Health systems in transition : Uzbekistan

7.5 Health system efficiency
7.5.1 Allocative efficiency
In Uzbekistan, the allocation of resources is not informed by comprehensive 
health needs assessments, and the use of cost–effectiveness and comparative 
effectiveness studies in policy and decision-making is very limited. Instead, 
aggregate proxies for health needs are used as a basis for resource allocation. 
The allocation of public resources follows a planned process, in which resource 

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allocations are made according to established standards and protocols, often 
based on geographical and population indicators. The mechanisms for resource 
allocation differ between the primary, secondary and tertiary care level. 
In public sector primary care, resource allocation has been increasingly 
linked to the size of the population covered. Conceptually, population size 
represents a proxy for health needs, as there is a comparatively even geographical 
distribution of income, education, age and gender within Uzbekistan’s territorial 
units. Furthermore, capitation payments are based on coefficients that take into 
account the population structure in terms of age, sex and density (Cabinet of 
Ministers, 2005a). However, in large urban units, such as Tashkent, certain 
neighbourhoods attract more affluent groups with distinct health needs and 
health-seeking behaviour.
Financing of secondary and tertiary inpatient care in the public sector is 
still based on norms, inputs and past expenditures, except where it has been 
shifted to self-financing. This mode of financing does not take account of 
the outputs produced. Allocative efficiency is further undermined through 
the existence of out-of-pocket payments (both formal and informal) and 
physician-induced demand. 
Over recent years, public sector facilities are increasingly being shifted 
towards self-financing. This primarily concerns tertiary and selected secondary 
care facilities. This financing scheme enforces organizational behaviour 
that prioritizes the goals of the facility over those of the health system and 
society at large. For instance, to protect revenue sources, organizations 
can engage in activities that reduce the efficiency and effectiveness of the 
overall health system. Examples include duplicate tests and procedures, and 
inappropriate hospitalizations. The allocation of resources to public providers 
on the self-financing scheme (except for those patients included in the benefits 
package) and to providers in the private sector is based on market forces. In 
these cases, resources are tailored to demand, not health needs, resulting in low 
allocative efficiency. 
Allocative efficiency also depends on health spending by levels of care. 
Corresponding to a decreased spending on tertiary care, public funds were 
shifted in recent years towards primary and secondary care services, increasing 
allocative efficiency. 
Fragmentation of the health system remains a challenge to allocative 
efficiency. Lack of coordination between different levels of care, as well as 
within the same level of care, can lead to fragmented and uncoordinated care of 

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patients, the duplication of services, less efficient care delivery modes and lower 
quality of care due to lack of continuity. There is no clear pathway or framework 
that coordinates patient care once they leave primary care. Furthermore, in 
the absence of strong gatekeeping, the primary care system can be skipped 
altogether in favour of accessing higher levels of care directly. Patients can 
access care at any level (secondary or tertiary) and any type of ownership 
(public or private). Physicians do not have the means and tools to properly 
coordinate patient care once they leave their practice. Furthermore, in the 
context of fee-for-service arrangements, tests and procedures performed by 
other providers are not accepted by facilities and patients are required to have 
them performed anew, leading to duplication and fragmentation of care. Recent 
reforms have aimed to create a tighter link between primary and specialty 
care at the district level. However, it is not clear how this new framework 
will contribute to improved coordination of care both within and beyond the 
district level. Further fragmentation results from the existence of parallel health 
systems maintained by the National Security Service, the Ministry of Internal 
Affairs, Uzbek Airlines and other ministries or state companies.