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6.1.3 Secondary and tertiary care reforms
In Uzbekistan, district- and city-level hospitals are considered to be part of the
state-guaranteed primary health care system. These hospitals are primarily
financed from state funds and reforms have been closely aligned with primary
care reforms. Health facilities at the regional and republican level, on the other
hand, are considered providers of secondary and tertiary care. The majority
of these
facilities are hospital-based, but they also provide outpatient services.
Until now, secondary and tertiary care reforms have focused on redesigning
governance arrangements in republican-level tertiary facilities and on
nationwide reductions of bed numbers in state-funded hospitals. In 2003, four
tertiary care facilities at the republican level were transformed into specialty
centres with expanded roles in governance and financial and human resource
management. The centres were permitted to set the prices for services and
technically became fee-for-service institutions. The price-setting processes
in these institutions, however, had to comply with
the guidelines set by the
Ministry of Finance, the Ministry of Health and the state committee that deals
with issues on competition and monopolies. Up to 20% of services had to be
provided for individuals defined as “vulnerable”; the expenses for the care
provided for this population group are covered by the Ministry of Health
(President of Uzbekistan, 2003;
Cabinet of Ministers, 2004). In 2009, tertiary
care pilots were expanded to involve six more tertiary care facilities (Cabinet
of Ministers, 2009b).
As of 2013, pilot tertiary care facilities were expected to gradually become
shareholding entities, with the government holding the controlling set of shares.
These changes were anticipated to lead to increased management flexibility,
revenues and innovations (Cabinet of Ministers, 2012a). However, it remains
unclear what effect these pilot schemes had on the finances of pilot facilities,
the quality
of care provided by them, and access to tertiary care for different
groups of the population.
Reform initiatives of facilities at the regional (
viloyat
) level have so far been
largely confined to facility redesign and rationalization (President of Uzbekistan,
2007c, 2007d; Cabinet of Ministers, 2008). At present, three distinct secondary-
level facilities are being established at the regional level: multi-specialty adult
and paediatric medical centres and medical diagnostic centres. While the
first two are hospital-based facilities providing both inpatient and outpatient
care
services, the third type of facility provides only outpatient care. Medical
diagnostic centres are expected to be self-financing, adult multi-specialty
centres are expected to be based on a mix of budgetary and self-financing, and
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paediatric centres are to be fully funded by the state. Currently, at the
viloyat
level, there is a host of specialty clinics functioning in parallel with the newly
established
facility types, duplicating many services. At present, it is not yet
clear what the government plans to do with these providers of specialty care
that fall outside the three new types of facilities.
As one main element of health reforms, the government was able to
significantly reduce the number of acute care hospital beds since independence.
In the early 2000s acute care hospital beds were
reduced to about half the
level they had in the 1990s (see Chapter 4). However, it is unclear if officially
reported statistics are limited to state-funded beds, include all beds in the public
sector, or beds in both the public and private sector.
In 2011, a new
Presidential Decree
(President of Uzbekistan, 2011a) aimed
to further reduce the number of state-funded hospital beds (by 18 000 beds,
equivalent to a reduction of approximately 14%). It also envisaged closing more
than 1000 buildings in the state health sector. Table 6.5
provides information
on the numbers and types of buildings that are envisaged to be closed down in
coming years.
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