In 2019, Uzbekistan embarked upon an ambitious transformation of its health system, including service delivery and health financing. Prior to this, the country’s healthcare system was largely financed through household out-of-pocket payments (46%), indicating inadequate financial protection. Compounding this issue of out-of-pocket expenditure was a heavy dependence on hospitals for healthcare services. This dependence was in part due to the ineffectiveness of primary health facilities in preventive treatment, as well as low uptake of outpatient treatment services. More than 40% of patients, receiving inpatient treatment at the district level, could receive outpatient treatment at home or in a day-time hospital—reducing costs. Furthermore, Uzbekistan has a large and fragmented network of hospitals and specialist clinics that complicates efforts to utilize health resources efficiently. Investing in primary health care—thereby prioritizing prevention—facilitates better care, at lower costs. Uzbekistan’s health system therefore required reforms in three areas: equity of healthcare financial protection, quality of primary healthcare services, and efficiency in healthcare resource allocation.

WHO supported the development of a legal foundation for this transformation, including a Presidential Resolution establishing mandatory health insurance and a strategy for piloting service delivery reforms in Sydarya Oblast—with the intent to scale reforms to the entire country by 2025. Highlights from these reforms include:

• Establishing a State Health Insurance Fund (SHIF) to address high out-of-pocket expenses and enhance financial protection. The MOH will introduce SHIF as the single purchaser of a state-guaranteed package of health services that contracts with health providers under a new model of payment. The Fund will establish a system for strategic purchasing of health services, with a view to providing all strata of the population with quality and essential health care within the scope of a guaranteed package.
• Strengthening service delivery in primary care to ensure that patients are treated more efficiently, at lower levels of care and closer to their communities. Proposed service delivery reforms promote evidence-based provision of primary care services, expand the role and functions of family physicians, nurses and GPs in early detection and preventive health services and change the current patient pathway. PHCs will be equipped with medical brigades comprising a family physician and midlevel health workers, nurses and midwives. To ensure quality of service delivery, primary-healthcare-worker performance will be monitored, with incentive payments made based on results. PHCs in Uzbekistan will also be equipped with multi-disciplinary teams to tackle NCDs or chronic diseases through evidence-based service delivery.
• Restructuring service-delivery systems in public hospitals to address high expenditure associated with tertiary hospitals. PHCs will share health resources and work tangentially with public hospitals to ensure optimal and efficient usage of resources—and avoid duplication of service delivery. Efficiency gains achieved in this health reform will also support establishment of stronger people-oriented PHCs, and support better equity and equality in service delivery. 

It is expected that these reforms will contribute to intermediate outcomes in effectiveness, efficiency, equity, responsiveness and accountability and, in turn accelerate Universal Health Coverage (UHC).

Reforms were underway, when the COVID-19 health crisis emerged. To maintain momentum, WHO’s Country Office continued to participate in high-level meetings, facilitate technical working groups, share guidelines and good practices, as well as review and revise draft legislation. To allay government concerns about implementing service delivery and health financing reforms in the midst of a pandemic, WHO provided additional evidence and facilitated several rounds of discussion. The process of re-building consensus within the Government of Uzbekistan provided an opportunity to further engage other health development partners in the proposed Sydarya pilot. WHO convened regular monthly meetings with all health development partners, as well as ad hoc meetings with key partners in health financing such as the World Bank, Asian Development Bank and German Development Bank. These partners joined WHO in expressing verbal support for the Presidential Resolution, pledging technical and financial support as well.

WHO continued to push for larger health reforms despite additional priorities related to COVID-19. Significant outcomes in both health reforms and COVID-19 management, characterise WHO’s achievements in 2020. In addition to sector reforms, WHO’s Country Office developed a strategic preparedness and response plan for COVID-19, delivered a 36-hour training program for postgraduate students of Intensive Care Units that was adopted by the MOH, and disseminated Uzbekistan’s first Weekly National Influenza Bulletin. WHO’s efforts in the region contributed towards building resilient health systems and accelerating UHC. These achievements will serve to protect Uzbekistan from epidemics and other health emergencies in the future.

Photo caption: RKI-WHO mission on Intra Action Review to COVID-19 Response, Bukhara, Uzbekistan.

Photo credit: WHO

Disclaimer: This image was taken during a time of no community transmission of COVID-19. Community transmission is defined as the inability to relate confirmed cases through chains of transmission for a large number of cases, or by increasing positive tests through sentinel samples (routine systematic testing of respiratory samples from established laboratories). Preventative measures such as mask wearing and physical distancing should be used to prevent the spread of COVID-19.