Health systems in transition : Uzbekistan

6.1.1 Directions of recent health reforms 
In Uzbekistan, laws and presidential decrees generally set out the overall 
priorities and directions for health reforms. Follow-up decrees by the Cabinet 
of Ministers and the Ministry of Health provide more detailed guidance and 
information on the implementation of plans and the achievement of objectives. 
Since 2007, the government has issued three major policy documents 
(
Presidential Decree No. 3923
 of 19 September 2007; 
Presidential Edict 
No. 700
 of 2 October 2007 and 
Presidential Decree No. 1652
 of 28 November 
2011) which outline the broad directions for the next steps of health reforms 
in the country. Some of the most important changes these documents have 
triggered include:
•
  Dual accountability has been established for all health authorities and 
medical facilities. All medical facilities and health authorities are now 
accountable to both the Ministry of Health and their respective local 
government. 
•
  Management of the state funds allocated to medical facilities was delegated 
to newly established treasury offices. Under this scheme, treasury offices 
have become the primary holders of state funds for state entities and 
disburse financing according to set guidelines. All medical facilities 
receiving state funds have become separate legal entities and work 
directly with local treasury offices on the utilization of state funds. 
Previously, regional and district health authorities were the primary 
recipients of state funds. They had accounting departments that dealt 
with the management of state funds. Levels of allocation of funds to 
subordinate medical facilities were to some extent based on their discretion. 

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A number of further reforms are envisaged by the three major health policy 
documents. They include the following: 
•
  At the district level, central district multi-specialty polyclinics are 
anticipated to become part of central district hospitals, forming an 
entity that provides specialized outpatient and inpatient care under a 
single umbrella. Previously, central district hospitals and central district 
polyclinics used to function as separate entities and were also often 
geographically separate. Under the proposed reforms, the new entity 
will be called the 
tuman tibbiyot birlashmasi
 (district medical union) and 
will provide care at district level for a geographically defined population. 
Previously separately located central hospitals and polyclinics will be 
merged, so that both inpatient and outpatient care can be provided at a 
single facility or facilities in close proximity. 
•
  At the regional level, regional adult and paediatric hospitals, as well as 
some of the specialty care clinics, are anticipated to be transformed into 
regional multi-specialty adult and paediatric centres. In each region, 
medical diagnostic centres providing outpatient care on a fee-for-service 
basis are being established. The medical diagnostic centres will gradually 
be shifted away from state funding and towards self-financing, while 
regional multi-specialty adult and paediatric centres will continue to rely 
on state funding. 
•
  At the national level, in an expansion of earlier tertiary care pilot reform 
initiatives, six specialized clinical research institutes are anticipated to 
be transformed into new specialty centres. They will cover the following 
specialties: dermatology, paediatrics, obstetrics and gynaecology, 
internal medicine, endocrinology and pulmonology. The four existing 
pilot specialty centres will be shifted towards full “self-financing” and 
take the form of shareholding entities, although the government, by 
holding controlling shares, will remain a key player in their governance 
and management. 
•
  It is envisaged that a framework for the annual evaluation of health care 
managers by specially set up working groups will be established. These 
annual evaluations are expected to identify poorly performing managers 
and, if necessary, to replace them with more qualified candidates. 
Detailed mechanisms for the evaluation procedure have been set out 
by follow-up decrees. 

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•
  Improvement of the blood donation and transfusion systems is planned 
through significant capital investment and new regulatory initiatives. All 
medical facilities are now required to use disposable items for procedures 
dealing with blood and its components. 
•
  Capital investments for district and regional-level hospitals and tertiary 
care centres are envisaged.
The following are some of the major Cabinet of Ministers legal acts that 
followed the above-mentioned presidential policy documents:
•
 
Cabinet of Ministers Decree No. 227
, 25 October 2007, on the attestation 
framework for managerial staff 
•
 
Cabinet of Ministers Decree No. 48
, 18 March 2008, on structural changes 
to regional health care delivery frameworks
•
 
Cabinet of Ministers Decree No. 145
, 21 May 2009, on the organization 
and functional framework of tertiary care centres 
•
 
Cabinet of Ministers Decree No. 91
, 29 March 2012, on capital investment 
plans in the health sector and reforms of the organizational framework.
In addition to the reform initiatives mentioned above, a number of health 
reforms are currently ongoing, with changes to different elements of the health 
system. Primary care reforms focusing on health care infrastructure at the 
district level, supported by international funding, started in the late 1990s and 
continue to this day. In 2012, the government of Uzbekistan and the World 
Bank group signed two loan agreements that aim to further develop the reform 
initiatives at district level and expand them from primary care facilities to 
district-level hospitals. Tertiary care reforms initiated in the early 2000s are 
currently being expanded to involve six more specialty centres. A number of 
important initiatives were also undertaken to improve maternal and child health 
and medical education. Finally, the government enacted a number of laws on 
public health challenges that require a multi-sectoral approach.