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Uzbekistan: health system review

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Vol. 9 No. 3 2007

Mohir Ahmedov • Ravshan Azimov Vasila Alimova • Bernd Rechel

Editor: Bernd Rechel

Health Systems in Transition

Uzbekistan Health system review

Editorial Board

Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom and European Observatory on Health Systems and Policies

Editors Reinhard Busse, Berlin Technical University, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom and European Observatory on Health Systems and Policies Richard Saltman, Emory University, United States

Editorial team Sara Allin, European Observatory on Health Systems and Policies Olga Avdeeva, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies

International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Imperial College London, United Kingdom Johan Calltorp, Swedish Association of Local Authorities and Regions, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, London School of Hygiene and Tropical Medicine, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russia Peter C. Smith, University of York, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland

The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

2007

Health Systems in Transition

Written by Mohir Ahmedov Ravshan Azimov, School of Public Health, Tashkent

Vasila Alimova, Ministry of Health, Tashkent

Bernd Rechel, European Observatory on Health Systems and Policies

Edited by Bernd Rechel, European Observatory on Health Systems and Policies

Uzbekistan: Health System Review

© World Health Organization 2007, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full.

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Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/PubRequest

The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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Keywords: DELIVERY OF HEALTH CARE

EVALUATION STUDIES

FINANCING, HEALTH

HEALTH CARE REFORM

HEALTH SYSTEM PLANS – organization and administration

UZBEKISTAN

ISSN 1817-6127 Vol. 9 No. 3

Suggested citation: Ahmedov M, Azimov R, Alimova V, Rechel B. Uzbekistan: Health system review. Health Systems in Transition, 2007; 9(3): 1–210.

Printed and bound in the United Kingdom by TJ International, Padstow, Cornwall.

http://www.euro.who.int/PubRequest

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Contents

Preface ............................................................................................................ v Acknowledgements ...................................................................................... vii List of abbreviations...................................................................................... ix List of tables and figures ............................................................................... xi Abstract ........................................................................................................ xv Executive summary .................................................................................... xvii 1. Introduction ......................................................................................... 1 1.1 Geography and sociodemography .............................................. 1 1.2 Economic context ....................................................................... 2 1.3 Political context .......................................................................... 4 1.4 Health status ............................................................................... 6 2. Organizational structure ..................................................................... 19 2.1 Overview of the health system ................................................. 19 2.2 Historical background .............................................................. 21 2.3 Organizational overview ........................................................... 25 2.4 Decentralization and centralization .......................................... 31 2.5 Patient empowerment ............................................................... 32 3. Financing ........................................................................................... 37 3.1 Health expenditure ................................................................... 39 3.2 Population coverage and basis for entitlement ......................... 45 3.3 Revenue collection/sources of funds ........................................ 50 3.4 Pooling of funds ....................................................................... 58 3.5 Purchasing and purchaser–provider relations........................... 63 3.6 Payment mechanisms ............................................................... 65 4. Planning and regulation ..................................................................... 71 4.1 Regulation ................................................................................ 72 4.2 Planning and health information management ......................... 79

Health systems in transition Uzbekistan

5. Physical and human resources ........................................................... 87 5.1 Physical resources .................................................................... 87 5.2 Human resources ...................................................................... 97 6. Provision of services ........................................................................ 115 6.1 Public health ........................................................................... 115 6.2 Patient pathways ..................................................................... 120 6.3 Primary/ambulatory care ........................................................ 120 6.4 Specialized ambulatory care/inpatient care ............................ 127 6.5 Emergency care ...................................................................... 131 6.6 Pharmaceutical care ................................................................ 133 6.7 Rehabilitation/intermediate care ............................................ 137 6.8 Long-term care ....................................................................... 138 6.9 Services for informal carers ................................................... 138 6.10 Mental health care .................................................................. 138 6.11 Dental health care ................................................................... 141 6.12 Alternative/complementary medicine .................................... 145 6.13 Health care for specific populations ....................................... 146 6.14 Maternal and child health ....................................................... 146 7. Principal health care reforms ........................................................... 151 7.1 Analysis of recent reforms ..................................................... 151 8. Assessment of the health system ..................................................... 177 8.1 The stated objectives of the health system ............................. 177 8.2 Access to health services ........................................................ 178 8.3 Equity issues ........................................................................... 182 8.4 Quality of health services ....................................................... 183 8.5 Efficiency of the health system .............................................. 184 9. Conclusions ..................................................................................... 189 10. Appendices ...................................................................................... 193 10.1 References .............................................................................. 193 10.2 Useful web sites ..................................................................... 200 10.3 Principal legislation ................................................................ 201 10.4 HiT methodology and production process ............................. 203 10.5 About the authors ................................................................... 206

UzbekistanHealth systems in transition

Preface

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific

country. Each profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile.

HiT profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used:

to learn in detail about different approaches to the organization, financing • and delivery of health services and the role of the main actors in health systems;

to describe the institutional framework, the process, content and • implementation of health care reform programmes;

to highlight challenges and areas that require more in-depth analysis; •

to provide a tool for the dissemination of information on health systems and • the exchange of experiences of reform strategies between policy-makers and analysts in different countries.

Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the World Health Organization (WHO) Regional Office for Europe Health for All database, national statistical offices, Eurostat, the Organisation for Economic

Health systems in transition Uzbekistan

Co-operation and Development (OECD) Health Data, the International Monetary Fund (IMF), the World Bank, and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series.

A standardized profile has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals.

Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to: info@obs.euro.who.int.

HiT profiles and HiT summaries are available on the Observatory’s web site at www.euro.who.int/observatory. A glossary of terms used in the profiles can be found at the following web page: www.euro.who.int/observatory/glossary/ toppage.

mailto:info@obs.euro.who.int http://www.euro.who.int/observatory http://www.euro.who.int/observatory/glossary/toppage

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Acknowledgements

The Health Systems in Transition (HiT) profile on Uzbekistan was written by Mohir Ahmedov, Ravshan Azimov (School of Public Health, Tashkent), Vasila Alimova (Ministry of Health) and Bernd Rechel

(European Observatory on Health Systems and Policies). The HiT was edited by Bernd Rechel (European Observatory on Health Systems and Policies). The research director for the Uzbek HiT was Martin McKee.

The following people provided critical input to different sections: Bahtiyor Khashimov, Ahror Yarkulov, Zulhumor Mutalova, Parahat Menlikulov, Klara Yadgarova and Subrata Routh. Special thanks go to Abduhakim Hadjibaev (First Deputy Minister of Health) and Shuhrat Hashimov (Head of Department, Ministry of Health) for their support, their assistance in the data collection, and their helpful comments on the entire manuscript.

The European Observatory on Health Systems and Policies is grateful to Bruno Bouchet (World Health Organization), Peter Campbell (USAID ZdravPlus project), Jack Langenbrunner (World Bank), and Subrata Routh (USAID ZdravPlus project) for reviewing the report and to the Ministry of Health for their kind support.

The current series of HiT profiles has been prepared by the research directors and staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

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The Observatory team is led by Josep Figueras, Director, and Elias Mossialos, Co-director, and by Martin McKee, Richard Saltman and Reinhard Busse, heads of the research hubs.

Giovanna Ceroni and Jonathan North managed the production and copy- editing, with help from Nicole Satterley and with the support of Shirley and Johannes Frederiksen (layout). Administrative support for preparing the HiT profile on Uzbekistan was undertaken by Caroline White.

Special thanks are extended to the WHO European Health for All database, from which data on health services were extracted; to the OECD for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. Thanks are also due to national statistical offices which have provided national data.

The HiT reflects data available in May 2007.

UzbekistanHealth systems in transition

List of abbreviations

CARK Central Asian Republics and Kazakhstan

CDC (United States) Centers for Disease Control

CIS Commonwealth of Independent States

CRB Central rayon hospital

DFID (United Kingdom) Department for International Development

DHS Demographic and Health (Examination) Survey

DOTS Directly Observed Treatment Short-course

DRG Diagnosis-related group

DTP Diphtheria, tetanus, pertussis

EU European Union

EU15 Countries constituting the European Union before May 2004

EU25 Countries constituting the European Union after May 2004

FAP Feldsher-accoucheur point

GAIN Global Alliance for Improved Nutrition

GDP Gross domestic product

GMP Good Medical Practice

GNP Gross national product

GP General practitioner

HINARI Health InterNetwork Access to Research Initiative

HIV/AIDS Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome

IAEA International Atomic Energy Agency

IMF International Monetary Fund

IT Information technologies

JICA Japanese International Corporation Agency

KfW German Bank for Reconstruction and Development

LCU Local Currency Unit

MDS Medical Diagnostics Services (clinic – private provider)

MICS Multiple Indicator Cluster Survey

NGO Nongovernmental organization

NICE National Institute for Health and Clinical Excellence

Health systems in transition Uzbekistan

NIS Newly independent states

OECD Organisation for Economic Co-operation and Development

PPP Purchasing Power Parity

SRI Scientific Research Institute

STI Sexually transmitted infection

SUB Small local community hospital

SVA Small rural ambulatory facility

SVP Rural primary care unit (rural physician point)

TB Tuberculosis

UHES Uzbekistan Health Examination Survey

UNAIDS Joint United Nations Programme on HIV/AIDS

UNDP United Nations Development Programme

UNESCO United Nations Educational, Scientific and Cultural Organization

UNFPA United Nations Population Fund

UNIC Uzbekinvest National Export-Import Insurance Company

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

VAT Value-added tax

WHO World Health Organization

UzbekistanHealth systems in transition

List of tables and figures

Tables

Table 1.1 Population/demographic indicators, 1970, 1980, 1990, 2000, 2003–2005 3

Table 1.2 Macroeconomic indicators, 1995–2005 (selected years) 4

Table 1.3 Mortality and health indicators, 1970–2005 (selected years) 8

Table 1.4 Estimated deaths per 100 000 population by cause, 2002 9

Table 1.5 Healthy life expectancy indicators, 2000–2002 10

Table 1.6 Percentage of children aged 12–23 months vaccinated against childhood diseases, 2000 (percentages)

Table 1.7 Decayed, missing or filled teeth at age 12, 1990, 1995, 2000, 2001 13

Table 1.8 Incidence of anaemia among females per 1000 population, first time diagnosis, 1999 and 2000

Table 1.9 Pure alcohol consumption, litres per capita per year, Uzbekistan and selected countries, 1990, 1995, 2000–2003

Table 3.1 Trends in health expenditure, 1994–2005 (selected years) 39

Table 3.2 Health care expenditure (in million soms), national budget 2003 42

Table 3.3 Health care expenditure (in million soms), national budget 2004 42

Table 3.4 Health care expenditure (in million soms), national budget 2005 43

Table 3.5 Public health expenditure by type of service, in million soms, 1999–2005 44

Table 3.6 Public health expenditure by type of service as a percentage of total health expenditure, 1999–2005

Table 3.7 Public expenditure for medical services by source of funding, in million soms, 1999–2005

Table 3.8 Public expenditure for medical services by source of funding, as a percentage of total health expenditure, 1999–2005

Table 3.9 Population groups eligible for free tertiary care at four piloted public tertiary care providers

Table 3.10 Population and disease groups exempted from inpatient meal charges at public health care providers

Table 3.11 Share of paid services and paid inpatient meals in total public health expenditure, million soms and percentages, 1999–2005

Table 3.12 Examples of informal payments in cash, in soms 56

Table 3.13 Distribution of population paying for health services, by income groups 56

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Table 3.14 Major completed international health sector programmes/projects 59

Table 3.15 Major ongoing or planned international health sector programmes/ projects

Table 3.16 Health financing: division by level of government 61

Table 5.1 Expenditures for outpatient pharmaceuticals for covered groups of the population, in thousand soms and percentages, 2003–2005

Table 5.2 Health care personnel per 1000 population, 1980–2005 (selected years) 99

Table 7.1 Major health care reforms and policy measures 153

Table 7.2 Selected indicators from the evaluations of primary care facilities in 1999 and 2004

159

Table 7.3 Division of project activities by areas and external donors 166

Table 7.4 Performance indicators for the “Health II” project (World Bank) 169

Table 7.5 Performance indicators for the Woman and Child Health Development Project (Asian Development Bank)

172

Figures

Fig. 1.1 Map of Uzbekistan 2

Fig. 1.2 Officially recorded life expectancy in Uzbekistan, CIS, CARK and EU15, 1971–2005

Fig. 1.3 Officially recorded and estimated life expectancy at birth, 1990–2005 8

Fig. 1.4 Officially recorded maternal deaths per 100 000 live births, Uzbekistan, EU15, CIS, CARK, 1980–2005

Fig. 1.5 Tuberculosis incidence per 100 000, Uzbekistan, EU15, CIS, CARK, 1980–2004

Fig. 2.1 Overview chart of the health system 21

Fig. 2.2 Structure of the Ministry of Health 27

Fig. 2.3 Structural framework of oblast health authorities 31

Fig. 3.1 Financial flows in the Uzbek health system 38

Fig. 3.2 Health expenditure as a share (%) of GDP in the WHO European Region, 2004, WHO estimates

Fig. 3.3 Trends in health expenditure as a share (%) of GDP in Uzbekistan, CIS, CARK and EU15, 1998–2004, WHO estimates

Fig. 3.4 Public expenditure for medical services by type of service (in percentages), 1999–2005

Fig. 3.5 Per capita public expenditure on health by oblast, as a percentage of average, 2003

Fig. 3.6 Estimated monthly wages for health care workers following the 2006 reforms

Fig. 5.1 Acute hospital beds per 1000 population in Uzbekistan, CIS, CARK and EU15, 1990 and 2005

Fig. 5.2 Beds in acute hospitals per 1000 population in Uzbekistan, CIS and selected averages, 1990 and 2005 (available years in parentheses)

Fig. 5.3 Psychiatric hospital beds per 100 000, 1990–2005 91

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Fig. 5.4 Physicians per 1000 population in Uzbekistan, CIS, CARK and EU15, full-time equivalent, 1990–2005

Fig. 5.5 Number of dentists per 1000 population in Uzbekistan, CIS and CARK, full-time equivalent, 1990–2005

101

Fig. 5.6 Number of pharmacists per 1000 population in Uzbekistan, CIS, CARK and EU15, 1990–2005

102

Fig. 5.7 Number of nurses (full-time equivalent) per 1000 population in Uzbekistan, CIS and CARK, 1990–2005

103

Fig. 5.8 Educational framework in Uzbekistan 105

Fig. 6.1 Structure of the Sanitary-Epidemiological Services 117

Fig. 6.2 Outpatient contacts per person in the WHO European Region, 2005 or latest available year (in parentheses)

123

Fig. 6.3 Hospital types in rural and urban areas 128

Fig. 6.4 Organizational structure of the Department for Quality Assurance of Drugs and Medical Equipment

134

Fig. 7.1 The multi-tiered Soviet primary care model (top) and the new two-tiered model (bottom)

156

Fig. 7.2 Primary care financing as a share of rayon health budgets, Ferghana oblast, 1999–2004

163

Fig. 8.1 The production process in health systems 186

UzbekistanHealth systems in transition

Abstract

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different

approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis.

The Uzbek health system has undergone significant changes since the country became independent in 1991. While Uzbekistan has made progress in the restructuring of different layers of health services with an increased emphasis on primary care, the coordination of different levels of care remains a major challenge. The establishment of a state-guaranteed benefits package was an important element of health reforms. However, a number of essential services were left outside the state-guaranteed benefits package for the majority of the population, including secondary and tertiary services and outpatient pharmaceuticals. This has created many challenges, such as increasing the pressure on emergency services, which are comparatively well equipped and formally free of charge. Overall, access to secondary and tertiary care seems to have deteriorated in recent years and out-of-pocket payments (both formal and informal) present a major barrier to accessing health services and pharmaceuticals, in particular for low-income groups. In addition, there are significant differences in terms of per capita health expenditure across regions and many rural physician points face staffing shortages. Quality improvement is another major challenge for the Uzbek health system and initial quality improvement initiatives are now being undertaken.

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Executive summary

The Uzbek health system has undergone significant changes since the country became independent in 1991. Although a number of health programmes and projects have been documented, a comprehensive

and up-to-date description and evaluation of the Uzbek health system has so far been lacking. This country profile aims to provide an outline of the health system in Uzbekistan in accordance with the guidelines developed for the Health Systems in Transition (HiT) series by the European Observatory on Health Systems and Policies.

The first chapter provides a brief overview of the Uzbek health system, placing it in the context of a transition economy with changing demographics, politics and health indicators. This chapter also describes recent changes to the political system, including the introduction of a bicameral Parliament. The chapter further outlines the health status of Uzbekistan’s population and provides information on a range of health indicators, such as causes of mortality and the prevalence and incidence of selected infectious conditions.

The second chapter describes the organizational structure of the Uzbek health system. It begins by outlining the overview of the health system and its key historical developments, with a particular focus on the Soviet health system, which continues to shape the reform trajectory of the Uzbek health system. The chapter then sets out the current organizational structure of the public health system, which is the dominant mode of health care provision, as the organized private health sector is still in the process of developing. The chapter concludes by discussing issues of patient empowerment.

Chapter 3 focuses on financial aspects, providing an overall picture of health spending and revenue sources in Uzbekistan. While taxation remains the main source of health financing, new revenue sources have emerged in recent years, including out-of-pocket payments, voluntary health insurance and international

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development assistance. The final part of this chapter describes pooling agencies and disbursement mechanisms, focusing mostly on the disbursement and reimbursement mechanisms in the public sector, as little public funding is directed towards private health care providers.

The fourth chapter deals with regulatory aspects of the Uzbek health system. As the private sector is subject to little regulation, the main focus of this chapter is the regulatory framework for the public sector, which is described from three perspectives: the national, local and provider levels. Health technology assessment as a regulatory tool is still at an early stage of development in Uzbekistan. While health system data are key to regulatory processes, health- related information in Uzbekistan is currently collected by five separate data- collection systems and continues to be tailored towards the quantitative planning and control functions of governmental health authorities. This chapter provides details of the main data-collection system, which is managed by the Institute of Health, and concludes by exploring the framework for public research funding, which has undergone significant changes since 2002.

Chapter 5 focuses on the physical resources of the Uzbek health system. It outlines the framework for capital investments and provides information on the current use of information technologies (IT) in Uzbekistan’s health sector. In 2002, only 0.3% of the population owned computers and there were overall only approximately 55 000 Internet users. However, this situation is changing rapidly, as both the Internet and other IT become more accessible, and as the Government facilitates the expansion of IT. By September 2006, there were approximately 1.4 million Internet users (a 30-fold increase since 2002) and approximately 2 million mobile phone users (a 10-fold increase since 2002) (UzA 2006b; Communications and Information Agency of Uzbekistan 2006). The chapter proceeds to describe the framework for the procurement of medical equipment, devices and pharmaceuticals, which follows different paths in the public and private sectors. It concludes by describing human resource trends and by detailing the training paths for different groups of health professionals (physicians, nurses, pharmacists and dentists) and the framework for registration and licensing.

Chapter 6 discusses the delivery of health services and provides in-depth information about public health services; primary, secondary and tertiary care; pharmaceuticals; mental health care; maternal and child health; and dental care. This reviews health care delivery in the public and private sector, referral processes, patient pathways and the quality of care.

Chapter 7 presents the major reform initiatives in the Uzbek health system. A new vision for the Uzbek health sector was outlined in two major documents: the “Law on Health Protection” of 1996 (Republic of Uzbekistan 1996) and the

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“Presidential Decree on the State Programme for the Reform of the Health Care System of Uzbekistan” of 1998 (President of Uzbekistan 1998). Subsequent government initiatives in the health sector aimed to achieve the objectives set out in these two documents. After detailing the main points of these key documents, the chapter concludes by analysing the reform processes with regard to primary, secondary, tertiary and emergency care.

The assessment of health systems can make use of a range of different criteria or indicators. Although no health system excels according to all criteria, a regular assessment can help to redirect resources and efforts to those aspects of the health system that could be improved. Chapter 8 assesses the Uzbek health system using criteria such as access and coverage, equity, and allocative and technical efficiency.

Access and coverage can be considered in terms of geographical access, financial access and the overall quality of services provided. Uzbekistan is currently restructuring its network of primary care facilities, which should improve geographical access to quality primary care services for all strata of the population. At the same time, however, inpatient and specialized care have become less accessible, in particular in rural areas. In the period between 1997 and 2003, overall bed capacity was reduced by 50%, with a reduction of the number of hospitals in rural areas by 50% and in urban areas by 20%. Although financing reforms resulted in the establishment of a state-financed basic benefits package, the costs for services outside the basic benefits package have been shifted to individual users, as third-party pooling systems are not in place in Uzbekistan. This has reduced access to services outside the package, such as tertiary or inpatient care and outpatient pharmaceuticals.

Chapter 8 proceeds by considering equity from a horizontal and vertical perspective and explores the efficiency of resource allocations, which differ for the public and private health sectors and for different levels of care. While the public sector follows established protocols and guidelines, allocation in the private sector relies on market forces, that is, demand and the ability to pay. The chapter concludes by exploring technical efficiency according to both quantitative and qualitative approaches. However, in Uzbekistan, as in many other countries of the region, there is a lack of data on the efficiency of health services and systems, so that conclusions have to remain, to some degree, tentative.

The final chapter summarizes the future challenges facing the Uzbek health system. While the country has made progress in the restructuring of different layers of health services, such as primary care, emergency care, and secondary and tertiary care, the coordination of different levels of care remains a major challenge. A more holistic approach to care delivery processes and training

Health systems in transition Uzbekistan

programmes would result in improved efficiency and better health outcomes. A reform of the financing and information system, linking resource flows to performance, would be crucial to realize the full potential of investments made at the various levels of care. It would also necessitate quality improvements, which could be facilitated by development and effective dissemination of appropriate guidelines; a shift in medical education from factual knowledge to self-learning skills, continuing professional development, a strong emphasis on English proficiency, and health information systems that would allow the continuous monitoring and evaluation of appropriate quality indicators. At present, reforms in the Uzbek health system have reduced access to health services outside the state-financed basic benefits package. The development of pooling schemes and third-party payers would be useful for improving access to health services, and for strengthening the efficiency and equity of the country’s health system.

UzbekistanHealth systems in transition

1 Introduction

1.1 Geography and sociodemography

Uzbekistan is a landlocked country located in central Asia (see Fig. 1.1). It is bordered to the north and north-east by Kazakhstan, to the west and south-west by Turkmenistan, to the south by Afghanistan and to

the east by Tajikistan and Kyrgyzstan. Uzbekistan’s territory is 447 400 km2. Its terrain is a combination of sandy deserts, intensely irrigated river valleys and mountains. The climate is continental, with long hot summers and short mild winters.

Since the 1970s, Uzbekistan’s population has more than doubled. The most recent estimates put the total population at 27 million (UNFPA 2006). The high population growth rates that occurred in the 1970s, however, have gradually decreased and population growth was 1.5% in 2005. This change can be primarily attributed to decreasing birth and fertility rates, as death rates slightly declined. The declining population growth is reflected in a changing demographic structure and age–dependency ratio. The share of the population aged 0–14 decreased from 45% of the total population in 1970 to 33.2% in 2005, while the age–dependency ratio declined by 40% over the same period.

Despite these demographic developments, the pressures on the health system that arise from an ageing population in many countries in western Europe do not seem to be currently in place in Uzbekistan. The share of the population over 65 years of age has decreased from 5.9% in 1970 to 4.7% in 2005. However, the overall demographic trends imply an ageing of Uzbekistan’s population in the long run (Table 1.1).

Uzbekistan is a multiethnic country. It has been estimated that in 1996, 80% of the population were ethnic Uzbeks, 5.5% Russians, 5% Tajiks, 3% Kazakhs, 2.5% Karakalpaks and 1.5% Tatars, with the remaining 2.5%

Health systems in transition Uzbekistan

Fig. 1.1 Map of Uzbekistan

Source: United Nations Cartographic Section, 2007.

belonging to smaller ethnic groups (CIA 2006). It can be assumed that the ethnic composition of Uzbekistan’s population has changed since then, as the country has experienced significant emigration, in particular of Russian- speaking residents.

In terms of religious affiliation, most of the population identify themselves as Muslims (88%, mostly Sunnis). Other religious groups represented in Uzbekistan are Eastern Orthodox Christians (9%) and Jews (3%) (CIA 2006). The majority of the population (63%) live in rural areas (CIA 2006; Republic of Uzbekistan 2007b).

UzbekistanHealth systems in transition

Table 1.1 Population/demographic indicators, 1970, 1980, 1990, 2000, 2003–2005

1970 1980 1990 2000 2003 2004 2005 Age–dependency ratio (dependants to working-age population)

1.0 0.8 0.8 0.7 0.7 0.6 0.6

Birth rate, crude (per 1000 people)

– 33.9 33.7 22.2 – – 19.9

Death rate, crude (per 1000 people)

– 7.5 6.1 6.1 – – 6.4

Fertility rate, total (births per woman)

5.6 4.8 4.1 2.6 2.3 2.3 2.2

Population ages 0–14 (% of total)

45.2 40.9 40.9 37.2 34.8 34.0 33.2

Population ages 65 and above (% of total)

5.9 5.1 4.0 4.3 4.6 4.7 4.7

Population density (people per km2)

28.1 37.5 48.2 57.9 60.1 60.8 61.5

Population growth (annual %)

3.1 2.6 2.4 1.0 1.2 1.2 1.2

Population, total (million)

12.0 16.0 20.5 24.7 25.6 25.9 26.6

Source: World Bank, 2007.

1.2 Economic context

Uzbekistan’s economy is mostly oriented towards services and agriculture, with a small share of gross domestic product (GDP) generated by industry. Despite being a dry and landlocked country, 11% of Uzbekistan consists of intensely cultivated, irrigated river valleys. It is the world’s second-largest cotton exporter, a large producer of gold and oil, and a regionally significant producer of chemicals and machinery (CIA 2006).

Since independence, Uzbekistan has focused on the development of its industry and pursued a policy of self-sufficiency in energy, grain and other selected items. The Government has provided subsidies to textile and car production and to many other industries.

After the break-up of the Soviet Union, Uzbekistan experienced a significant fall in its GDP. Following a steady recovery in the period 1995–1999, GDP declined again by almost 40% between 1999 and 2002. Since then, GDP has slowly increased again (UzA 2006a). Table 1.2 shows some macroeconomic indicators for the period 1995–2005.

Health systems in transition Uzbekistan

Table 1.2 Macroeconomic indicators, 1995–2005 (selected years)

1995 1997 1999 2001 2003 2004 2005 Agriculture, value added (% of GDP)

32.3 32.2 33.5 34.0 33.1 30.8 28.1

Industry, value added (% of GDP)

27.8 26.1 24.3 22.6 23.5 26.0 28.7

Services, etc., value added (% of GDP)

39.9 41.7 42.2 43.4 43.4 43.3 43.2

GDP (current US$ in billions)

13.4 14.8 17.1 11.4 10.1 12.0 14.0

GDP per capita (constant 2000 US$)

1 341 1 381 1 457 1 540 1 630 1 735 1 835

GDP per capita, PPP (current international $)

1 235 1 318 1 426 1 577 1 733 1 893 2 063

GDP, PPP (current international $ in billions)

28.1 31.2 34.8 39.4 44.3 49.0 54.0

Labour force, total (millions) 8.5 9.0 9.6 10.1 10.7 11.0 11.3

Official exchange rate (LCU per US$, period average)

29.8 62.9 124.6 – – – –

Short-term debt (% of total external debt)

11.8 14.5 12.7 10.3 4.5 3.7 0.9

1.3 Political context

The Constitution of Uzbekistan of 1992 defines the country as a democratic republic with the state power divided between the executive, legislative and judicial branches of government (Republic of Uzbekistan 1992). Uzbekistan has 14 administrative divisions: 12 oblasts (regions), one autonomous republic (Karakalpakstan) and one administrative city, the capital Tashkent (CIA 2006; Republic of Uzbekistan 1992).

The State is headed by the President who is elected for seven years through popular vote for a maximum of two terms. The current President is Islom Karimov, who has held this position since March 1990, when he was elected President by the then Supreme Soviet. The last presidential election took place in January 2000, when President Karimov was re-elected with 91.9% of the vote.

The legislative system is represented by the Parliament (Oliy Majlis), which is the highest representative body in the country. Uzbekistan has a bicameral Parliament which is elected and appointed for a 5-year term. It consists of:

Source: World Bank, 2007.

Notes: GDP: gross domestic product; PPP: purchasing power parity; LCU: local currency unit.

UzbekistanHealth systems in transition

an Upper House or Senate with 100 members, 84 of whom are elected • by oblast governing councils (six from each oblast) and 16 of whom are appointed by the President;

a Lower House or Legislative Chamber with 120 members, who are elected • by popular vote (Republic of Uzbekistan 1992).

Five parties are at present officially registered in Uzbekistan. At the last elections for the Legislative Chamber in December 2004, the parties gained the following representation (CIA 2006):

Liberal Democratic Party of Uzbekistan – 41 seats;•

National Democratic Party – 32 seats;•

Fidokorlar• (Self-sacrificers) National Democratic Party – 17 seats;

National Revival Party – 11 seats; •

Adolat• (Justice) Social Democratic Party – 9 seats;

Unaffiliated – 10 seats.•

The executive branch of government is represented by the Cabinet of Ministers, which consists of the Prime Minister, the deputy prime ministers, the heads of government agencies, bodies and ministries, and the Head of Government of the Karakalpakstan Autonomous Republic. The Prime Minister is nominated by the President, subject to approval by the two chambers of parliament. Other members of the Cabinet of Ministers are nominated by the Prime Minister, subject to approval by the President. The Cabinet of Ministers is formally headed by the Prime Minister and is accountable to the President and the Parliament (Republic of Uzbekistan 1992).

Oblast governments are represented by oblast councils which consist of elected members and are headed by governors. Oblast governors and the governor of Tashkent are appointed by the President, subject to approval by the oblast councils. Governors of rayons (districts) and cities in each oblast are appointed by the oblast governor, subject to approval by local (rayon or city) councils. Councils at the oblast, rayon or city levels are elected through popular vote. The governors of oblasts, rayons and cities are the highest authorities of the respective territories (Republic of Uzbekistan 1992).

All courts in Uzbekistan are de jure independent from the legislative and executive governments, political parties or any community or social groups (Republic of Uzbekistan 1993b). The chairperson and the judges in the Supreme Court and the Constitutional Court are nominated by the President, subject to approval by the Upper House of Parliament. All other judges (at oblast, rayon and city courts) are appointed by the President upon nomination by a special selection committee. Judges in the Karakalpakstan Autonomous Republic are elected by the Karakalpak Parliament upon nomination by the chairperson of

Health systems in transition Uzbekistan

the Karakalpak Parliament, subject to approval by the President (Republic of Uzbekistan 1993c).

Uzbekistan is a member of the World Health Organization (WHO), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Development Programme (UNDP) and a number of financial organizations that invest in the health sector, such as the World Bank and the Asian Development Bank (Republic of Uzbekistan 2007a).

1.4 Health status

Due to diverging estimates of infant and child mortality, estimates of life expectancy at birth in Uzbekistan differ considerably. According to the WHO Regional Office for Europe Health for All database, which is based on the official vital statistics reported to WHO by Uzbekistan, the country recorded a life expectancy at birth of 70.54 years in 2005. According to these official statistics, life expectancy decreased from 72.85 in 1970 to 67.16 in 1980, after which it increased to 69.71 in 1990 (see Fig. 1.2). After independence, life expectancy decreased to 67.47 in 1994 and has since followed an upward trend. This trajectory closely resembles the trends in other countries of the former Soviet Union. Comparing Uzbekistan with the countries constituting the European Union (EU) before 1 May 2004 (EU15), a growing divergence of life expectancies can be observed since the 1970s. In 2002, life expectancy at birth in the EU15 exceeded the officially recorded rate in Uzbekistan by nine years (WHO Regional Office for Europe 2007).

As the infant and child mortality rates which are recorded in official statistics in central Asia underestimate actual mortality, life expectancy in Uzbekistan can be assumed to be lower than recorded by official statistics (World Bank 2004a; Aleshina and Redmond 2003). According to World Bank estimates, mortality rates have increased for both males and females since 1990, whereas mortality rates for infants and children under five have slightly decreased (see Table 1.3) (World Bank 2007; UNICEF 2006). The World Bank estimated that actual life expectancy at birth in Uzbekistan stood at 67.4 years in 2005 (World Bank 2007) and WHO estimates are even lower, suggesting a life expectancy of 66 years in 2003 (see Fig. 1.3).

Diseases of the circulatory system are the most common cause of death in Uzbekistan, accounting for 65.6% of age-standardized mortality in 2005 (WHO Regional Office for Europe 2007). The mortality rate from diseases of the circulatory system has increased in Uzbekistan since the 1980s, a development that mirrors the trends in other countries of central Asia and the Commonwealth

UzbekistanHealth systems in transition

Fig. 1.2 Officially recorded life expectancy in Uzbekistan, CIS, CARK and EU15, 1971–2005

Source: WHO Regional Office for Europe, 2007.

Notes: The officially recorded life expectancy for Uzbekistan is an overestimate, as it underestimates infant mortality; CIS: Commonwealth of Independent States; CARK: Central Asian Republics and Kazakhstan; EU15: European Union Member States before May 2004.

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of Independent States (CIS), but contrasts with trends in western Europe, where mortality from diseases of the circulatory system has continuously declined in the last few decades. These developments have resulted in a significant divergence between the rates in Uzbekistan and western Europe. In 2005, age-standardized mortality rates from diseases of the circulatory system in Uzbekistan were more than three times higher than the average in the EU15 in 2004 (WHO Regional Office for Europe 2007).

Ischaemic heart diseases and cerebrovascular conditions constitute almost two thirds of all circulatory system mortality cases in Uzbekistan (see Table 1.4). Although there are no significant gender gaps in the aggregate data on circulatory system mortality, some significant differences exist. Males, for example, are more likely to die of ischaemic heart disease (WHO 2005).

Malignant neoplasms (cancer) are the second most prevalent cause of death in Uzbekistan, closely followed by accidents and infectious diseases (WHO 2005). Age-standardized mortality rates from malignant neoplasms are two and

Health systems in transition Uzbekistan

a half times lower than the EU15 average (WHO Regional Office for Europe 2007), equally affecting both genders (WHO 2005).

More than half of the mortality related to infectious conditions in 2000 was attributable to tuberculosis (WHO 2005). Although aggregate mortality rates from infectious diseases have continuously decreased in Uzbekistan since

Fig. 1.3 Officially recorded and estimated life expectancy at birth, 1990–2005

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Official statistics Estimated life expectancy (World Health Report)

Source: WHO Regional Office for Europe, 2007.

Table 1.3 Mortality and health indicators, 1970–2005 (selected years)

1970 1980 1990 2000 2002 2003 2004 2005 Life expectancy at birth, female (years)

– 70.7 72.4 71.1 70.3 – – 70.7

Life expectancy at birth, male (years)

– 64.0 66.1 64.7 63.8 – – 64.2

Life expectancy at birth, total (years)

– 67.3 69.2 67.9 67.0 – – 67.4

Mortality rate, adult, female (per 1000 female adults)

146.6 116.1 109.2 – 148.6 – – 144.8

Mortality rate, adult, male (per 1000 male adults)

253.6 219.1 207.5 – 252.0 – – 247.2

Mortality rate, infant (per 1000 live births)

83 73 65 59 – – – 57

Mortality rate, under-5 (per 1000)

101 89 79 71 – – – 68

Source: World Bank, 2007.

UzbekistanHealth systems in transition

the second half of the 1980s, mortality attributable to tuberculosis has almost doubled since reaching its lowest point in 1990. This trend in tuberculosis mortality is similar to the trends observed in other countries of the former Soviet Union. It is related to the economic decline, breakdown of public support systems, and impoverishment of large parts of the population associated with the transition towards a market economy in these countries. In 2002, the mortality rate attributable to tuberculosis in Uzbekistan was 30 times higher than the EU15 average. It affected predominantly males whose mortality rate attributable to tuberculosis was almost two and a half times that of females (WHO Regional Office for Europe 2007).

Males in Uzbekistan are also more likely to die from various types of injuries. Mortality due to injuries is almost three times more common among males than among females. Motor vehicle traffic accidents, accidental drowning, and suicide or self-inflicted injuries account for almost two thirds of all mortality from external causes (WHO 2005).

Table 1.4 Estimated deaths per 100 000 population by cause, 2002

Communicable, maternal, perinatal and nutritional conditions 91.5

Infectious and parasitic diseases 26.9

Respiratory infections 43.4

Maternal conditions 0.9

Perinatal conditions 18.9

Nutritional deficiencies 1.3

Noncommunicable diseases 531.7 Malignant neoplasms 46.9

Other neoplasms 0.4

Diabetes mellitus 11.5

Endocrine disorders 0.9

Neuropsychiatric conditions 13.7

Cardiovascular diseases 375.2

Respiratory diseases 28.6

Digestive diseases 36.6

Genitourinary diseases 12.1

Skin diseases 0.5

Musculoskeletal diseases 0.8

Congenital anomalies 4.6

Injuries 44.0 Unintentional injuries 31.2

Intentional injuries 12.9

All causes 667.2

Source: WHO, 2004.

Health systems in transition Uzbekistan

The mortality rate from motor vehicle accidents in Uzbekistan is less than half the CIS average and approximately two thirds of the European average. The mortality from suicide or self-inflicted injuries shows a similar picture. In 2002, the central Asian average was almost two times higher than the rate in Uzbekistan, while the CIS average exceeded the rate in Uzbekistan almost four times and the European average one and half times. Whereas mortality rates related to suicide or self-inflicted injuries have stayed almost unchanged in Uzbekistan since the 1980s, mortality related to motor vehicle accidents reached a high in 1990 and has since declined almost threefold (WHO Regional Office for Europe 2007), mostly as result of enforcement of traffic regulations. The largely unchanged mortality rate from suicide and self-inflicted injuries might be due to a strong social stigmatization of suicide and a traditionally strong social support network within local communities.

Reported healthy life expectancy indicators show a significant improvement in recent years for both males and females (see Table 1.5). It is, however, not clear how this improvement over such a short period of time can be explained, calling into question the validity of the data. In general, females in Uzbekistan have a longer healthy life than males.

According to data from the Uzbekistan Health Examination Survey (UHES) in 2002, the total fertility rate in Uzbekistan (2.9) was much higher than in many other countries in central Asia or the CIS, such as Ukraine (1.4), Georgia (1.7) and Kazakhstan (2.1). However, as already mentioned, the fertility rate in Uzbekistan has shown a significant decline from 4.1 in 1990. It is noteworthy that there are different estimates of total fertility rates in Uzbekistan. According to data from the Ministry of Health, the total fertility rate was 2.5 in the period 2000–2002, while the nationally representative UHES found a rate of 2.9 for the same period. Fertility rates are higher among ethnic Uzbeks, Tajiks and Kazakhs than among ethnic Russians and Tatars.

Table 1.5 Healthy life expectancy indicators, 2000–2002

2000 2001 2002 Healthy life expectancy at birth (years), total population

53.4 53.5 59.4

Healthy life expectancy at birth (years), males 52.7 50.9 57.9

Healthy life expectancy at birth (years), females 55.8 56.1 60.9

Healthy life expectancy at age 60 (years), females 11.6 10.8 12.6

Expectation of lost healthy years at birth, males 9.4 11.7 7.6

Expectation of lost healthy years at birth, females 12.2 12.4 10.0

Percentage of total life expectancy lost, males 15.1 18.7 11.6

Source: WHO, 2006.

UzbekistanHealth systems in transition

The UHES in 1996 and 2002 provided some additional information on determinants of maternal and child health. They indicate an increase in child spacing and in the age when the first child is born. The percentage of births that occurred within two years of the preceding birth decreased from 30% in 1996 to 24% in 2002. Among women aged 15–19, only 2% reported to have given birth to a child in 2002, compared to 7% in 1996 (Measure DHS 2004).

There are significantly different estimates of infant mortality in Uzbekistan. As already mentioned, the official vital statistics collected by the Ministry of Health tend to underestimate the actual infant mortality rate in Uzbekistan. More appropriate estimates can be derived from nationally representative surveys based on reproductive histories. The UHES of 2002 estimated the infant mortality rate to be 62 per 1000 live births for the period 1998–2002, which is similar to the results of the Multiple Indicator Cluster Survey (MICS) conducted in 2000 by the United Nations Children’s Fund (UNICEF). In contrast, data from the Ministry of Health for the same period range from 16.3 to 21.8 infant deaths per 1000 live births, with an average infant mortality rate of 19 per 1000 live births.

The difference between officially recorded rates and estimates based on survey data is a result of two main factors (World Bank 2004a; Aleshina & Redmond 2003). The first is that the more restrictive Soviet definition of a live birth, which does not count neonates dying in the first seven days of life, is still in use in Uzbekistan, so that fewer infant deaths are recorded than would have been the case if the WHO definition was used. It has been estimated that the continued use of the Soviet definition of a live birth accounts for 37% of the difference between Ministry of Health data and the estimate derived from the UHES of 2002 (Measure DHS 2004). The second reason for the discrepancy between official data and estimates is the misreporting of births and infant deaths by medical staff, partly due to the fear of negative consequences by medical personnel. According to the UHES, 63% of the difference between official and survey data is due to infants dying after seven days of life, indicating general underreporting of infant deaths in the registration system (Measure DHS 2004).

There are significant regional variations in infant mortality. According to the UHES of 2002, the infant mortality rate for the period 1998–2002 was higher in rural areas (75 per 1000 live births) than in urban areas (43 per 1000 live births) and higher among women with primary or mid-level education (95 per 1000 live births) than among women with higher education (29 per 1000 live births) (Measure DHS 2004).

Malnutrition among children and women of reproductive age continues to be a major problem. The UHES of 2002 found 21% of children under the age

Health systems in transition Uzbekistan

of five years to be moderately or severely stunted (short for their age) and 7% moderately or severely wasted (underweight for their height) (Measure DHS 2004). Children in the lowest income groups are twice as much at risk of being underweight than those in the highest income groups. There are also significant urban–rural differences. Prevalence of stunting and underweight is 1.5 times higher in rural areas compared to urban areas (Kamatsuchi 2006).

Among children aged 6–59 months, the UHES found 49% to have some degree of anaemia, with lower levels in Tashkent (20%) than in other regions (46–58%). The survey also revealed severe vitamin A deficiency among 9% of children in Ferghana oblast, with 44% suffering from moderate vitamin A deficiency, despite a generally rich supply of fruits and vegetables in this oblast compared to other parts of the country (Measure DHS 2004). Iodine deficiency is another important public health challenge. The MICS conducted by UNICEF in 2000 found that only 19% of households consumed adequately iodized salt (Kamatsuchi 2006).

As a result of Ministry of Health immunization protocols and strict control over compliance, immunization rates have been traditionally high in Uzbekistan, although actual immunization rates might be somewhat lower than officially reported, as there are no adequate systems for the monitoring of compliance. Table 1.6 shows data for vaccinations against childhood diseases for the year 2000. Taking the official incidence of the respective infections as a measure of the effectiveness of vaccinations, Uzbekistan fares well when compared to the former Soviet Union and EU15 rates for the main vaccine-preventable childhood illnesses, including pertussis, rubella, measles, diphtheria, tetanus, acute poliomyelitis and mumps (WHO Regional Office for Europe 2007).

According to official data, the number of decayed, missing or filled teeth at age 12 in Uzbekistan in 2000 was approximately two thirds of the EU15 average (see Table 1.7) (WHO Regional Office for Europe 2007). However, according to the UHES of 2002, 64–65% of children under the age of five rarely or never cleaned their teeth (Measure DHS 2004). These low rates of regular teeth cleaning suggest that the comparatively low number of decayed, missing or filled teeth at age 12 in Uzbekistan may be an underestimate. However, a nationally representative survey conducted in 1996, the Demographic and

Table 1.6 Percentage of children aged 12–23 months vaccinated against childhood diseases, 2000 (percentages)

BCG DTP1 DTP2 DTP3 Polio0 Polio1 Polio2 Polio3 Measles 98.9 98.4 97.6 95.7 96.3 98.4 97.6 95.7 97.0

Source: UNICEF, 2000.

Notes: BCG: Bacillus Calmette-Guérin vaccine; DPT: Diphtheria-Tetanus-Pertussis vaccine.

UzbekistanHealth systems in transition

Health Survey (DHS), found numbers of decayed, missing or filled teeth at age 12 which were similar to the data reported in the WHO Regional Office for Europe Health for All database (WHO Regional Office for Europe 2007; Measure DHS 1997).

The maternal mortality rate in Uzbekistan has followed a development similar to the overall trends in central Asia and the CIS. In 2005, maternal mortality in Uzbekistan was recorded at 29.24 per 100 000 live births, which was

Table 1.7 Decayed, missing or filled teeth at age 12, 1990, 1995, 2000, 2001

1990 1995 2000 2001

Uzbekistan 2.80 – 0.90 0.90

EU15 3.37 1.94 1.47 –

CIS 3.46 – – –

CARK 2.26 – – –

Source: WHO Regional Office for Europe, 2007.

Notes: EU15: European Union Member States before May 2004; CIS: Commonwealth of Independent States; CARK: Central Asian Republics and Kazakhstan.

Fig. 1.4 Officially recorded maternal deaths per 100 000 live births, Uzbekistan, EU15, CIS, CARK, 1980–2005

Source: WHO Regional Office for Europe, 2007.

Notes: EU15: European Union Member States before May 2004; CIS: Commonwealth of Independent States; CARK: Central Asian Republics and Kazakhstan; some data for 1980 and 2005 are not available.

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slightly higher than the CIS average (28.72) and five times higher than the EU15 average, which stood at 5.64 per 100 000 live births in 2004 (Fig. 1.4) (WHO Regional Office for Europe 2007). Currently, in Uzbekistan, a maternal death is considered to have arisen from a criminal offence and is subject to criminal investigations by the prosecutor’s office (MoH Department of Treatment and Prevention, personal communication), creating a powerful incentive for underreporting in official statistics.

The prevalence of anaemia among women of reproductive age (15–49 years) in Uzbekistan (60.4%) is the highest found in DHSs in central Asia, and was especially high in the western and eastern parts of the country (see Table 1.8) (Kamatsuchi 2006). Anaemia rates are highest in poorer and more rural areas, such as the Aral Sea region, while the lowest incidence rates were found in Tashkent city.

Table 1.8 Incidence of anaemia among females per 1000 population, first time diagnosis, 1999 and 2000

1999 2000

Regions Total Children

(< 14) Teenagers

(15–17) Adult Total Children

(< 14) Teenagers

(15–17) Adult

Tashkent City 19.60 16.50 17.08 20.99 26.54 25.28 27.02 27.00

Andijan 123.05 69.77 150.16 156.49 139.57 88.45 163.35 171.91

Bukhara 136.08 119.62 245.64 134.58 116.87 98.42 251.95 113.80

Djizzak 47.46 19.23 37.48 71.80 53.77 29.41 91.58 68.82

Kashkadarya 64.60 35.11 83.31 87.63 64.44 38.73 82.37 84.31

Navoi 100.28 85.93 190.61 99.32 109.49 85.80 197.12 115.20

Namangan 114.08 54.94 118.74 157.85 128.79 65.94 196.66 167.78

Samarkand 72.52 23.86 61.10 112.72 71.97 29.03 59.96 107.68

Surkhandarya 61.50 20.18 83.14 95.56 65.43 30.05 78.81 95.29

Syrdarya 24.91 13.42 51.05 30.32 23.85 8.92 39.68 33.35

Tashkent 52.79 36.82 59.31 61.82 51.96 37.33 75.75 58.37

Ferghana 75.68 62.13 44.03 88.35 76.97 59.58 117.51 84.36

Khorezm 28.87 41.69 36.80 18.48 23.35 33.70 30.65 14.86

Karakalpakstan 164.47 171.76 102.22 167.39 178.22 127.74 365.52 190.30

National average 78.06 53.12 87.10 94.42 81.59 53.71 123.83 96.15

Source: World Bank, 2003.

Since independence, Uzbekistan has seen a steep rise in the rates of sexually transmitted infections (STIs), in particular with regard to syphilis and – to a lesser extent – gonococcal infections, which are the two most prevalent STIs. These trends correspond with developments in other countries of the former Soviet Union, although the increase in recorded rates in Uzbekistan was less pronounced (WHO Regional Office for Europe 2007). According to official data, the rate of gonococcal infections in Uzbekistan in 2005, at 23.95 per

UzbekistanHealth systems in transition

100 000 population, was about half of the CIS average (53.83 per 100 000) and significantly below the central Asian average in 2004 (35.56 per 100 000). Nevertheless, the rate in Uzbekistan was 2.5 times higher than the EU15 average in 2005 (9.78 per 100 000).

More striking differences exist for the rates of syphilis, which, at 16.2 per 100 000 population in Uzbekistan in 2005, were more than three times higher in the CIS (49.46 per 100 000), while the central Asian average in 2004 (34.38 per 100 000) was twice the rate in Uzbekistan. Although comparing favourably with many other countries of the former Soviet Union, the rate of syphilis in Uzbekistan in 2005 was more than five times higher than the EU15 average (2.94 per 100 000) (WHO Regional Office for Europe 2007).

In Uzbekistan, there seem to be significant gaps in public knowledge about STIs. The UHES in 2002 found that men (64%) are more likely to have ever heard of STIs other than HIV than women (39%). Women living in Tashkent (88%) were almost two and a half times more likely to have some knowledge of these diseases than women in the rest of the country (34%), with a less striking difference among men (91% in Tashkent versus 61% in the rest of the country). Among young people aged 15–19, 21% of female respondents and 37% of male respondents were found to be aware of STIs (Measure DHS 2004).

Uzbekistan has maintained the system of strict monitoring and obligatory treatment of STIs that was practised in the Soviet Union. The resulting lack of anonymity and confidentiality, in conjunction with processes of social stigmatization, likely leads to an underreporting of STIs.

HIV/AIDS is a newly emerging challenge for the Uzbek health system. In 1998, the total number of registered infections was less than 50 (UNAIDS/ WHO 2004), while in 1999 only 18 new infections were registered. Since then, however, the number of registered HIV cases has increased exponentially, similar to developments in other countries of the former Soviet Union. In 2004, there were 2016 newly diagnosed cases and the total number of HIV infections reached 5600 (UNAIDS 2005). In the first 11 months of 2005, 2010 cases were newly diagnosed, of which 49.5% were attributed to injections and 19% to sexual intercourse (UNDP Uzbekistan 2006b). Injecting drug use continues to be the most prevalent mode of transmission. Of all transmissions registered by 2004, 63.4% were attributed to injecting drug use, 11.3% to heterosexual contacts, and less than 1% to homosexual contacts. The mode of transmission was unknown for 24% of cases. A large percentage of unidentified modes of transmission could be due to the strong social stigma that is associated with homo- or bisexual practices (UNAIDS/WHO 2004). There is, however, a clearly identifiable trend from injecting drug use as the predominant mode of transmission to an increasing percentage of cases attributable to unsafe sex.

Health systems in transition Uzbekistan

One of the population groups at highest risk are prisoners and almost 35% of recent new cases have been registered in the prison system (UNDP Uzbekistan 2006b).

As already mentioned, mortality from tuberculosis increased significantly in the 1990s. The incidence of tuberculosis declined from 57.5 per 100 000 population in 1980 to 43.1 in 1995, but has since almost doubled, reaching 78.4 per 100 000 population in 2004 (Fig. 1.5). Although this mirrors trends in central Asia and the former Soviet Union, rates in Uzbekistan are almost eight times the EU15 average of 9.8 per 100 000 (WHO Regional Office for Europe 2007).

There are hardly any reliable and nationally representative data on lifestyle factors affecting the health of Uzbekistan’s population. Tobacco use seems to be the factor that has been studied most extensively. According to the UHES of 2002, the prevalence of tobacco smoking is insignificant among women, less than 1% of whom were smoking. This low prevalence of smoking among females could be due to negative cultural perceptions of smoking by females. These perceptions seem to be strongest among ethnic Uzbeks. Only 0.3% of females identifying themselves in the survey as ethnic Uzbeks were smokers,

Fig. 1.5 Tuberculosis incidence per 100 000, Uzbekistan, EU15, CIS, CARK, 1980–2004

Source: WHO Regional Office for Europe, 2007.

Notes: EU15: European Union Member States before May 2004; CIS: Commonwealth of Independent States; CARK: Central Asian Republics and Kazakhstan.

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compared to 4.5% of non-Uzbeks. The prevalence of smokers in the overall population is significantly higher among men than among women, and reached 21% in 2002. As among females, smoking was more common among non-Uzbek ethnic groups, where it reached 30%, compared to 19% among ethnic Uzbeks. Naswhy, a homemade chewing tobacco, is another form of tobacco that is used in Uzbekistan. In the 2002 UHES, approximately 38% of male respondents indicated that they have (ever) used naswhy, with no significant differences between the country’s ethnic groups (Measure DHS 2004). Uzbekistan has been the setting for major investment by the British American Tobacco Company, which at one point accounted for 31% of total foreign investment in Uzbekistan. This factor enabled it to block an attempt to implement a proposal that would have strengthened tobacco control efforts in 1994 (Gilmore, Collin & McKee 2006).

Reflecting the traditional nature of Uzbek society, reported alcohol consumption is relatively low in Uzbekistan. According to official statistics, in 2003, 1 litre of pure alcohol per capita was consumed in Uzbekistan per year, which was roughly comparable to the central Asian average (1.34 litres), but substantially lower than the CIS (6.19 litres) or EU15 (9.35 litres) averages (see Table 1.9) (WHO Regional Office for Europe 2007).

An increase in overweight and obesity among the adult population has been reported in Uzbekistan, and this trend is expected to continue due to lifestyle changes and an ageing population. According to a survey in 2002, 28% of women and 32% of men were either overweight or obese. The increase in overweight and obesity can be expected to lead to an increase in multiple chronic diseases, including hypertension, type 2 diabetes, coronary heart diseases and certain forms of cancer (Kamatsuchi 2006).

Table 1.9 Pure alcohol consumption, litres per capita per year, Uzbekistan and selected countries, 1990, 1995, 2000–2003

Country 1990 1995 2000 2001 2002 2003 Kazakhstan – 3.33 2.49 2.06 2.55 2.24

Kyrgyzstan 2.83 1.99 2.37 3.61 2.05 2.43

Russian Federation 5.46 8.90 8.78 8.72 8.72 8.87

Tajikistan – 1.03 0.21 0.50 0.29 0.25

Turkmenistan – 1.29 1.00 0.68 0.73 0.72

Uzbekistan – 0.92 1.04 0.99 0.96 1.00

EU15 10.78 9.93 9.53 9.53 9.56 9.35

CIS – 6.03 6.06 5.93 5.93 6.19

CARK – 1.79 1.45 1.42 1.38 1.34

Source: WHO Regional Office for Europe, 2007.

Notes: EU15: European Union Member States before May 2004; CARK: Central Asian Republics and Kazakhstan; CIS: Commonwealth of Independent States.

Health systems in transition Uzbekistan

Access to safe water remains a major problem, with significant differences across Uzbekistan’s regions. According to the MICS of 2000, in some oblasts only 59% of the population had access to safe water, while in others this percentage was 96%. On average, 84.3% of respondents had access to safe drinking water, with a higher share in urban (94.4%) than in rural (79.4%) areas (UNICEF 2000). The Uzbekistan Household Budget Survey of 2001 confirmed that there are massive problems with securing safe water supply. Less than 50% of respondents throughout the country had running water, and only 42.7% had running water within their dwelling, a figure declining to less than 20% of respondents in rural areas (World Bank 2003). The lack of access to safe drinking water has been suggested as one of the reasons for the observed high levels of malnutrition (Kamatsuchi 2006).

UzbekistanHealth systems in transition

2.1 Overview of the health system

The Uzbek health system has evolved from the Soviet Semashko model of health care and the public sector continues to constitute its core. The Cabinet of Ministers, which is accountable to the President and the

Parliament, is at the top of the hierarchy of the health system both in terms of regulation and financing. It develops strategies, approves the health budget and holds other governmental agencies accountable for the implementation of health policies.

At lower hierarchical levels, the Government is represented by implementing agencies. The Ministry of Health and the oblast (region) or rayon (district) health authorities assume administrative responsibilities, whereas the Ministry of Finance and its oblast branches (the oblast and rayon finance departments) are responsible for the implementation of financing directives.

Although the administrative functions of the Ministry of Health and the oblast and rayon health authorities are tailored primarily towards the public sector, some of their functions extend to some degree to the private sector, such as the licensing of health care providers. The Ministry of Finance and its oblast and rayon branches, on the other hand, only deal with the disbursement and control of public funding to public providers of health care.

The lowest layer in the hierarchy of the Uzbek health system is formed by a mixture of public and private health care providers. Public providers are tasked with the delivery of health care within a centrally set framework and can be divided into three categories, depending on their accountability and source of funding.

2 Organizational structure

Health systems in transition Uzbekistan

Primary health care providers are administratively accountable to the rayon or urban health authorities and draw on public and private financing. Public financing to health facilities at the rayon level comes from the rayon or urban finance departments. The exception is the primary care units in the oblasts covered by the World Bank-financed “Health” project, which are financed from oblast finance departments. Private funding is obtained through the delivery of services outside the state-guaranteed basic benefits package of medical services.

The next category of public health care providers is located at the oblast level. These are administratively accountable to the oblast health authorities and are financed through the oblast finance departments. These oblast health care providers include general or specialized hospitals and specialized outpatient clinics.

The final category of public health care providers is located at the national (republican) level. A number of health facilities receive public funding directly from the Ministry of Health and are also administratively accountable directly to the Ministry of Health.

Private providers, which are still small in numbers, are subject to the regulations of “for-profit” (profit-making) entities. Administratively, they are accountable to the local governments, while financial accountability lies with the local tax departments, to which private providers are required to submit regular financial reports.

In addition to the statutory health system outlined above, some government agencies, such as the Ministry of Internal Affairs, national security services and major industrial companies, maintain their own health facilities. These parallel health care providers are directly accountable to, and receive funding from, the respective state agency or company. They primarily serve their respective employees, with little or no access by the general population.

Medical education in Uzbekistan is exclusively provided by public institutions. They are administratively accountable directly to the Ministry of Health and the local and central governments, and are obliged to comply with the regulations of the Ministry of Higher and Specialized Education. Public financing to these institutions is provided by either the national or the local government. Figure 2.1 gives an overview of the health system.

UzbekistanHealth systems in transition

2.2 Historical background The practice of medicine in the territory that is now Uzbekistan dates back thousands of years. Most of the ancient scholars practised medicine in addition to other sciences, as medicine was considered as an integral part of science. The most prominent representative of ancient scholars in medicine is Avicenna. He was born in 980 near the present-day Uzbek city of Bukhara.

Avicenna is considered to be the father of oriental medicine. Of his surviving works, some 40 were dedicated to medicine, the most significant contributions being The Book of Healing and The Canon of Medicine (University of St Andrews 1999). Although many scholars who significantly advanced knowledge in medicine existed, historical circumstances were not conducive to the development and transfer of medical knowledge, partly due to the lack of structured medical education and of a health care delivery system. Health care was mostly provided outside any institutional framework by self-trained or apprenticed “tabibs” (physicians). A health care delivery system and systematic medical education only came into being in the second half of the 19th century.

Fig. 2.1 Overview chart of the health system

President

Cabinet of Ministers

Health care providers at

regional level

Ministry of Health

Regional governments

Regional finance

departments

Health care providers at district or

urban level

Professional medical colleges

Medical schools

Ministry of Higher and Specialized Education

Parliament

District finance

departments

Regional health authorities

District governments

District health authorities

Public providers of primary health

care

Health care providers at

national (republican)

level

Tax Committee

Ministry of Finance

National Security Services

Ministry of Internal Affairs

Large industries

Pharmacies

Parallel health systems

Private providers

administration

financing

taxation

Source: Authors’ compilation.

Health systems in transition Uzbekistan

Russian conquest brought western medical concepts to the territories of present-day Uzbekistan. Under this Russian influence, a structured health care delivery system was gradually introduced from the second half of the 19th century onwards. Initial steps towards establishing a systematic medical education system can be traced to the beginning of the 20th century, when the Turkistan State University, with its Medical Faculty, was founded.

Following the Russian revolution of 1917, all medical institutions and pharmacies were nationalized and incorporated into the highly centralized Soviet health system. Being part of the Soviet Union, the Uzbek health system underwent the same changes as the Soviet health system. Under the Soviet Union, most health data were aggregated across the various member states, which means that published health data for Uzbekistan specifically, up to the time of the break-up of the Union, are difficult to find.

The Soviet health system only allowed health delivery through the public sector, with no room for private practitioners. While it provided all its citizens with 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 and similar health issues specific to developing countries, but major system-based problems surfaced with a change in the burden of diseases (Rowland 1991).

One weakness of the Soviet health system was the emphasis on quantitative indicators, with very limited attention to outcomes and the quality of care. In 1989, the Soviet Union had three times more hospitals and two times more physicians per capita than the United States, although both countries had a comparable demographic structure. Health expenditure in the Soviet Union as a share of gross national product (GNP), however, was less than one third of the share spent in the United States. In absolute numbers, the difference was even more telling. In 1979, the Soviet Union spent almost eight times less on health care than the United States. The Soviet Union also lagged behind most western nations in terms of health indicators (Rowland 1991). Major structural changes in Soviet health care resulted from the amendment of Article 42 of the Soviet Constitution in 1977, entitling all citizens to free medical services provided by state-owned health care facilities.

Other structural weaknesses of the Soviet health system were inflexible management and financing arrangements. The extensive network of health facilities was rigidly managed and regulated, both in terms of financing and decision-making, and policies were set centrally by the National Ministry of Health, based in Moscow. In 1989, 80% of health expenditures were distributed directly through the Ministry of Health, with large state-owned enterprises

UzbekistanHealth systems in transition

accounting for the remaining 20%. The National Ministry of Health directly operated 96% of inpatient care and 94% of outpatient care (Rowland 1991).

The National Ministry of Health also had tight control over medical education, personnel planning and distribution. The organizational structure of the health system was based on vertical management. The highest layer, the National Ministry of Health, was followed by the republican Ministries of Health of the 15 Soviet Republics. The next layers of management were the oblast and rayon health authorities. This centralized approach left little flexibility to tailor resources to local needs in oblasts and rayons.

In addition, many system-based inequities existed in the seemingly equitable system. There were, for example, serious geographical imbalances in the distribution of health resources. In 1987, present-day Uzbekistan had 3.5 physicians per 1000 population, which was approximately 20% less than the Soviet average of 4.3 physicians per 1000 population in the same year (Rowland 1991).

In the Soviet health system, inpatient care was provided by the following facilities (Rowland 1991):

small local community hospitals (S• el’skaya uchastkovaya bol’nitsa, SUBs) serving approximately 5000 people

rural and urban • rayon hospitals serving up to 50 000 people

central city hospitals serving up to 200 000 people•

regional and national hospitals serving up to 2–3 million people.•

Outpatient care was provided by a comprehensive network of free-standing polyclinics, rural physician points (small rural ambulatory facilities, Sel’skaya vrachebnaya ambulatoryia, SVAs) and feldsher-accoucheur (midwifery) points (FAPs), or feldsher/obstetrical points, as well as polyclinics incorporated into inpatient clinics. FAPs were staffed with feldshers (health professionals equivalent to western physician assistants or nurse practitioners) and provided basic primary care including immunization, midwifery and minor surgery.

Health financing was heavily biased towards secondary care which, in 1988, accounted for approximately 78% of overall health expenditure, with much lower allocations to ambulatory care (11%), emergency services (2%) and sanitary-epidemiological services (9%) (Rowland 1991). In the mid-1980s, Uzbekistan had almost twice as many hospitals per 100 000 population (7.89 in 1985) than the EU15 (4.15 in 1986) (WHO Regional Office for Europe 2007). Primary care was neglected and did not fulfil the role of gatekeeper for higher levels of care. Even cases which could have been easily managed at primary care level were increasingly referred to hospitals. The ineffective use of resources was exacerbated by inefficient hospital procedures, with

Health systems in transition Uzbekistan

diagnostic investigations requiring hospital stays of up to seven days (Rowland 1991). In 1980, the average length of stay in hospitals was approximately 16 days. However, similar or even higher lengths of stay were common in western Europe (EU15 average: 16.4 days, United Kingdom and Germany: 19 days) (WHO Regional Office for Europe 2007). Inefficiencies in the Soviet Union were also sustained by the lack of incentives for health professionals to raise the productivity and quality of care (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% of hospitals did not have sewage and 17% did not have running water. Health personnel were inadequately trained and poorly paid, with physicians receiving approximately 70% of the average salary of non-farm workers (Rowland 1991).

In the late 1980s, the need for reforms was recognized by the Soviet Government, resulting in more flexible regulations and the entry of private providers into the Soviet health arena. Quasi-independent groups of health professionals (cooperatives) were allowed to provide health care outside the state sector. These enterprises required out-of-pocket payments for the services provided and were only regulated to a limited extent by local state authorities. By 1990, approximately 3300 such cooperatives had been formed in the health sector, employing some 20 000 full-time and 40 000 part-time physicians (Rowland 1991).

Another failure of the Soviet health system was related to health spending. Soviet health spending had been significantly lower than in other developed nations, in particular given its commitments to provide most health care free at the point of access. Health expenditure for the Soviet Union was estimated to be around 3% of GDP in the period 1980–1989, when the population-weighted average figure for the countries of the Organisation for Economic Co-operation and Development (OECD) was 7.5% (Rowland 1991).

Environmental and behavioural factors significantly contributed to the poor health status of the Soviet population. Approximately 15% of the population of the country lived in heavily polluted air conditions, while smoking and alcohol consumption had become major problems (Rowland 1991). With the dissolution of the Soviet Union, the newly independent states (NIS) were confronted with the legacy of the Soviet health system, while undergoing economic, social and political transition.

UzbekistanHealth systems in transition

2.3 Organizational overview

Uzbekistan has a single statutory health care system, which includes public, private and other forms of non-public actors.

The public sector consists of health care providers managed by oblast and rayon health authorities and the Ministry of Health, as well as all the institutions owned by the State and involved in health care delivery, rehabilitation, sanitary- epidemiological services, medical and pharmaceutical education, medical research, and the production of pharmaceuticals and medical equipment. The public sector also includes health care providers and pharmacies owned and operated by state agencies other than the Ministry of Health, such as the Ministry of Internal Affairs or the military (President of Uzbekistan 1998).

Private and other forms of non-public actors in the health sector comprise pharmacies, physicians working in single practices, and institutions involved in health care delivery or the production and supply of pharmaceuticals or medical equipment (President of Uzbekistan 1998).

The Uzbek health system is organized according to different levels of management and health care delivery.

Organization of health care delivery

From the perspective of health care delivery, the Uzbek health system can be divided into primary, emergency and specialized care, and the care for conditions deemed “socially significant and hazardous” (President of Uzbekistan 1998).

While the Law on Health Protection defines primary, specialized, and “socially significant and hazardous” conditions, it does not provide an explicit definition of emergency care.

Primary care has been defined in Uzbek legislation as the treatment of certain prevalent diseases, traumas and other emergency conditions; the rendering of sanitary-hygienic and anti-epidemic activities; and the carrying out of certain activities related to the protection of family, maternal and child health, as well as other medical-sanitary activities (President of Uzbekistan 1998).

Care related to tuberculosis, oncology, mental health, drug addiction, endocrinology, and occupational conditions classified as “socially significant and hazardous” is provided by public health institutions and fully financed by public sources (President of Uzbekistan 1998; Cabinet of Ministers 1999a).

Specialized care has been defined by the Government as care which requires special methods of prevention, diagnosis or management and involves the use of complex or sophisticated medical technologies. Only specialized physicians

Health systems in transition Uzbekistan

in health facilities licensed to deliver this type of care are authorized to provide specialized care. The types, volume and quality of specialized care provided in health facilities are regulated by the Ministry of Health (President of Uzbekistan 1998).

Management

Based on managerial and regulatory functions as well as accountability, the Uzbek public health care system falls into three distinct hierarchical layers:

national level (republican)•

oblast• level

rayon• /urban level.

National (republican) level

The highest hierarchical layer is formed by the Ministry of Health and other national institutions.

The Ministry of Health is the major player in organizing, planning and managing the Uzbek health system (MoH 1998). The structure of the Ministry, approved by the Cabinet of Ministers on 2 October 2006, is outlined in Fig. 2.2 (Cabinet of Ministers 2006).

The Ministry of Health has 78 staff responsible for administration and management, not including the staff involved in secretarial and maintenance services. It is headed by the Minister of Health who is appointed and dismissed by the President with the approval of the Parliament. The Minister has one first deputy and four deputy ministers. The deputy ministers are appointed and dismissed by the President (Republic of Uzbekistan 1993a).

The central decision-making body of the Ministry of Health is called the Collegiya. Appointed members of the Collegiya are: the Minister of Health (who is also the head of the Collegiya), the deputy ministers, an adviser to the minister, the head of the health department of the Tashkent city administration, and the chair of the Red Crescent Society. Other members of the Collegiya need to be approved by the Cabinet of Ministers. The Collegiya is a consultative body with responsibilities including the development of the Uzbek health system, the selection and appointment of key management/policy-making personnel, the development of key documents and, more generally, health care delivery and education. The implementation of decisions of the Collegiya depends on approval by the Minister, who can reject proposals put forward by the Collegiya. In case of disagreement, the issue is reported to the Cabinet of Ministers.

UzbekistanHealth systems in transition

The Scientific Council under the Ministry of Health is responsible for the application of medical science in the Uzbek health system. It includes leading scientists and experts.

The Ministry of Health develops health care legislation and regulation; sets standards for the quality and volume of health services; monitors the quality of health care; identifies priorities for medical research; monitors population health; develops curricula for the training of health professionals; issues licences; certifies health care providers; and coordinates international aid for the health sector (see Chapter 3). It also evaluates the implementation of governmental and ministerial policies (Cabinet of Ministers 1999a).

The Ministry of Health provides guidance to the Minister of Health of the autonomous Republic of Karakalpakstan and acts as the supervisory authority for oblast, city and rayon health departments.

The structure of the Ministry of Health of Uzbekistan has changed frequently during recent years. Since the first years of independence, there has been a substantial reduction in the number of departments and staff. The names of departments have also changed frequently.

Fig. 2.2 Structure of the Ministry of Health

MinisterCollegiya

First Deputy Minister Deputy Minister

Deputy Minister, Head Sanitary Physician

Department of Inspection Control (4 staff)

Deputy Minister Deputy Minister

Department of Preventive and Curative Care

(1 staff)

Department of Sanitary-

Epidemiological Control (1 staff)

Department of Science and

Medical Education Institutions (1 staff)

Division of Human

Resources (2 staff)

Department of Maternal and Child Health

(4 staff)

Department of Development of Material and Technical Capacity (6 staff)

Division of Analysis and Control of Utilization

Appropriateness of State Allocations

(2 staff)

Department of Economics and Financing

(1 staff)

Division of Medical Education Institutions (2 staff)

Division of Sanitary and Hygiene (2 staff)

Division of Inpatient and Specialized

Care (3 staff)

Division of Accounting and

Reporting (4 staff)

Division of Coordination of Science (5 staff)

Management Apparatus (5 staff)

Division of Primary Care

(3 staff)

Division of Medicosocial Issues (2 staff)

Division of Epidemiology

(2 staff)

Division of Forecasting, Health System

Development and Financing (3 staff)

Division of Coordination of Science (5 staff)

Source: Ministry of Health, personal communication, 2007.

Health systems in transition Uzbekistan

The Department of Treatment and Prevention is one of the main departments responsible for the overall management and supervision of health services. It is responsible for developing practice guidelines and protocols for preventing and treating diseases.

The Department for Maternal and Child Health administers maternal and child health facilities and supervises health care for children and mothers.

The main tasks of the Department of Sanitary-Epidemiological Control are the monitoring of sanitation issues, the control of infectious diseases, and the supervision of all sanitary-epidemiological institutions.

The Departments of Human Resources and Science and Medical Education Institutions are in charge of the education and training of health personnel and of forecasting the requirements for health personnel and human resource planning. The Department of Science and Medical Education Institutions is also in charge of developing curricula for health care professionals in cooperation with the Ministry of Higher and Specialist Education.

The Department of Inspection Control oversees the implementation of health care reforms and the pharmaceutical supply system, and inspects legal and reporting documents processed by other departments in the Ministry of Health. Health facilities are regularly inspected by clinical specialists and heads of health departments with the aim of ensuring that health facilities meet normative targets and comply with central regulations.

The highest hierarchical layer of the Uzbek health system also comprises health care delivery and research institutions. These institutions at the national level are financed and regulated directly by the Ministry of Health. An important difference between these institutions and those at lower levels is the extent of direct accountability. Although the Ministry of Health exerts to some extent managerial and regulatory functions over all actors in the health system, only national-level institutions are directly managed by, and accountable to, the Ministry of Health. Heads of these institutions are appointed by the Minister of Health. They also receive direct financing from the Ministry of Health and report directly to relevant departments of the Ministry or to the Minister himself. For all other institutions, these administrative and regulatory functions are performed by other agencies, such as oblast, city and rayon health authorities. The institutions at national level include:

medical and research institutions;•

institutions of higher medical education – medical schools, the Pharmaceutical • Institute, and some colleges for health professionals;

health care delivery institutions classified as being of national importance;•

the National Centre for Emergency Care.•

UzbekistanHealth s

Introduction

Geographical, political and economic context

Uzbekistan is a landlocked country located in central Asia. It was part of the Soviet Union until it became independent in 1991. Uzbekistan is a presidential republic in which the President is both the head of state and the head of government. Islom Karimov has been President since 1990.

After the break-up of the Soviet Union, Uzbekistan experienced a period of severe recession and the economy is only slowly recovering. In 2006, the country recorded a gross domestic product (GDP) per capita of $ 2247 (measured in current international $ in pur- chasing power parity, PPP), which compared to $ 1511 in 1991. Using a poverty headcount of PPP US $ 2 per day, 2% of the population were poor in 2003, while the Gini index in the same year stood at 36.8 (1), indicating a moderate degree of income inequality.

Health status

In 2005, Uzbekistan had a population of 26.6 million, 33.2% of which was below 15 years of age (1). The majority of the population (63% in 2006) lives in rural areas. As in other countries in central Asia, officially recorded infant mortality does not capture actual rates and official statistics consequently overestimate life expectancy. Survey-based estimates put life expectancy at birth in 2005 at 70.7 years for females and 64.2 years for males, each about two years lower than estimated life expectancies in 1990 (1). Estimated infant mortality stood at 57 per 1000 live births in 2005 (1). Officially recorded maternal mortality in the same year stood at 29.2 per 100 000 live births (2). The leading causes of death are diseases of the circulatory system, followed by cancer and diseases of the respiratory system (2). Similar to other countries of the region, there has been a resur- gence of tuberculosis and sexually transmitted diseases in the last 15 years, as well as more recently a sharp increase of people living with Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome (HIV/AIDS).

Organizational structure

Historical origins of the system

During the Soviet period, the health system followed the Semashko model, with centralized planning and administration and a focus on high numbers of doctors and hospital beds rather than on outcomes and quality of care. In the years following 1991, this communist legacy remained one of the major factors shaping health policy and practice in Uzbekistan.

Organizational overview

The highest hierarchical layer is formed by the Ministry of Health (MoH) and other national institutions. The MoH is the major player in organizing, planning and managing the Uzbek health system. It develops health care legislation and regulation (based on the decrees of the President), sets standards for the quality and volume of health services, monitors the quality of health care, identifies priorities for medical research, monitors pop- ulation health, issues licences, certifies health care providers and coordinates international aid for the health sector. It also evaluates the implementation of govern- mental and ministerial policies. Furthermore, the MoH provides guidance to the MoH of the autonomous Republic of Karakalpakstan and acts as the supervisory authority for oblast (regional), city and rayon (local) health departments. Health care institutions at the oblast and rayon level represent the second and third manage- rial and regulatory layer of the Uzbek health system (3).

Decentralization and centralization

In Uzbekistan, decentralization has been approached gradually. Administrative functions have been delegated to oblast health authorities, while decision-making has been retained at the national level. This means that the mid-level managers of the health system (in oblast and rayon health departments) act as administrators of centrally issued regulations.

Devolution (the granting of powers from the central to local governments) in the system is largely reflected in the delegation of budgetary responsibilities from the

HiT profile in brief: Uzbekistan 2008 1

Uzbekistan

Health Systems in Transition

HiT profile in brief

national level to the oblasts, while keeping a strictly ver- tical structure and tight national guidelines and norms, on which decisions at the oblast level are based (3).

Health care financing

Health expenditure

The World Health Organization (WHO) estimated that total health expenditure in 2004 amounted to 5.1% of GDP, equivalent to PPP US $ 160 per capita (see Figure 1) (2). In the Soviet period, almost all health expenditure came from public sources. This changed dramatically in the years of transition, with consequences for the affordability of health services for poorer parts of the population. In 2004, government expenditure was esti- mated to constitute 47% of total health expenditure, with private expenditure accounting for 53% (2).

According to national budget data, 66% of public expenditure in 2005 was spent on hospitals, 13% on polyclinics and ambulatories, and 8% on rural primary care units. The vast majority of public expenditure (86% in 2005) was generated at the local level, from oblast,

rayon and urban budgets, although there are large vari- ations in per capita expenditure across oblasts (3).

A state-guaranteed basic benefits package was intro- duced in 1996 with the aim of making more efficient use of limited resources. The basic benefits package includes primary care, emergency care, care for “socially significant and hazardous” conditions, and specialized care for certain groups of the population.

Revenue

The main financing sources for the Uzbek health system are out-of-pocket payments (both formal and informal), state funding (mainly from the local level), international agencies, and, to a very small degree, voluntary health insurance.

Formal out-of-pocket payments were introduced in 1998. Furthermore, most outpatient pharmaceutical expenses are covered by individual direct payments. The magnitude of informal payments is unknown, but in the Living Standards Assessment produced by the World Bank in 2003 more than two thirds of health care users

HiT profile in brief: Uzbekistan 2008 2

Figure 1: Trends in total expenditure on health as a percentage of GDP in Uzbekistan, 1998–2004 (WHO estimates)

1998 1999 2000 2001 2002 2003 2004

Uzbekistan

EU15

CIS

CARK

Notes: CARK: Central Asian Republics and Kazakhstan; CIS: Commonwealth of Independent States; EU15: EU Member States before 1 May 2004.

reported to have made informal payments (4).

State funding is mostly derived from different types of taxes. External sources of funds are being extensively used to support ongoing reforms and to strengthen the existing health infrastructure. While voluntary health insurance only seems to account for a tiny share of health expenditure, health insurance providers have become more visible in recent years (3).

Pooling and resource allocation

The national government is responsible for the financing of specialized medical centres, research institutes, emergency care centres and national level hospitals. Local governments (at oblast, rayon or urban level) are responsible for expenditure related to all other hospitals, primary care units, sanitary-epidemiological units and ambulance services in the respective areas under their administrative jurisdiction (3). However, pooling of primary health care funds at the oblast level and their reallocation among primary health care providers on the basis of a unified per capita rate set for the oblast is followed under the ongoing reforms of the primary health care sector.

Payments

Traditionally, rural primary care units were paid on the basis of fixed budget lines and past expenditures. A new capitation financing mechanism for the rural primary health care sector has now been introduced nationwide, according to which per capita rates are set by oblast governments for the population covered by rural primary care units, with adjustments for age and gender. Analogous pilots on capitation financing are currently being implemented for urban primary health care providers and polyclinics. Otherwise, in general, providers of primary care in non-pilot urban areas, along with specialized outpatient and inpatient care, and sanitary-epidemiological services are paid on the basis of traditional prospective budgets based on past expen- diture and inputs (3).

Public sector employees in the health sector were tradi- tionally paid according to strict guidelines from the Ministry of Finance, with no incentives for the produc- tivity, quality and efficiency of care. In recent years, the government has increased the flexibility of health care providers in the reimbursement of health professionals, with a greater use of financial incentives. Despite recent increases in the salary of health care workers, however, salary levels remain below the national average across

sectors and are particularly poor for health professionals working in primary care (5).

Planning and regulation

In the Soviet period, planning and regulation were under the central control of the Soviet State. Following inde- pendence, the Uzbek MoH assumed the leading role in health planning and regulation. The stewardship role of the government is mainly exercised at the national level. Regional health administrations at the oblast, rayon or urban level are responsible for the management of health services in their territorial units and allocate resources to health care facilities according to guide- lines determined by the MoH (3).

The governance and management structure of public health care providers has not changed much since inde- pendence. Hospitals are managed by the head physician, who is exclusively responsible for all hospital activities. Reforms are under way to strengthen management skills and to increase the flexibility of health care providers.

Uzbekistan has inherited a comprehensive data- collection system from the Soviet period. However, this system is fragmented and the data-collection system is rather disconnected from daily needs. Furthermore, official statistics on many indicators, including infant and maternal mortality, are not reliable, partly due to the fact that the more restrictive Soviet definition of a live birth is still in use (3).

Physical and human resources

Physical resources

At the time of independence, Uzbekistan had inherited an excessive hospital network from the Soviet period. Since then, the ratio of hospital beds has been reduced more than twofold: from 10.9 beds per 1000 population in 1991 to 5.2 per 1000 in 2005, which was close to the central Asian average (see Table 1) (2).

A new focus on primary health care has resulted in a certain redirection of funds from inpatient to primary care. The structure of public primary care is undergoing comprehensive reforms, in which rural primary care units and outpatient clinics of central rayon hospitals are becoming the main providers of primary care in rural areas (5).

Human resources

The ratio of physicians (physical persons) to population has shown a downward trend since Uzbekistan’s

HiT profile in brief: Uzbekistan 2008 3

independence, from 343 in 1991 to 270 in 2005. In contrast, the ratio of nurses (physical persons) has only slightly decreased, from 1104 in 1991 to 1024 in 2005, which was considerably above the central Asian and Commonwealth of Independent States (CIS) averages (Table 1) (2) and might indicate an underused work- force. As in other countries of central Asia, there are sig- nificant disparities in the regional distribution of health care workers, with a concentration in urban areas and a shortage in rural areas.

Medical education is entirely provided by the State, although a proportion of students enter and pay for this on a contract basis. At present, there is one medical academy, four medical schools and three regional branches of medical schools. Nursing training is pro- vided by 57 professional colleges. Higher nursing education has only recently been introduced and is offered by the country’s medical schools. A training programme for a Master of Public Health was introduced in 2001. Medical education has also under- gone reforms and graduates are now qualified as general practitioners rather than being broad specialists in internal medicine, surgery or obstetrics/gynaecology, as under the Soviet model (3).

Provision of services

With the exception of dental and pharmaceutical care, which has been largely privatized, most health services continue to be provided by the public sector.

Public health

In the Soviet period, public health services were provided by the Sanitary-Epidemiological Service. This service continues to be responsible for environmental health services, food safety and controlling communicable diseases (including supervision of immunization pro- grammes implemented by primary care). It is organized vertically, with services at the national, oblast and rayon level, and also comprises several research institutes and centres. A separate vertical structure was created in 1998 to deal with HIV/AIDS prevention and treatment. Health promotion and education is carried out by a number of governmental and nongovernmental agencies, including public providers of primary care. In 2001, the Institute of Health was created to strengthen health promotion and education. It has at present 14 oblast branches, 159 rayon and 15 urban health centres (3).

Primary health care

The delivery of primary health care differs in rural and urban areas. In rural areas primary care was traditionally delivered by feldsher-accoucheur points (FAPs), small rural ambulatories and outpatient clinics of community clinics or central rayon hospitals (CRBs). This structure is currently being replaced within the ongoing health reform programme by a two-tiered system, consisting of rural primary care units and outpatient clinics of central rayon hospitals. In urban areas, primary care and selected secondary care services are provided by

HiT profile in brief: Uzbekistan 2008 4

Table 1: Selected health care resources (physicians, nurses, acute hospital beds) per 100 000 population, 2005 or latest available year (in parentheses)

Physicians (physical persons) Nurses (physical persons) Acute hospital beds

Uzbekistan 270 1 024 431

CARK average 283 767 525

CIS average 372 788 730

EU15 average 336 (2004) 749 (2004) 393 (2004)

Source: (2).

Notes: CARK: Central Asian Republics and Kazakhstan; CIS: Commonwealth of Independent States; EU15: EU Member States before 1 May 2004.

polyclinics. These are currently being transformed into family polyclinics, providing primary care for all groups of the population (instead of separately for adults, chil- dren and women, as was previously the case). The pri- mary care reform has been piloted in a number of oblasts and is currently being rolled out nationwide (5).

Hospital care

In rural areas, secondary care is provided by rural hos- pitals, rayon hospitals and CRBs. Many rural hospitals have been closed in recent years. In urban areas, secondary care is provided by oblast and city hospitals. Tertiary care is provided in large hospitals and research institutes at the national level. At oblast level, many disease categories and population groups are treated in separate hospitals, including children’s hospitals, tuber- culosis hospitals, hospitals treating sexually transmitted infections, neurological and psychiatric hospitals, and emergency hospitals (3). A new presidential decree adopted in November 2007 envisaged a reorganization of the hospital sector by integrating vertical services and decreasing the number of hospital beds.

Emergency care

Since independence, emergency care services have undergone far-reaching reforms, in particular with regard to hospital-based emergency care. Throughout the country, a vertical network of emergency depart- ments has been organized. In 2004, the emergency care framework consisted of 1 Centre of Emergency Care in the capital, Tashkent, 12 branches and 204 ambulance stations (3). It is planned that primary care will assume a more pivotal role in emergency care, especially for patients with heart attacks and strokes.

Pharmaceutical care

After independence, the production and distribution of pharmaceuticals were almost entirely privatized, and the government mainly retained regulatory functions. Uzbekistan adopted a national essential drug formulary in 1998. The Essential Drugs List is based on the WHO model and contains about 240 products. Price regula- tion is exercised for 20 basic drugs. However, this list of drugs has not been changed since 1994 (3).

Mental health care

Although Uzbekistan has yet to adopt a comprehensive mental health strategy, a number of initiatives are under way to facilitate a shift from inpatient to out-patient mental health care. Between 1990 and 2005, psychiatric bed capacity has been reduced by about half, from 60 to

31 per 100 000 population, and is now one of the lowest in the CIS (2).

Mother and child health

Mother and child health has been one of the priorities of the national health policy. After Uzbekistan’s independence, the country embarked on a restructuring of maternity care. Maternity departments in general hospitals were closed and services shifted to primary care or to newly organized central maternity hospitals or units, which provide all maternity and infant inpatient services for the covered population. Mother and child health services form part of the state-guaranteed package of services and are almost entirely provided by the public sector (3).

Health reforms

Health reforms in Uzbekistan were to a large degree triggered by the challenge of sustaining an excessive network of health facilities with declining governmental health expenditure. Reforms aimed to make more efficient use of resources and promoted the development of the private sector. The first major step towards reforming Uzbekistan’s health sector was done with the 1996 Law on Health Protection, which was followed in 1998 with the Presidential Decree on the reform of the health system.

Two major initiatives were undertaken so far with the aim of restructuring primary health care in Uzbekistan. The first initiative, project “Health” (1998–2005; subsequently renamed “Health 1”), was the result of a collaboration between the World Bank and the Uzbek Government and piloted several new mechanisms and frameworks for the delivery, financing and management of rural primary care. The new approaches mainly entailed general practice/family medicine-based clinical practices and a per capita payment system for rural primary health care providers. The second primary care initiative, consisting of project “Health 2” of the World Bank and the “Women and Child Health Development Project” of the Asian Development Bank (2005–2010), aims to roll out the rural primary health care reforms throughout the country and to implement similar new pilots with regard to urban primary health care reforms, as well as to introduce new approaches to maternal and child health, public health, and monitoring and evalua- tion, in order to strengthen the primary care sector. On- the-ground, technical assistance to implement the World Bank projects is extended mostly by the United States

HiT profile in brief: Uzbekistan 2008 5

Agency for International Development-funded Zdrav- Plus project.

Reform initiatives at the secondary care level were so far more limited, but pilot initiatives on a case-based hospital payment system are under way. The restruc- turing of emergency services has been one of the major health reforms in Uzbekistan and has benefited from the largest single investments in the Uzbek health sector in recent years. The network of emergency facilities is now much better equipped than other health facilities in the public sector. In addition, as the delivery of emergency care is formally free of charge, patients who would not otherwise have done so seem to have increasingly accessed emergency services.

In 2003, a Presidential Decree initiated a pilot on reforming tertiary care research institutions. Four institutions were initially included as pilot institutions in the reform of tertiary care: the Research Centre for Urology, the Research Centre for Surgery, the Research Centre for Cardiology and the Regional Centre for Microsurgery in Ophthalmology. These four institutions were transformed into national specialty centres in their respective fields. The centres have mixed financing, consisting of funds from the state budget, their revenues and other external sources (such as grants and spon- soring funds) (3).

Assessment of the health system

Uzbekistan is currently restructuring its network of pri- mary care facilities, which should improve geographical access to quality primary care services. At the same time, however, inpatient and specialized care have become less accessible, in particular in rural areas. Between 1997 and 2003, overall bed capacity was reduced by 50%, with a reduction of the number of hos- pitals in rural areas by 50% and in urban areas by 20%. Although financing reforms resulted in the establish- ment of a state-financed basic benefits package, the costs for services outside the basic benefits package have been shifted to individual users, as third-party pooling sys- tems are not in place in Uzbekistan. This has reduced access to services outside the package, such as tertiary or inpatient care and outpatient pharmaceuticals (3).

There is a general consensus that the quality of care in Uzbekistan leaves much to be desired and several ini- tiatives have been taken to improve clinical practice, the most important being the launch of the Centre for Evi- dence-Based Medicine, the first such centre in central

Asia. The Centre has already produced several clinical guidelines based on international recommendations (3).

Conclusions

Uzbekistan has made substantial progress in the restruc- turing of different layers of health services, such as primary care, emergency care, and secondary and tertiary care. However, challenges remain. One of them is a better coordination of different levels of care. A more holistic approach to care delivery processes and training programmes, coupled with improved manage- ment, especially at the delivery level, would result in improved efficiency and better health outcomes. A reform of the financing and information systems, linking resource flows to performance, would be cru- cial to realize the full potential of investments made at t h e various levels of care. It would also necessitate quality improvements, which could be facilitated by develop- ment and effective dissemination of appropriate guide- lines; a shift in medical education from factual knowledge to self-learning skills; continuing profes- sional development; and health information systems that would allow the continuous monitoring and evaluation of appropriate quality indicators. At present, reforms in the Uzbek health system seem to have reduced access to health services outside the state-financed basic benefits package. The development of pooling schemes and third-party payers might be useful for improving access to health services, and for strengthening the efficiency and equity of the country’s health system.

References

1. World Bank (2007). World development indicators. Washington DC, World Bank.

2. WHO Regional Office for Europe (2007). European Health for All database (HFA-DB) [offline database]. Copenhagen, WHO Regional Office for Europe (June 2007 version).

3. Ahmedov M, Azimov R et al. (2007). Health Systems in Transition: Uzbekistan. Copenhagen, WHO Regional Office for Europe on behalf of the European Observa- tory on Health Systems and Policies.

4. World Bank (2003). Uzbekistan living standards assessment. Washington, DC, World Bank (Report No. 25923-UZ).

5. Ahmedov M, Rechel B et al. (2007). Primary health

HiT profile in brief: Uzbekistan 2008 6

care reform in Uzbekistan. International Journal of Health Planning and Management, 22(4):301–318.

Acknowledgements

Health Systems in Transition (HiT) profile in brief for Uzbekistan was written by Mohir Ahmedov, Ravshan Azimov (School of Public Health, Tashkent), Vasila Alimova (Ministry of Health) and Bernd Rechel (Euro- pean Observatory on Health Systems and Policies) and is based on data available in November 2007. This HiT profile in brief builds on and updates the full HiT pro- file on Uzbekistan of 2007, written by Mohir Ahmedov, Ravshan Azimov, Vasila Alimova and Bernd Rechel. The research director was Martin McKee (European Observatory on Health Systems and Policies).

The Observatory gratefully acknowledges Bruno Bouchet, Peter Campbell, Subrata Routh and Martina Pellny for acting as reviewers.

The European Observatory on Health Systems and Poli- cies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

HiT profile in brief: Uzbekistan 2008 7

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 1 janvier 2007

Source Organisation mondiale de la santé