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3.7.2 Paying health workers
In the public sector, health workers are salaried and paid according to strict
state guidelines, which were most recently updated in 2005. The guidelines
differentiate salaries depending on position (such as head, physician, nurse or
unskilled worker) and qualifications (Cabinet of Ministers, 2005b; President
of Uzbekistan, 2005).
The workload of each position is regulated in quantitative terms, specifying,
for example, the number of patient consultations or of inpatient care beds.
However, there are no explicit regulations on whether and how a higher number
of consultations or better quality should be rewarded. The existing payment
mechanism does not incentivize improvements in the productivity, quality
and efficiency of care. Consequently, disincentives, that is, compliance with
administrative protocols, remain the predominant management tool.
Minimum salaries for each position are defined by state guidelines. Salaries
are generally paid from funds allocated by the state, except in facilities based
on “self-financing”. Higher salaries are allowed, but need to be funded from
external funding accounts of health care providers. Government initiatives in
recent years have aimed to give health care providers the opportunity to use
financial incentives as management tools. The government decree establishing
separate accounts for non-state funds in public organizations was one of the
major initiatives in this direction. Up to one-quarter of the funds in these
accounts can be used to supplement salaries (Cabinet of Ministers, 1999b).
Organizations are free to determine the recipients and the size of supplements.
However, it should be noted that, although the share of non-state funds has been
increasing over recent years, they still only account for a small share of overall
health funding in the public sector.
Health systems in transition
Uzbekistan
56
The 2005
Presidential Decree
(President of Uzbekistan, 2005) further
emphasized the role of financial incentives and aimed to introduce reimbursement
mechanisms into the public sector health system that:
•
take into account the personal contribution of health workers, as well
as the quality and complexity of the work performed;
•
help to retain health professionals in rural areas and in providers of
specialized health care;
•
empower the management of provider institutions to objectively evaluate
and adequately reimburse health professionals.
In line with these aims, the document introduced:
•
an amended financial reimbursement mechanism taking effect in January
2006, that differentiates staff reimbursement by type of provider, position,
qualifications and supplemental coefficients, and builds on an existing
11-grade health sector wage grid;
•
pay increases of 25% to physicians in rural primary care units (Cabinet
of Ministers, 2014);
•
pay increases of 25% to physicians applying new health technologies
in their clinical practice;
•
pay increases based on continuity of employment;
•
a change in the extra-budgetary accounts of health care providers,
introducing “development and financial incentives accounts”.
Under these arrangements, up to 5% of the allocated public budget is
channelled into the development and financial incentives account, with
additional funds coming from sponsors, unutilized public funds and fees
received for designated services. Funds from this account can be spent on
financial incentives for staff or on the structural strengthening or reconstruction
of facilities. The ratio of expenses on these two budget lines is determined by
the Ministry of Health, the Ministry of Finance, and the Ministry of Labour
and Social Protection, according to types of health care providers.
The latest government initiatives on shifting public facilities to
“self-financing” schemes aim, in part, to increase the flexibility of health care
providers in reimbursing health professionals, giving them the opportunity to
use financial incentives as a management tool. One example is the management
and financing pilot carried out in selected tertiary care institutions (see
Chapter 6). This pilot granted the respective institutions the freedom to
Health systems in transition
Uzbekistan
57
determine the framework for paying employees, and to place an emphasis on
incentives for efficiency, quality and productivity (Ministry of Health, 2013c).
However, providers are limited in what they can do, as they are still tied to
protocols by the Ministry of Finance and the Ministry of Health that were
initially developed for state-funded facilities. Staff salaries still need to follow
salary scales set by the Ministry of Finance. These salary scales are in turn
used for calculating the prices for services. Given the limits on mark-ups
for services, pilot facilities are very limited in how much funding they can
generate and how well they can remunerate their staff. Where centrally set
salaries are comparatively low, incentives are created for informal payments or
inappropriate care, and health care providers face problems in retaining highly
qualified staff. The situation is similar in the selected secondary care facilities
that have been included in “self-financing” schemes.
As of August 2014, salary rates for health professionals in the public sector
were comparatively low. On average, the basic monthly salaries for physicians
in the state-funded public sector in 2014 ranged from US$ 300 to US$ 600, and
the salaries for nurses were lower. Anecdotally, salaries in the state-funded
health facilities are considered insufficient to cover the cost of living (World
Bank, 2009). Some health care providers in the public sector, mostly those
on self-financing schemes, pay their health professionals salaries that are
several times higher than the rates in state-financed facilities, thus attracting
and retaining better qualified staff. However, these health care providers
only constitute a small proportion of facilities in the public sector. Financial
incentives are particularly insufficient for health professionals working in
primary care (World Bank, 2009).
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