Health systems in transition : Uzbekistan

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8. Conclusions
T
he Uzbek health system has undergone major reforms in the last two 
decades, encompassing all levels of care, as well as governance and 
financing. There were substantial reductions in the number of acute care 
hospital beds, while a range of initiatives were taken to strengthen primary 
health care, as well as secondary, tertiary and emergency care. Primary health 
care in rural areas has been restructured into a two-tiered system, while in 
urban areas all types of polyclinics (previously separate for adults, children, 
and polyclinics specializing in women’s health) are currently transformed 
into family polyclinics which will provide primary care for all groups of the 
population. There are also efforts to introduce new approaches to maternal and 
child health, public health, noncommunicable disease prevention and control, 
and monitoring and evaluation. 
Reforms included the establishment of new mechanisms for the allocation 
of resources. Primary care in rural areas is now paid for on a capitation basis 
and primary care in urban areas is expected to follow by 2015. Furthermore, 
a growing number of providers of tertiary and specialized care is being 
moved towards self-financing. Uzbekistan has also embarked on reforms of 
medical education. 
Recognizing fiscal constraints following the transitional recession in 
the early 1990s, the 1996 
Law on health protection
 defined a basic benefits 
package to be funded by the state; the law still provides the overall framework 
for policies and regulations related to benefits. The basic benefits package 
guaranteed by the government includes primary care, emergency care, care 
for “socially significant and hazardous” conditions, and specialized care for 
groups of the population classified by the government as vulnerable.

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However, despite wide-ranging reforms, the country has also retained some 
features of the Soviet system. Most health care providers continue to be public 
and the private sector, although growing, is still small. The health system still 
follows an integrated approach, with no contracting taking place, and almost 
all health workers are government-salaried employees. 
Some of the greatest challenges relate to health financing. Uzbekistan 
only spends a comparatively low share of its GDP on health and, although 
public sector expenditure accounted for an increasing share of total health 
expenditure in recent years, private expenditure remains substantial, mostly 
taking the form of (both formal and informal) out-of-pocket payments. This 
has obvious implications for equity in financing and health service utilization. 
Further increasing the share of government expenditure on health might enable 
policies that achieve a better financial protection of the population. These 
might include increasing the coverage of the benefits package and drawing up 
a benefits package for outpatient pharmaceuticals, as is being done in some 
other former Soviet countries. The current shift towards fee-for-service based 
payment mechanisms in the public sector might need thorough re-examination 
to make sure it is not associated with unintended negative effects.
Improving allocative efficiency could be another area for future reforms. 
The government has allocated an increasing share of its expenditure to primary 
health care, but more could be done. This also applies to efforts to overcome 
duplication and fragmentation of care, such as through the lack of clear patient 
pathways and referral mechanisms and the continued existence of parallel 
health systems.
The uneven allocation of resources across the country is another area of 
concern. There is a shortage of physicians and specialists in rural and remote 
areas, but an oversupply in large urban areas. Health outcomes, as well as the 
allocation of government expenditure on health, also differ across regions, and 
mechanisms need to be set in place to monitor and overcome these inequities.
As in other countries of the region, informal payments are a challenge. 
These are notoriously difficult to overcome, but first of all what would be 
necessary is a recognition of the scale of the problem and the ways that these 
payments undermine key health system goals. This could pave the way for 
more transparency in the health system, including through strengthened patient 
rights, a clearer focus on user experience and higher salaries for health workers. 
Focused and well-designed reform initiatives in these areas are likely to lead 
to improvements in access, equity, quality of care, effectiveness and efficiency.

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Quality of care is increasingly recognized as a problem, with ongoing 
efforts to update treatment protocols, and revise medical education, continuous 
professional development, and quality assurance and improvement frameworks. 
These efforts will need to intensify in the future to further improve quality of 
care. Attention will also need to be paid to the substandard medications and 
medical devices that are currently being used, and stricter government oversight 
might be required.
Lastly, further investments in health information systems are required. 
There is a lack of data on functional status, patient satisfaction, access and 
quality. Local capacity in survey and qualitative data collection methods could 
be strengthened to support regular data collection in selected areas of interest. 
This could help to bridge gaps in many areas where better data are needed, 
providing a better basis for evidence-based health policy-making.

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