Health systems in transition : Uzbekistan

7.3.2 Equity of access to health services
Access to care requires availability of services and equity of access (Gulliford 
et al., 2002). Availability of services when they are wanted or needed can be 
described as potential access. Actual access is concerned with whether available 
services can be utilized or whether there are barriers that impede the use of 
available services (Aday & Andersen, 1974; Andersen, 1995). 
In Uzbekistan, quantitative data are regularly collected on the available 
infrastructure, such as the number of hospital beds, outpatient clinics, physicians 
and nurses. These data can help to understand potential access to services. 
In the public sector, data on health care utilization, that is, actual access, are 
also collected regularly. In the private sector, however, data collection protocols 
are not strictly enforced, and the reported data do not capture actual utilization 
rates. Furthermore, utilization data do not convey information on unmet health 
care needs. This is particularly the case in areas such as specialized care that 
function on a fee-for-service basis. 
Two main types of barriers to access are often identified. Geographical 
access is concerned with the distance to health care providers: the longer the 
distance, the higher are the costs associated with receiving care (that is, costs 

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Health systems in transition
  
Uzbekistan
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for travel and accommodation). Financial access is concerned with whether 
and how ability to pay affects the utilization of services. Where out-of-pocket 
payments are common, such as for specialized care in Uzbekistan, higher 
financial barriers to access exist. 
While primary care reforms have led to closures of primary care facilities 
in rural areas, the government aimed to ensure equal geographical access 
to restructured primary care units (Ahmedov et al., 2007). For this purpose, 
a mapping and geographical placement of primary care units in relation to 
populated areas was carried out. Urban primary care has not undergone major 
closures of facilities. It is therefore safe to assume that geographical access to 
primary care services in urban areas has remained similar to the period prior 
to reforms. 
In terms of inpatient secondary care, there were some reductions in the 
number of small rural hospitals, but each urban or 
tuman
 unit has at least one 
central urban or 
tuman
 hospital. It can therefore be assumed that geographical 
access to inpatient care was largely maintained, despite the closure of small 
rural hospitals. Tertiary inpatient care was not affected by any major facility 
closures, although access might have been affected by reductions in bed 
capacity. Improved availability of a number of complex tertiary care services 
was the primary goal of reforms of the tertiary care sector in Uzbekistan. 
Since independence, a number of specialized tertiary care centres have been 
established in areas such as neurosurgery, ophthalmic microsurgery and 
cardio surgery. 
Financial access has been undermined through the expansion of formal 
and informal user charges over the last two decades. According to WHO 
estimates, in 2012 out-of-pocket payments accounted for almost half of total 
health expenditure (WHO Regional Office for Europe, 2014a). User charges 
can limit access to necessary care, disproportionately affecting lower income 
groups. This is a particular problem in Uzbekistan, as eligibility criteria for the 
benefits package are not directly linked to income levels. Consequently, major 
differences in financial access exist between the patient or population groups 
covered by the benefits package and the rest of the population. 
Other types of barriers to access also exist. Many rural primary care 
facilities face physician shortages. Unreliable electricity and water supply to 
rural health facilities also cause barriers to the utilization of health services 
(World Bank, 2009; Expert-Fikri, 2011; Ministry of Health, 2014). No recent 
studies could be identified that explore unmet health care needs in Uzbekistan. 

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Health systems in transition
  
Uzbekistan