HEALTH CARE IN UZBEKISTAN

HEALTH CARE IN UZBEKISTAN

There is universal free health care. Some private practices and health insurance have been introduced since the early 1990s. There are shortages of medicine, equipment, and trained personnel. In the post-Soviet era, the quality of Uzbekistan’s health care has declined. Between 1992 and 2003, spending on health care and the ratio of hospital beds to population both decreased by nearly 50 percent, and Russian emigration in that decade deprived the health system of many practitioners. In 2004 Uzbekistan had 53 hospital beds per 10,000 population. Basic medical supplies such as disposable needles, anesthetics, and antibiotics are in very short supply. [Source: Library of Congress February 2007 **]

Health expenditures: 6.1 percent of GDP (2013), country comparison to the world: 118. Physicians density: 2.53 physicians/1,000 population (2013). Hospital bed density: 4.4 beds/1,000 population (2010). [Source: CIA World Factbook =]

Although all citizens nominally are entitled to free health care, in the post-Soviet era bribery has become a common way to bypass the slow and limited service of the state system. In the early 2000s, policy has focused on improving primary health care facilities and cutting the cost of inpatient facilities. The state budget for 2006 allotted 11.1 percent to health expenditures, compared with 10.9 percent in 2005. **

The Uzbeks have a rich tradition of folk medicine. The Soviets did not the use of such medicines. Today, doctors sometimes expect a bribe in return for treatment.

Health Care System in Uzbekistan

Uzbekistan has retained many Soviet features, such as strict government control of public health. Government-paid doctors and nurses are assigned to each district or village. In the mid-1990s, Uzbekistan continued a health care system in which all hospitals and clinics were state owned and all medical personnel were government employees. Although health care ostensibly was free of change, this rarely was the case in practice. [Source: Library of Congress, March 1996 *]

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Based on managerial and regulatory functions as well as accountability, the state-run health system falls into three distinct hierarchical layers: the national (republican) level, the viloyat (regional) level, and the tuman (district) or city level. The highest hierarchical layer is formed by the Ministry of Health and other national institutions. The private sector is still small and mainly comprises pharmacies, physicians working in small practices, and institutions involved in health care delivery or the production and supply of pharmaceuticals or medical equipment. [Source: “Uzbekistan: Health System Review” by Mohir Ahmedov Ravshan Azimov, School of Public Health, Tashkent Medical Academy, Uzbekistan Zulkhumor Mutalova, Institute of Health and Medical Statistics under the Ministry of Health of Uzbekistan Shahin Huseynov, WHO Regional Office for Europe Elena Tsoyi, WHO Country Office in Uzbekistan Bernd Rechel, European Observatory on Health Systems and Policies, Health Systems in Transition, 2014 ^=^]

The government disburses its funds through the national Ministry of Health, through the health agencies of local and province governments, and through specialized facilities serving ministries and state enterprises. Treatment in the last two categories is generally better than in general state facilities because staff salaries and work conditions are better. As in the Soviet system, special facilities exist for top political, cultural, and scientific dignitaries. In 1994 some US$79 million, or 11.1 percent of the annual budget, was allocated for health care. Of that amount, about 60 percent went to state hospitals, 30 percent to outpatient clinics, and less than 6 percent to medical research. *

In the early 1990s, some private medical practices have supplemented state facilities to a small extent. In 1993 Uzbekistan undertook a program of privatization that began with the introduction of health insurance and continued with the gradual privatization of health care facilities, which is optimistically projected at about three years. Under the new program, the government would require private health facility owners to maintain the same standards as state facilities and to offer minimum free health care for the indigent. In the first few years of the program, however, only pharmacies and small clinics were privatized. Plans for 1995 called for privatizing twenty-four dental clinics and twelve prenatal clinics. In 1995 no plan provided for government divestiture of medium-sized health care facilities. *

In 1993 a total of 16.8 million patients were treated, of whom 4.8 million were treated in hospitals and about 275,000 in outpatient clinics--meaning that the vast majority of patients received treatment only at home. Experts predicted that this trend would continue until the level of care in government facilities improved substantially. *

Health Care in Uzbekistan in the Soviet Era

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “In the Soviet health system, almost all health services were delivered through the public sector. While all citizens enjoyed access to health care free at the point of delivery and a wide range of medical services were available for all, the Soviet model of health care contained several structural weaknesses. It proved to be effective in tackling infectious diseases, but major system problems surfaced with a change in the burden of diseases (Rowland, 1991). Weaknesses of the Soviet health system included an emphasis on quantitative indicators, with limited attention to outcomes and the quality of care, as well as inflexible management and financing arrangements. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“Another weakness of the Soviet health system was related to health spending. Soviet health spending had been significantly lower than in other developed nations. Furthermore, it was heavily biased towards secondary care. In the mid-1980s, Uzbekistan had almost twice as many hospitals per 100 000 population (7.89 in 1985) than those countries that joined the European Union (EU) before May 2004 (the EU15) (3.87 in 1985). Primary care was neglected and did not fulfil the role of a gatekeeper for higher levels of care. The ineffective use of resources was exacerbated by inefficient hospital procedures, with diagnostic investigations requiring hospital stays of up to seven days (Rowland, 1991). ^=^

“Although the Soviet health system had a comprehensive network of health facilities, it faced major problems related to their operation. Facilities were poorly equipped and maintained, and a shortage of medical supplies existed throughout the system. In rural areas, 27 percent of hospitals did not have sewerage and 17 percent did not have running water. Health personnel were inadequately trained and poorly paid, with physicians receiving about 70 percent of the average salary of non-farm workers (Rowland, 1991). With the dissolution of the Soviet Union, independent Uzbekistan was confronted with the legacies of the Soviet health system, while undergoing significant economic, social and political transformations. ^=^

Health Care Expenditures in Uzbekistan

Health expenditures: 6.1 percent of GDP (2013), country comparison to the world: 118. [Source: CIA World Factbook =]

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Uzbekistan spends a comparatively low share of its gross domestic product (GDP) on health, amounting to an estimated 5.9 percent in 2012. This was below the average of the WHO European Region of 8.3 percent, but slightly above the average for the central Asian republics of 5.2 percent. While the share of public sector expenditure has increased in recent years, private expenditure remains substantial. Voluntary health insurance does not play a major role. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“According to WHO estimates, total health expenditure per capita reached US$221 in 2012 . This compares to US$967 in the CIS (2012), US$1463 in the EU member states that joined the EU since 2004 and US$3852 in the EU member states that formed part of the EU before 2004 . Furthermore, there are large variations in per capita government expenditure on health across viloyats. Poorer viloyats generally spend less per capita on health than richer viloyats. For instance, in 2013, the per capita rate paid to primary care facilities in Navoi viloyat was twice the rate paid in Khorezm viloyat and about 50 percent higher than the national average. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“Just over half of total health expenditure (53.1 percent) in 2012 came from public sources, with private expenditure (mostly out-of-pocket payments) accounting for 46.9 percent (Table 3.1 and Fig. 3.4). According to these WHO estimates, the share of public sector expenditure in total health expenditure had increased from 44.6 percent in 2005 to 53.1 percent in 2012. In 1998, 72 percent of total government expenditure on health was spent on inpatient services and only 16 percent on outpatient services. By 2010, the share of total government expenditure devoted to inpatient services had decreased to 58 percent, while the share devoted to outpatient services had increased to 29 percent (Ministry of Health, 2014). ^=^

“The government pools and allocates public funding for health care. There is a distinct divide between national (republican) and subnational (viloyat, tuman or city) governments with regard to health financing. The national government is responsible for the financing of specialized medical centres, research institutes, emergency care centres and national-level hospitals. Regional and local governments are responsible for expenditures related to other hospitals, primary care units, sanitary-epidemiological units and ambulance services. Primary care in rural areas is now financed on a capitation basis and primary care in urban areas is expected to follow by 2015. Specialized outpatient and inpatient care is financed on the basis of past expenditures and inputs, as well as, increasingly, “self-financing”. ^=^

“Health workers in the public sector are salaried employees and paid according to strict state guidelines. However, there are efforts to increase the flexibility of health care providers in reimbursing health professionals. Salaries of physicians in the public sector ranged from US$ 300 to US$ 600 per month in 2014 and salaries of nurses are even lower. These salary levels are considered insufficient to cover the cost of living (although some providers on “self-financing” schemes are able to pay substantially better salaries). ^=^

Paying for Health Care Expenditures in Uzbekistan

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Health care provision has largely remained in public ownership but nearly half of total health care expenditure comes from private sources, mostly in the form of out-of-pocket expenditure. There is a basic benefits package, which includes primary care, emergency care and care for certain disease and population categories. Yet secondary care and outpatient pharmaceuticals are not included in the benefits package for most of the population, and the reliance on private health expenditure results in inequities and catastrophic expenditure for households. While the share of public expenditure is slowly increasing, financial protection thus remains an area of concern. Quality of care is another area that is receiving increasing attention. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“Payments for health services are both formal and informal. Formal payments have been increasingly introduced and now account for a major share of revenue, in particular for health facilities that are expected to finance themselves largely through user fees rather than allocations from the state budget. This approach is being increasingly encouraged for secondary and tertiary care facilities. There is also anecdotal and survey evidence of informal payments, in particular for secondary and tertiary care. Other sources of funds include technical assistance programmes by multilateral and bilateral agencies. ^=^

“The basic benefits package guaranteed by the government includes primary care, emergency care, care for “socially significant and hazardous” conditions (in particular major communicable diseases, plus some noncommunicable conditions such as poor mental health and cancer), and specialized (secondary and tertiary) care for groups of the population classified by the government as vulnerable. It thus excludes secondary and tertiary care for significant parts of the population. Pharmaceuticals for inpatient care that forms part of the basic benefits package are included in the package. Outpatient pharmaceuticals are not covered, except for 13 population categories, including veterans of the Second World War, HIV/AIDS patients, patients with diabetes or cancer, and single pensioners registered by support agencies. ^=^

Organization of the Health Care System in Uzbekistan

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Most health care providers in Uzbekistan are public. The state-run health system consists of three distinct hierarchical layers: the national (republican) level, the viloyat (regional) level, and the tuman (district) or city level. The private sector is still small and mainly comprises pharmacies, small practices, and institutions involved in health care delivery or the production and supply of pharmaceuticals or medical equipment. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“The Ministry of Health (with a total staff of 88) is the major player in organizing, planning and managing the Uzbek health system. Regulation remains the almost exclusive prerogative of the government, with little or no role played by nongovernmental organizations (NGOs) or professional associations. As the government-owned health system still largely follows the integrated model (with the government being the principal payer and provider of health services), almost all health workers are government-salaried employees. ^=^

“Although the government initially left the private sector free to develop, with only limited oversight, following an increase in unnecessary, unsafe or substandard care in the private sector, the government has significantly limited the type of services that can be provided in the private sector, in particular with regard to complex surgical procedures. Regulatory oversight has also been strengthened, allowing the Ministry of Health to conduct unannounced inspections. Patient rights and patient choice have been set out by law, but are still underdeveloped in actual practice. ^=^

Health Care Coverage in Uzbekistan

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Uzbekistan’s public health care system is nominally committed to universal coverage. The country’s constitution of 1992 provides that “everyone shall have the right to receive skilled medical care” (Republic of Uzbekistan, 1992). While the constitution guarantees access to all levels of care, it does not, in contrast to the Soviet constitution, guarantee that services are free. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“The Law on health protection of 1996 confirmed the right of citizens to health care. This right applies to all health services, including delivery, antenatal and neonatal care, paediatric services, immunization, family planning, outpatient services and specialized services. The state guarantees health protection irrespective of age, race, gender, ethnicity, religion, social status and beliefs (Republic of Uzbekistan, 1996). ^=^

“The 1996 Law on health protection defined the services to be funded by the state (the basic benefits package) and the services to be reimbursed from other sources of funding (complementary services). All citizens have universal state coverage for the basic benefits package. While residents are entitled to the same rights in accessing health services as citizens, the law states that foreigners are guaranteed health protection in line with the bilateral international treaties of which Uzbekistan is a signatory (Republic of Uzbekistan, 1996). Refugees and foreigners are eligible for free emergency services. ^=^

“While VHI has been set up in recent years by profit-making companies, no data are available on their market share in the utilization of health services, although anecdotal evidence suggests that they remain insignificant. ^=^

“Prisoners, soldiers and military personal have access to parallel health services which are run outside the framework of the Ministry of Health. For cases in which specialized care is not available within these parallel services, the Ministry of Health system can be utilized. The mechanisms and financing arrangements for these rare cases are defined in special agreements between the Ministry of Health and the respective agencies. ^=^

Benefits of Health Care Coverage in Uzbekistan

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “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 (Republic of Uzbekistan, 1996; Mamatkulov, 2013). It thus excludes secondary and tertiary care for significant parts of the population. Public providers offer the state-guaranteed package of medical services free of charge. All medical services outside the package are financed by non-public sources (Republic of Uzbekistan, 1996). Anecdotally, access to the basic benefits package is not fully utilized by high-income groups, who often opt for the private sector or utilize services under private arrangements. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“Pharmaceuticals for the period in which inpatient care is provided are covered by the guaranteed package, provided that the inpatient care provided forms part of the basic benefits package. Outpatient pharmaceuticals are not covered, except for 13 population categories, including veterans of the Second World War, HIV/AIDS patients, patients with diabetes or cancer, and single pensioners registered by support agencies (Cabinet of Ministers, 2013; Ministry of Health, 2013a). However, the extent to which the needs of these 13 groups are covered with regard to outpatient pharmaceuticals is not clear. ^=^

“The following range of primary care services are included in the basic benefits package: 1) management of prevalent and emergency conditions; 2) preventive and sanitary-epidemiological activities; 3) initiatives in family, maternal and child health. In 2004, as part of a document outlining the functions of primary care units, an explicit list of services covered in primary care was developed by the Ministry of Health (Ministry of Health, 2004). The document lists the conditions to be diagnosed and managed in primary care (such as chronic heart failure, bronchitis and diabetes), the diagnostic procedures to be used (such as electrocardiography), and the conditions that should be subject to rehabilitative services and continuous observation. The document also obliged primary care providers to offer health promotion and education on an individual basis. ^=^

“Another group of services included in the basic benefits package is emergency care. Although an extensive network of public sector emergency care units exists, every citizen has the legal right to obtain emergency services from any health care provider, irrespective of the form of ownership (Republic of Uzbekistan, 1996). The law stipulates that all medical and pharmaceutical professionals must provide emergency care when required; they could otherwise be held legally responsible. However, issues related to the reimbursement of services in the private sector or in public facilities that use mixed financing (i.e. a combination of government funding and user fees) have so far not been clarified. ^=^

Problems with the Uzbekistan Health Care System

Despite marked growth throughout the Soviet era, the public health care system in Uzbekistan is not equipped to deal with the special problems of a population long exposed to high levels of pollutants or with other health problems. Although the numbers of hospitals and doctors grew dramatically under Soviet rule--from almost no doctors in 1917 to 35.5 doctors per 10,000 population and to 1,388 hospitals and clinics per 10,000 population in 1991--the increasing incidence of serious disease raises questions about the effectiveness of care by these doctors and their facilities. [Source: Library of Congress, March 1996 *]

Among the serious problems plaguing health care delivery are the extremely short supply of vaccines and medicines in hospitals; the generally poor quality of medical training; and corruption in the medical profession, which exacerbates the negative impact of changes in the system for the average patient and diverts treatment to favored private patients. According to a 1995 private study, the state system provided less than 20 percent of needed medicine and less than 40 percent of needed medical care, and budget constraints limited salaries for medical professionals. In 1990 the percentage of children receiving vaccines for diphtheria, pertussis, measles, and polio averaged between 80 and 90 percent. That statistic fell sharply in the first years of independence; for example, in 1993 fewer than half the needed doses of measles vaccine were administered.

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “The years since independence have seen substantial reductions in the number of beds in acute care hospitals and further cuts are envisaged. In terms of acute care hospital beds per population, the country now ranks below the averages for the central Asian countries and the CIS. There has also been a decline in the number of physicians per population, which is now also below the average for the central Asian countries, while the number of nurses per population has remained largely constant in the last two decades and is now the highest in the central Asian region. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“Rigorous and comprehensive evaluations of the quality of care in primary care facilities are lacking. Quality evaluations are mainly limited to public facilities and focus mostly on structural aspects rather than outcomes, while process evaluations are generally not carried out. Structural evaluations of the state of health facilities and equipment are undertaken by agencies of the Ministry of Health. While no representative national survey to assess the quality of care has been conducted so far, anecdotal evidence suggests that many medical practices are outdated (Asadov & Aripov, 2009; Expert-Fikri, 2011; Ahmedov et al., 2012). ^=^

Informal Payments in the Uzbekistan Health Care System

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Although there is only limited hard evidence, anecdotally informal payments were already a feature of health care during the Soviet era. With the break-up of the Soviet Union, they have become more common throughout the region (Belli, Gotsadze & Shahriari, 2004). [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

“In Uzbekistan, informal payments can be defined as payments that go unregistered. Informal private practice by publicly employed physicians is a major reason for informal payments, supplementing the low official income of health professionals. In a household survey conducted in 2007, 42 percent of respondents reported to have made some kind of informal payment for health services. This included voluntary gifts (in kind or cash) or payments without a receipt (World Bank, 2009). ^=^

“Informal payments impede the utilization of health services, in particular for the poor. As they are more prevalent in secondary and tertiary care, poorer segments of the population face particular obstacles in accessing these levels of care. In addition, the existence of informal and formal payments can result in a poverty trap for those with serious illnesses. The likelihood of falling into impoverishment is quite high for those facing serious health problems in Uzbekistan (World Bank, 2003). ^=^

“The introduction of official user fees, the greater flexibility in the use of funds and the shift towards self-financing were expected to formalize and reduce the share of informal payments. The Ministry of Health has also endeavoured to address the general lack of awareness about new policies related to benefits, rights and obligations by drawing up a protocol that obliges all health care providers to inform patients on posters displayed in health care facilities about the benefits package and prices for chargeable services. However, it is unclear whether these policies and mechanisms have reduced informal payments. There are incentives for patients to receive informal services, since the overall fee negotiated directly between the patient and the provider could be lower than official charges (World Bank, 2003, 2009). ^=^

Reforming the Uzbekistan Health Care System

The Ministry of Health has identified the following as its priorities, should expansion of services become possible: improvement of maternal and infant health care, prevention of the spread of infectious disease, and improvement of environmental conditions leading to health problems. In 1995 Uzbekistan was receiving aid from the United States Agency for International Development (AID), the United Nations Children's Fund (UNICEF), and the World Health Organization (WHO) for improving infant and maternal health care and for storage and distribution of vaccines. [Source: Library of Congress, March 1996 *]

According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Over the past two decades, Uzbekistan has initiated several major health reforms, with the aim of improving health care provision, governance and financing. Areas of reform included primary care (initially in rural areas), secondary and tertiary care, and emergency care. Primary care has been changed from a multi-tiered to a two-tiered system, the training of GPs has been initiated and the financing of primary care is increasingly based on capitation. There are also efforts to introduce new approaches to maternal and child health, public health, noncommunicable disease prevention and control, and monitoring and evaluation. In secondary and tertiary care, capacities have been scaled back and new governance and financing arrangements for pilot tertiary care facilities introduced. Reforms of medical education have also been initiated. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]

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Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, U.S. government, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Foreign Policy, Wikipedia, BBC, CNN, and various books, websites and other publications.

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© 2008 Jeffrey Hays

Last updated April 2016

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