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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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Uzbekistan
124
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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Uzbekistan
125
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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