Health systems in transition : Uzbekistan

3.3.4 Purchasing and purchaser–provider relations
In terms of purchaser–provider relations, the public sector health system follows 
an integrated approach, with the government being the principal provider and 
purchaser of health services in the public system and no formal provider–
purchaser split. However, in recent years forms of reimbursement models, such 
as fee-for-service arrangements, are being incorporated into this approach. 
Health care delivery in the private sector is primarily on a fee-for-service basis 
and covered by out-of-pocket payments. 
In the public sector, the organizational relationship between purchasers and 
providers of health services differs between the primary care system (rural 
primary care units known as SVPs) and specialized care (both outpatient and 
inpatient). As part of national health reforms, per capita payment has been 
introduced for primary health care. Under these new financing arrangements, 
rural primary care units are expected to provide a package of services to the 
enrolled population free of charge, covered by state funding on a capitation 
basis. This type of organizational relationship does not entirely fit any of the 
common organizational models. Although the rural primary care units included 
in the reforms are tasked with the provision of specified services for the per 
capita financing they receive from local governments, no contracts exist, health 
facilities are government owned, and all health personnel are government 
employees. Two mechanisms are used for the regulation of organizational 
behaviour: financial incentives and protocols. There are very few financial 
incentives for improving the efficiency and quality of care; the most prevalent 
mechanism for regulating behaviour continues to be the protocols drawn up by 
higher levels of management. 
The regulation of the organizational behaviour of inpatient, specialized 
outpatient and emergency care providers in the public sector is much closer 
to the integrated model. Government funding of these providers is strictly 

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Health systems in transition
  
Uzbekistan
52
based on line-item budgeting, and financing mechanisms are not used as a 
management tool. Administrative protocols and hierarchical management are 
the prevalent tools for regulating organizational behaviour. 
However, there are also new developments in the financing and management 
of inpatient care providers, such as reform initiatives covering selected tertiary 
and secondary care providers (see Chapter 5). These new mechanisms have 
changed purchaser–provider relationships, with a shift towards greater use 
of contracts. The selected facilities have moved from state funding towards 
“self-financing” on the basis of user fees and have been allowed greater 
autonomy in terms of management, staff planning, and service pricing and 
delivery. Providers are reimbursed by the Ministry of Health for the treatment 
of patients who qualify for state funding. All other services need to be paid 
for from other sources, primarily private out-of-pocket payments. Allocations 
from the Ministry of Health consist of annual budgets that are allocated to 
each provider in advance. The provider then needs to provide the matching 
services to eligible individuals to justify the allocated funds. These funds are 
thus generally not used to influence organizational behaviour, but rather to 
provide coverage for a selected group of eligible patients. 
For some regional-level providers on the full “self-financing” scheme, no state 
reimbursement mechanisms are in place. For them, regulatory frameworks and 
administrative protocols are the main tools that shape organizational behaviour.