2012年-世界发展银行全球_Hospital_Sector_Reform_in_Uzbekistan___A_Policy_Note_19页_957kb

Summary of Hospital Sector Reform in Uzbekistan

Core Content

Uzbekistan has been implementing hospital sector reforms since the mid-1990s, with a focus on restructuring primary health care and establishing an emergency medical care (EMC) network. These reforms have led to improvements in clinical quality and patient satisfaction, while also reducing outpatient attendances and inpatient admissions at central rayon hospitals. The EMC network, however, has remained a key success, offering 24/7 services free of charge and improving access to acute care.

Main Views and Key Information

1. Primary and Emergency Care Reforms

• Primary Care Reforms: Have resulted in better clinical outcomes and patient satisfaction.
• Emergency Medical Care (EMC) Network: Includes national and oblast level hospitals, EMC departments, and ambulance services, providing high-quality 24/7 care for acute conditions.
• Referral Systems: Established between rayon, oblast, and republic levels to improve service coordination.

2. Secondary and Tertiary Care Developments

• Sub-national Hospitals: Have undergone gradual downsizing, with a 50% reduction in total hospital bed capacity between 1997-2005.
• Oblast Hospitals: Experienced a 20% reduction in numbers and a 1.8% decrease in beds, while doctor numbers decreased by 3.8%.
• Republican Specialized Tertiary Centers: Expanded, with a 46.6% increase in doctor numbers and a 56.2% rise in admissions.
• Bed Reductions: Not uniform across regions, leading to uneven access to secondary care.
• Future Plans: Further bed reductions, especially in rehabilitation hospitals, are expected over the next five years.

3. Financing and Payment Reforms

• User Fees: Increased in response to reduced government subsidies, especially in non-emergency and non-specialized hospitals.
• Voucher System: Provides free care for socially protected groups, with vouchers allocated by rayon-level health facilities.
• Payment System: The "completed case" basis is being introduced in some Republican Specialized Centers, with potential extension to Oblast hospitals.
• Budget Allocation: Sub-national hospitals account for over 85% of total public health expenditure, with rising costs per bed and per admission despite reductions in capacity.

4. Challenges in the Sector

• Fragmentation: The health system is highly fragmented, with multiple vertical programs and single-specialty facilities.
• Inefficiency: Leads to duplication of services, high costs, and poor utilization, especially among middle-aged and elderly populations.
• Quality and Access: Many sub-national hospitals are in poor condition, and patients often self-refer to Tashkent due to perceived lower quality and lack of diagnostic equipment.
• Informal Payments: Widespread, with many households paying bribes or informal fees for primary care, and limited awareness of official payment policies and free services.

5. Government Plans for Reform

• Welfare Improvement Strategy (2008-2010) and Presidential Decree PP-700 outline the direction of hospital reform, emphasizing:
  • Structural Changes: Consolidation of rayon/city hospitals under a single legal entity.
  • Diagnostic Centers: Stand-alone centers at oblast level, managed by maternal and child health departments.
  • Treasury Reforms: Integration of health facilities into the single Treasury system, with fixed monthly budgets and input categories.
  • Investment Plan: US$500 million allocated for upgrading facilities, with additional funding sought from development partners.
  • Training Programs: For doctors and healthcare managers to improve clinical and managerial practices.

6. Donor-Supported Initiatives

• Purchaser-Provider Split Framework: Recommended by development partners, aiming to give providers financial and managerial autonomy.
• Zdrav-Plus Project: Supported development of a pilot for this framework in Ferghana, including Health Management Information Systems (HMIS) and case-based payment proposals.
• World Bank's Role: Technical support for Treasury reforms and potential investment in priority areas, though a more outcome-oriented approach is needed for better acceptance.

7. Navoi Health Care Improvement Program

• A recent initiative focused on reducing NCD-related mortality and improving chronic disease management.
• Emphasizes a holistic approach to care, including prevention, diagnosis, treatment, and coordination.
• Suggests a more acceptable model for reform, aligning with Presidential Decree PP-700 while proposing additional integration of specialist dispensaries into general hospitals.

8. Financing and Financial Protection

• Budget Allocation: Hospitals consume 65% of the national health budget, with sub-national hospitals accounting for 70% of hospital expenditure.
• Financial Barriers: Increasing user fees and informal payments create access challenges, especially for the poor and those with high healthcare costs.
• Need for Transparency: Clear mechanisms for handling co-payments and displaying price lists are required to improve accountability.

Key Reform Issues and Options

A. Sector Organization: Fragmentation

• Problem: Inherited fragmented structure from the USSR, leading to inefficiencies, duplication, and poor access.
• Option: Consolidate management and facilities into multi-profile general hospitals, integrating emergency and non-acute services.

B. Financing of Health Services: Budget Allocation, User Fees, and Financial Protection

• Problem: Informal payments, lack of transparency, and limited financial protection for vulnerable groups.
• Option: Implement a transparent co-payment mechanism, expand free services for socially protected groups, and improve information dissemination on costs and services.

Conclusion

Uzbekistan's hospital sector reform has made progress in primary and emergency care, but secondary and tertiary care systems remain fragmented and inefficient. The government's current reforms aim to improve quality and efficiency through structural and financial changes, but these face challenges due to uneven implementation, informal payments, and lack of transparency. A more outcome-oriented approach, such as the Navoi model, may offer a better path for reform, with potential support from development partners like the World Bank.