HEALTH CARE WORKERS IN UZBEKISTAN
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “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). [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 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. ^=^
“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). ^=^
“A perceived surplus of physicians in the early years of independence resulted in cutbacks in the enrolment of medical schools. The number of physicians per 100 000 population has declined since 1990 and is now slightly below the average for the central Asian countries. There has been no major reduction in the number of nurses per population and rates in Uzbekistan exceed regional averages. The number of dentists per 100 000 population has declined since 1990 and is now lower than in central Asia as a whole . The share of physicians working in hospitals declined from 63.8 percent in 1991 to 39.7 percent in 2000 and then increased to 45.3 percent in 2009 (WHO Regional Office for Europe, 2014a). However, there are significant disparities in the regional distribution of health care workers, with a concentration in urban areas and shortages in rural areas.
“The number of pharmacists per 100 000 population has been remarkably low since the second half of the 1990s (Fig. 4.7) and is at odds with an increase in the number of those graduating. This inconsistency might be due to the omission of pharmacists in the private sector (where most pharmacists are currently working) in governmental statistics. ^=^
Training of Health Workers in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “The major groups of health professionals in Uzbekistan are physicians, nurses, dentists and pharmacists. Public health professionals and managers in the health system are seen as one type of specialization within the group of physicians. All educational institutions involved in the training of health professionals in Uzbekistan are public. Currently, there is one medical academy, four medical schools and three regional branches, all of which are state-owned. Each of the four major professional groups follows a separate training pathway. Physician and dentistry training is provided in medical schools, while nursing schools provide basic nursing training. There are four main faculties for the training of medical doctors in medical schools: treatment (general medicine), treatment with an emphasis on teaching skills (pedagogy of general medicine), general paediatrics and sanitary-epidemiology. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“There is one medical academy, four medical schools and three regional branches, all of which are state-owned. Four main faculties for the training of medical doctors in medical schools exist: treatment (general medicine), treatment with an emphasis on teaching skills (pedagogy of general medicine), general paediatrics and sanitary-epidemiology. There are 72 professional colleges offering basic nursing training. Medical education has been revised, with an extension of undergraduate medical education from six to seven years and the replacement of early specialization with a more generalized orientation. Graduates are now qualified as general practitioners. The training of nurses has been extended to two years for nursing students with high school certificates and to three years for students with secondary school certificates. ^=^
Training of Doctors in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “After independence, a number of changes related to the framework and content of medical education were introduced in Uzbekistan. The duration of undergraduate medical education was extended from six to seven years. Early specialization has been replaced by an orientation towards generalization. Graduates are now qualified as GPs, in contrast to the three broad specializations in the Soviet period (internal medicine, surgery or obstetrics/gynaecology). In terms of content, medical education has been gradually moving from a training based on diseases to a training oriented towards symptoms or syndromes. The development of clinical skills was identified as another priority and new assessment tools for clinical skills have been introduced in all medical schools. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“At the postgraduate level, the Soviet clinical ordinatura (residency programmes in a sub-specialty) was planned to be replaced by a magistratura, which has a different duration and training structure. However, the clinical ordinatura framework is still largely in place. For the academic year 2013/2014, for instance, almost 1500 residency places were allocated (Ministry of Health, 2013b). ^=^
“The emphasis in the magistratura is on the combination of mentorship and didactic learning, with a unified content for all programmes. The duration of the magistratura varies between two and three years, depending on the specialty, and lasts three years for most clinical specialties. Magistratura graduates can work as specialists both in inpatient and outpatient care and are involved in teaching activities. Clinical ordinatura, on the other hand, is a two-year programme and has a much more flexible structure. It does not need to meet the strict requirements set for the magistratura. ^=^
“Graduates of the sanitary-epidemiological faculty follow a very similar track. Differences are mostly related to the course load and content, which is less clinically oriented. The duration of the programme is six years, and postgraduate training follows a structure similar to clinical medical education. ^=^
“Mandatory continuing medical education is based on the requirement of obtaining a minimum of 288 credit hours every five years, of which 144 hours need to come from attending a short training course (Ministry of Health, 2005; Cabinet of Ministers, 2009c). The Tashkent Institute for Postgraduate Medical Education is responsible for the development and delivery of courses in continuing medical education. There are also departments of continuing medical education in some regional medical schools, which serve as hubs for the surrounding regions. ^=^
“A set of documents, including evidence of credit hours, needs to be submitted to the Centre for Licensing and Attestation of Physicians and Pharmacists, along with a fee, for those planning to obtain categories (qualification grades) which are used to determine salary increases in state-owned facilities. ^=^
“For an advanced degree in nursing, higher nursing education has been introduced and new faculties were launched in medical schools. The prerequisite for admission to the new programme is a nursing diploma from professional colleges. In the programmes of higher nursing education, all students can choose one of four specialization courses in the last year of their studies: internal medicine, surgery, midwifery (obstetrics/gynaecology) and management. For those graduating from programmes of higher nursing education, it will be possible to pursue Master’s degrees in selected disciplines. Currently, a Master’s degree in Nursing Management is offered by medical schools. ^=^
Training of Midwives, Dentists and Pharmacists
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “As part of the reforms of medical education, all nursing schools have been transformed into community colleges for health professionals. Currently these colleges offer professional education in five specialties: general nursing, treatment and preventive medicine (assistants to epidemiologists), pharmacy, orthopaedic dentistry and laboratory diagnostics. The training duration has been extended to two years for nursing students with high school certificates and to three years for students with secondary school certificates. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“The framework for the continuing medical education of nurses is similar to that for physicians. The main entity responsible for the continuing medical education of nurses is the Republican Centre of Advanced Education and Specialization of Mid-level and Pharmaceutical Personnel, with 13 affiliated branches (one in each region). There is a mandatory requirement to attend continuing medical education courses at least once every five years, with a minimum duration of 144 hours. These courses are offered at 13 specialized regional centres for advanced medical education of mid-level health professionals. ^=^
“Dental education is provided by two medical schools in Uzbekistan, the Tashkent State Medical Academy and the Bukhara State Medical Institute. In recent years, it has been transformed into a two-level training programme, in line with the reforms in higher education. The first level consists of five years of undergraduate education, exposing students to general dentistry. The graduate level, magistratura, is a two-year programme which allows students to specialize in one of three broad areas: therapeutic, orthopaedic or surgical dentistry. ^=^
“Training in biotechnology and the pharmaceutical industry is provided in a four-year undergraduate programme. Pharmacy training follows two different programmes. In the first, students receive training only in pharmacy, while in the second they are also exposed to teaching skills, enabling graduates to hold teaching positions. Postgraduate pharmaceutical education consists of a two-year magistratura either in “technologies of immuno-biological and microbiological medicines” or in the “biotechnology of medicines”. ^=^
Health Care Services in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “In the area of public health, the sanitary-epidemiological services have retained their traditional focus on environmental health services, food safety and controlling communicable diseases. However, new players have emerged, including the separate and nationally-organized centres for HIV/AIDS, the Institute of Health and Medical Statistics, primary health care units, NGOs and international agencies (such as WHO, UNICEF [the United Nations Children’s Fund], UNFPA [the United Nations Population Fund] and the World Bank). [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“Primary care services are provided by public primary care facilities, outpatient clinics of public secondary and tertiary institutions, and private outpatient clinics. In rural areas, the first point of contact is the rural physician point, while secondary outpatient care is provided by outpatient clinics of central tuman hospitals. Four types of rural physician points have been determined, each with a specified number and type of personnel, space and equipment. In all cases, they are staffed by GPs, who lead the team efforts at the practice. ^=^
“Emergency care services have undergone significant reforms and a network of emergency departments has been organized throughout the country within the existing inpatient facilities at the local, regional and national level. Health reforms introduced the concept of formally free and accessible emergency care for all, which seems to have led to an overload of emergency services; this is also because the emergency care system is considered to be much better provided with equipment, medical aids and devices, and medications than other public health providers. ^=^
“In the area of pharmaceutical care, state pharmacies have now been almost completely privatized. The country has adopted a long-term strategy for self-sufficiency in essential drugs and blood products to overcome its reliance on expensive imports. A large share of expenditure on pharmaceuticals is paid privately. ^=^
Hospitals, Clinic and Health Care Facilities in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: ““In urban areas, primary health care and selected secondary care services are provided by polyclinics, with catchment populations of between 10 000 and 80 000 people. All types of polyclinics (previously separate for adults, children, and polyclinics specializing in women’s health) are currently being transformed into family polyclinics which provide primary care for all groups of the (urban) population. Specialists in urban family polyclinics are expected to be gradually replaced by general practitioners (GPs). [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“In rural areas, the first points of contact for patients seeking secondary care from the public sector are tuman hospitals or tuman medical unions (previously called central tuman hospitals) with multi-specialty outpatient units. In urban areas, viloyat and city multi-profile hospitals deliver inpatient care for the population. At viloyat level, many disease categories and population groups are treated in separate hospitals. These include children’s hospitals, tuberculosis hospitals, hospitals treating sexually transmitted and dermatological diseases, neurological and psychiatric hospitals, cardiology hospitals and hospitals for emergency care. Tertiary inpatient care is generally provided in large hospitals and research institutes and centres at the national level. Emergency care services have undergone significant reforms and a network of emergency departments has been organized throughout the country within the existing inpatient facilities at the tuman, viloyat and national level. ^=^
“In the area of pharmaceutical care, state pharmacies have now been almost completely privatized. The country has adopted a long-term strategy of increasing domestic drug production to overcome its reliance on expensive imports. A large share of expenditure on pharmaceuticals is paid privately. ^=^
Access to Health Care Facilities in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Patient pathways differ with regard to primary and secondary care. Patients can obtain free primary non-emergency care from: 1) 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; 2) 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: 1) outpatient units of secondary and tertiary care institutions, both at viloyat and national level; 2) private providers; 3) state providers when patients are seeking care outside their registered area of residence. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“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. 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 percent mark-ups on the costs), whereas private providers are free to set their prices. ^=^
“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: 1) 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: 2) 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. 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. Reimbursed care, however, should not exceed 20 percent of the total budget of the institution (for more information on reimbursement schemes. 3) 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. ^=^
Medical Equipment and Technology in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “The purchase and distribution of medical equipment, devices and aids does not have a unified institutional framework. Broadly, funds currently used for the purchase of medical equipment, devices and aids are either international loans, earmarked state funding, private capital in the private sector or, in the public sector, funds accumulated through fee-for-service schemes and sponsor initiatives. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“In the public sector, a major share of large-scale purchasing is conducted using international loans, when the purchasing process follows the stipulations outlined in the loan agreement. In most cases, the Ministry of Health acts as the purchaser, either through international bidding or local purchase. Equipment, devices and aids must be approved for sale in the Uzbek market by the Department of Quality Control of Pharmaceuticals and Medical Technologies under the Ministry of Health (the national regulatory authority). ^=^
“Health systems in the former Soviet countries have been slow in taking advantage of information technologies (IT). Major barriers to the application of these technologies in the Uzbek health system are the lack of access to IT hardware, the costs related to the development and application of software, and a lack of expertise, capacity and awareness. In Uzbekistan the use of IT in government-owned health institutions is very limited and mostly confined to basic electronic data collection and entry. No data are available with regard to the use of IT in the private sector. Health care users are not yet likely to use the Internet as a major tool for the selection of health care providers or for accessing health-related information, and Internet-based information or services are scarce in the Uzbek health system. However, many Russian-language Internet sites can be used by the country’s bilingual population. ^=^
“Recent government decrees are creating a strong impetus for the faster application of IT in state health care settings (Ministry of Health, 2012; President of Uzbekistan, 2012a). The establishment of an integrated national IT framework for the state health sector that links the Ministry of Health and viloyat and tuman health authorities is planned, to support reporting and information exchange. Electronic databases are planned to be implemented to coordinate emergency and ambulance care services, and to monitor and control selected infectious diseases, as well as blood transfusions. A number of health care providers are working on creating systems of electronic medical records at institutional level. The World Bank-funded health reform project and several donor-funded projects aim to establish nationwide electronic disease surveillance programmes
Drugs and Pharmaceutical Care in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “In the Soviet period, all inpatient pharmaceuticals were generally supplied by the state at no cost to the end users, whereas outpatient pharmaceuticals were either covered by the state or available over the counter at centrally set and controlled prices. After Uzbekistan’s independence, reform initiatives have limited state coverage for outpatient pharmaceuticals to a defined set of conditions and population groups (Cabinet of Ministers, 1997b). Anecdotally, most expenses for outpatient pharmaceuticals are covered by direct patient payments, although no reliable data on the share of different types of payments are currently available. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“Since independence, Uzbekistan has faced the challenge of maintaining the supply of drugs and vaccines, while developing and implementing its own national drug policy. The gradual development of a national drug policy resulted in a clear division of the roles of the government and the private sector. The government maintained mostly regulatory functions, while production and distribution were delegated to the private sector. ^=^
“Uzbekistan inherited a well-developed drug distribution system from the Soviet period. This included the centralized state pharmacy (Farmatsija) system and its regional divisions and pharmacies (Ilkhamov, Jakubowski & Hajioff, 2001). State pharmacies are now almost completely privatized, either as part of a joint shareholding association (Dori-Darmon, the former sole drug distributor), or as a single or group pharmacy. The relative success of privatization has helped to ensure competition and provided new opportunities for circumventing the shortages of foreign drugs. However, it is difficult to obtain up-to-date data on operational private pharmacies (such as their number or scope), as they are outside the framework of the Ministry of Health and do not report to any of the Ministry of Health agencies. ^=^
“Dori-Darmon has traditionally been the main source of drugs for hospitals, but the share of private distributors has recently been growing. Each hospital places an annual order with Dori-Darmon, and deliveries are normally made on a weekly basis. Private sector supply is based on individual negotiations. Private drug distributors also supply drugs to pharmacies, polyclinics and private practices. Vaccines for the public sector are directly distributed by the sanitary-epidemiological services. ^=^
“Telemedicine has been introduced in recent years with international support. Four tertiary care institutions have been linked, giving them the option of video consultation in complex clinical situations. There are plans to link all emergency units in the country, enabling them to consult the national centre in real time when faced with complex clinical situations.
Types of Health Care Found at Uzbekistan Clinics
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “In rural areas, the first point of contact was historically the FAP, providing access to basic health care services to a catchment population of between 600 and 3000. Staff provided basic curative, antenatal and postnatal care and undertook limited disease prevention and health promotion activities, such as immunization and health education. The posts were staffed by up to three health care workers, usually including a feldsher and a midwife. The next level of services in rural areas, rural outpatient clinics, were staffed with an average of four physicians. They usually included a specialist in internal medicine, a paediatrician, an obstetrician and a dentist. The third level of primary care consisted of the outpatient clinics of rural territorial or central tuman hospitals. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“This structure has been largely replaced by a two-tiered system, although a limited number of FAPs still exist. The first point of contact is the rural physician point, while secondary outpatient care is provided by outpatient clinics of central tuman hospitals. The number of primary care staff in this new “model” is determined by the size of the population covered. Four types of rural physician points have been determined, each with a specified number and type of personnel, space and equipment: level one will employ one physician to serve a catchment area of 1500–2500 inhabitants; level two will employ two physicians and serve 2500–3500 inhabitants; level three will provide three or more physicians to serve 3500–5500 inhabitants; and level four would represent a rural medical centre for training and education with 7–10 physicians. The number of training medical centres in rural areas is planned to be limited to one or two per viloyat. They will serve as education centres in general practice for physicians and nurses. ^=^
“In contrast to the previously existing teams of specialists, rural physician points are staffed by GPs, who lead the team efforts at the practice. Specialist physicians are being retrained to become GPs. It is envisaged that GPs will be the first point providers of primary health care in urban and rural areas in state health facilities. In urban areas, primary health care and selected secondary care services are provided by polyclinics, with catchment populations of between 10 000 and 80 000 people. There used to be several types of polyclinics – for adults, children, and polyclinics specializing in women’s health. Recent trends in introducing general practice in rural areas are being replicated in urban areas. All types of polyclinics are currently being transformed into family polyclinics which provide primary care for all groups of the population. Polyclinic staff previously consisted of specialists in internal medicine, paediatricians and other specialists. These specialists in urban family polyclinics are expected to be gradually replaced by GPs and, currently, specialists work alongside GPs. However, similar to the rural primary care model, tuman multi-specialty polyclinics will be staffed by specialists to whom GPs can refer difficult cases. ^=^
“Screening is a key function of primary care units. Primary care physicians should conduct regular screenings of different segments of the population, such as school children or pregnant women. Besides, screening is required by many employers in order to employ staff or by institutions of higher education as a part of the application process. These screenings, however, are not specific enough, are often supposed to cover a broad range of conditions, and may not always be the most cost-effective or efficient clinical practice. ^=^
“Medical documentation is primarily paper-based. No comprehensive evaluations of work processes in primary health care with the aim of improving efficiency and patient satisfaction seem to have been carried out. However, the most recent report by the Ministry of Health working group on the implementation of primary care reform has covered some aspects of work processes in primary care settings. Its recommendations included, for instance, improvements to patient waiting areas, new arrangements for booking appointments and revising reporting documents (Ministry of Health, 2007). However, it is unclear if any of these recommendations have been addressed
Maternal and Child Health Care in Uzbekistan
According to Azimov, Mutalova, Huseynov, Tsoyi, Rechel: “Almost all services for maternal and child health are provided in the public sector. Inpatient services are provided by maternity or children’s hospitals or departments for the population in the respective catchment area. At the tuman level, services for maternal and child health are provided as part of primary care either by GPs or by specialists (paediatricians or obstetriciansgynaecologists) at central tuman hospitals. More specialized care is provided at viloyat and national level, typically by stand-alone facilities with outpatient and inpatient units. [Source: “Uzbekistan: Health System Review” by Azimov, Mutalova, Huseynov, Tsoyi, Rechel, Health Systems in Transition, 2014 ^=^]
“The maternity care hospitals or departments are divided into a unit for pregnant women (which includes beds for normal deliveries and postnatal care) and a unit dealing with complications. The new structure of maternal health care also introduced a vertically integrated management and monitoring framework for maternal and child health, and respective departments are organized within viloyat health authorities and the Ministry of Health. The departments coordinate, manage and monitor the activities of all maternity and children’s hospitals and related services. ^=^
“Maternal and child health, including antenatal care, form part of the guaranteed package of services. A number of preventive and screening protocols were developed by the Ministry of Health and are strictly implemented nationwide. According to the protocols of the Ministry of Health, pregnancies are registered in the first three months, with subsequent monthly checks and examinations until delivery. Neonatal care starts from the first day of life in delivery departments. In the first two years, the child is regularly examined by the primary care provider at set time intervals established by the Ministry of Health. ^=^
“Rural physician points and polyclinics have a special registry for women of reproductive age and provide regular check-ups and screenings. All cases are first managed by primary care providers. When the primary care provider deems it necessary, patients are referred to the next level of care. In rural areas, the next level might consist of specialists at central polyclinics or maternity hospitals or units. In urban areas, polyclinics employ obstetricians/ gynaecologists. Specialized outpatient care can therefore be provided at the primary care institution itself. Cases requiring inpatient care are referred to urban inpatient facilities for maternal care. Child care follows the same pathway in the public framework with public primary care providers being the first points of contact. When required, children will be referred to paediatric hospitals. ^=^
“As a result of high infant and maternal mortality rates (see Chapter 1), maternal and child care have become one of the main governmental priorities in the health sector. A number of governmental programmes were developed with the aim of decreasing infant and maternal mortality, including a family planning programme. Furthermore, maternity and child health screening centres were established throughout the country and teams specialized in resuscitation and haemostasis were established at all viloyat centres. Extensive international support was provided for these and other initiatives. UNICEF, UNFPA, USAID and WHO assisted in the piloting of promotional and educational programmes, such as Safe Motherhood, Safe Vaccination and Breastfeeding (Borchert et al., 2010). ^=^
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Last updated April 2016