel Angel Velazquez, Director General of the National Institute of Health

As a first step, PAHO/WHO carried out a rapid assessment through its Special Initiative for Mental Health to evaluate the current mental health system and establish a baseline that would enable the measurement of future improvements.[5] This evaluation used a modified version of the Programme for Improvement in Mental Health Care (PRIME) situational analysis tool.[6] It focused on key areas such as mental health policies, the availability of services, and cultural factors, and broadened its perspective beyond the conventional health system to encompass community-based services. 

Following the initial assessment, PAHO/WHO provided technical support for the development of a five-year implementation plan for the Special Initiative for Mental Health, marking a significant stride towards further decentralization and aiming to support successful completion and adoption of a new Mental Health Law. PAHO/WHO offered ongoing technical support to monitor the plan's progress, implementing quarterly quantitative reviews and semi-annual qualitative evaluations.

^{Representatives of the National Institute of Health, the National Directorate for Mental Health and the PAHO team planning the implementation of the Mental Health and Substance Use. Mental Health Gap Action Programme (mhGAP) programme.}
Photo credit: PAHO/WHO Paraguay

PAHO/WHO was instrumental in engaging community partners and bolstering the skills of health workers through the Mental Health GAP Action Programme (mhGAP).[7] From late 2022 to early 2023, 75 mental health professionals were trained as Master trainers and tasked with training local health providers to equip them with the tools necessary for effectively supporting individuals with mental health conditions. Subsequent cascade training, conducted throughout the remainder of 2023, reached 82 first level of care health workers, comprising 70 doctors and 12 nurses. This effort expanded the availability of mental health services to approximately 383 500 individuals residing in targeted catchment areas. To further enhance community access to mhGAP services, 34 Master trainers were trained in the mhGAP Community Toolkit. Within the first few months of the initiative, they had already trained 18 community health workers, increasing their capacity to raise awareness and identify and refer people with mental health conditions to trained professionals.

“[The mhGAP community toolkit] is an excellent tool that will support us to continue our work in identifying the mental health gaps in the communities where we work.”

Gabriella Delvalle, mhGAP Community Toolkit trainee and Primary Health Care worker

The introduction of the new Mental Health Law in 2022 represented a pivotal moment, establishing the foundations for a comprehensive national mental health strategy and the creation of both a National Mental Health Directorate and a National Mental Health Observatory. This development signalled a commitment to systematic reform focused on reducing the dependence on prolonged hospitalization for individuals with mental, neurological, and substance use disorders.

In the coming years, Family Health Units (USFs) will become the primary providers of mental health care services nationwide, playing a key role in moving away from the traditional model of prolonged hospital care. Notably, in the latter half of 2023, a psychiatric ward in the capital was decommissioned, following the discharge and successful reintegration of 11 long-stay patients into the community.  This move towards community integration is supported by enhanced access to social services, including housing, employment, and community-based mental health centres, in conjunction with the USFs.

The shift towards community-based care and the move away from the isolation of institutional settings in Paraguay is expected to yield widespread benefits, including improved mental health outcomes, enhanced physical and social well-being, a decreased risk of human rights violations, and a transformative shift in the country's mental health narrative. This progress is the culmination of joint efforts by the Paraguayan government, PAHO/WHO, and local stakeholders. Key strengths of Paraguay's mental health system include the recent policy advancements, the expansion of the mhGAP in USFs, and a heightened political commitment towards establishing a community-based service network. However, challenges in funding and policy implementation persist. While initial improvements have been facilitated by catalytic funding to the Special Initiative for Mental Health, the continuity and expansion of the mental health care system will critically depend on sustained financial support.