Health systems in transition : Uzbekistan

5.2 Patient pathways
Patient pathways differ with regard to primary and secondary care. Patients can 
obtain free primary non-emergency care from:
•
  the limited number of 
feldsher
–midwifery posts (FAPs) located in 
hard-to-reach geographic areas, rural physician points in rural catchment 
areas; and family polyclinics in urban catchment areas;

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•
  outpatient clinics of central 
tuman
 hospitals if living in rural catchment 
areas; and outpatient clinics of urban multi-specialty polyclinics if living 
in urban catchment areas.
The following providers can charge for the primary care services rendered: 
•
  outpatient units of secondary and tertiary care institutions, both at 
viloyat
 
and national level; 
•
 private 
providers;
•
  state providers when patients are seeking care outside their registered area 
of residence. 
When obtaining primary care services from public providers, such as 
primary care institutions or outpatient units of central 
tuman
 hospitals, some 
fees may be charged for diagnostic and laboratory tests. Pharmaceuticals are 
generally covered by out-of-pocket payments (for exceptions see section 3.2). 
When obtaining care directly from the outpatient unit of secondary and tertiary 
care institutions, the patient will have to pay service charges. Visits to private 
providers have to be fully paid by the patient. Price-setting in public institutions 
of secondary and tertiary care has ceilings defined by the Ministry of Health 
(with up to 25% mark-ups on the costs), whereas private providers are free to 
set their prices. 
The right to choose health care providers was one of the early government 
initiatives when bringing market forces into the health care arena. The 
Law on 
health protection
 guaranteed the right to choose a physician and a health care 
institution (Republic of Uzbekistan, 1996). This new policy was in contrast to 
the Soviet model where the choice of providers was limited by the hierarchical 
order of the health system and based on a strict referral system. The law 
opened the field for competition between private and public providers based 
on mixed financing. 
According to the 1996 
Law on health protection
, patients have the right to 
obtain primary care in any primary care provider throughout the country. In 
practice, however, the regular utilization of primary care services in an area 
outside the registered place of residence is problematic. The new financing 
mechanism, which is based on capitation and is envisaged to be implemented 
nationwide, will further limit universal access to primary care services by 
the patients’ place of residence (see Chapters 3 and 6). Emergency services, 
however, will continue to be provided by any public primary care provider, 
irrespective of registration area (Republic of Uzbekistan, 1996). 

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Factors such as the availability of alternative providers and geographical 
access also play an important role in the realization of choice. About half of 
the population lives in rural areas where the choice of health care providers 
is limited mostly to public providers. No data are available, however, on the 
awareness of the population of their legal right to choose health care providers 
and how far this right is exercised. 
Patients in need of inpatient care can choose any of the following paths:
•
  They can visit 
tuman
/city hospitals, 
viloyat
 hospitals or any other public 
inpatient institution not included in the “self-financing” scheme. In 
this case, patients will be able to receive basic secondary care and be 
responsible for limited cost-sharing (such as for food, communal expenses 
or pharmaceuticals); specified population groups and clinical conditions 
are exempted from cost-sharing (Republic of Uzbekistan, 1996; President 
of Uzbekistan, 1998).
•
  They can visit public inpatient care institutions included in the 
“self-financing” scheme. In this case, patients will have to pay the price 
charged by the institution. The price-setting process is regulated and 
user charges have defined ceilings (see Chapter 3). If patients qualify 
for the government reimbursement scheme (people with disabilities, 
orphans, veterans, etc.), they are eligible to receive care free of charge in 
these institutions and expenses are reimbursed by the Ministry of Health 
(President of Uzbekistan, 1998). Reimbursed care, however, should not 
exceed 20% of the total budget of the institution (for more information 
on reimbursement schemes see Chapters 3 and 6). 
•
  They can visit any private provider. In this case, patients pay the price 
charged by the institution. According to legal provisions, specified groups 
of the population might obtain inpatient care from private institutions, 
expenses for which will be covered by the government (see Chapter 4).