Public health challenges and achievements in ensuring population health

Introduction

Uzbekistan's healthcare system is undergoing major changes aimed at providing quality healthcare to the entire population, with the goal of making services available to the population regardless of where patients live.

Uzbekistan's health care system is mainly centered on the state system, which in turn is divided into three hierarchical levels: the national (republican) level, the oblast level, and the local level, consisting of districts or cities, with an increasing share of the private sector. The private sector is still a small part of the system and is mainly represented by pharmacies, private medical clinics, and institutions involved in the production and supply of medicines or medical equipment.

Achievements of Uzbekistan in the field of health care

Uzbekistan continues its efforts to reform the health care system in order to maintain the health of the population and raise a physically and mentally healthy generation. Improving the quality and accessibility of medical services, introducing modern technologies, strengthening the regulatory and legal framework, protecting mothers and children, improving specialized medical care, developing medical education and strengthening human resources have been identified as priority areas for the complete transformation of the health care system.

In particular, over the last 7 years, more than 200 legal documents have been adopted in the field of health system development. As a result, significant changes are taking place in all parts of the health care system. Beginning with primary health care and ending with specialized centers, new technologies are being introduced and the achievements of world science and medicine are being widely used. These changes are based on the Decree of the President of the Republic of Uzbekistan "On comprehensive measures to radically improve the health care system of the Republic of Uzbekistan" dated December 7, 2018. The Decree approved the Concept of development of the health care system of the Republic of Uzbekistan for 2019-2025 (Reference: Decree of the President of the Republic of Uzbekistan dated 07.12.2018, № PD-5590).

The recommendations of WHO experts were taken into account in the development of the concept for the development of the health care system. It covers practically all areas: improvement of legislation and the system of financing health care, development of the private sector, improvement of the quality and accessibility of medical care, gradual introduction of compulsory health insurance, creation of an effective system of training, retraining and professional development of medical personnel, as well as development of medical science, widespread introduction of "e-health care".

The amount of funds allocated for health care has increased 6 times and amounts to about 30 trillion soums. The most widespread diseases and applications of the population form the scope of guaranteed medical services provided by the state free of charge.

Today, the technical base of more than 3,650 primary health care institutions operating in the country is undergoing significant renovation, and the capacity of medical personnel is increasing.

Since 2020, Uzbekistan has made significant progress in reforming its health system with WHO support. An important step has been the introduction of a primary health care approach, which has significantly improved access to health services. In particular, new methods of health care delivery have been successfully tested in the Syrdarya region and are now being extended to other regions. Uzbekistan has also made progress in the fight against tuberculosis, improving treatment and diagnosis rates. In 2021, the treatment success rate increased to 89% as a result of the introduction of the latest methods and legislative initiatives. (Reference).

Achievements in health care are also reflected in the analysis of key health indicators of Uzbekistan, provided by the Statistical Agency under the President of the Republic of Uzbekistan. Health indicators play an important role in assessing the overall well-being of the population and provide insight into the efficiency and effectiveness of the country's health system. By examining and analyzing key health indicators in Uzbekistan, including the number of hospitals, availability of hospital beds, access to specialized clinics, and availability of health workers, we can gain valuable information about the strengths and weaknesses of the health system, identify areas for improvement, and ultimately improve the quality of health services.

Source: Statistical Agency under the President of the Republic of Uzbekistan

The number of hospitals in Uzbekistan increased from 1,158 in 2010 to 1,432 in 2023, indicating positive progress in providing the population with accessible health facilities. The availability of hospital beds has fluctuated over the years and increased to 174,500 in 2023. However, the ratio of population per hospital bed increased to 243 in 2015 but decreased to 211 in 2023. This emphasises the importance of ensuring sufficient hospital beds to meet the health needs of the population.

The number of outpatient polyclinics has steadily increased from 5993 in 2010 to 8011 in 2023, indicating improved access to outpatient care and preventive services, contributing to a healthier population. However, there has been a decline in the number of specialised clinics, especially obstetric and gynaecological clinics. Access to specialised clinics, such as obstetric and gynaecological clinics, is critical to meet the specific health needs of women.

The availability of health care providers has shown a positive trend, with the number of doctors increasing from 79,900 in 2010 to 105,700 in 2023. However, the ratio of population per physician in general decreased slightly over the same period, indicating a decline in access to health care services. The number of nursing staff increased from 310,200 in 2010 to 387,600 in 2023, contributing to improved health care coverage.

Uzbekistan has made improvements in some areas of the health system, such as the number of hospitals, outpatient clinics and health workforce, but problems remain with the availability of hospital beds, access to specialised clinics and the ratio of population to health workers. The Government is currently taking steps to further address these challenges, which are important to provide better health care and promote healthier lifestyles for the population. One of the major steps in further improving the health care system is the National Strategy ‘Population Health 2030’.

National Strategy ‘Population Health - 2030’.

The Ministry of Health has developed and published a draft national strategy ‘Population Health - 2030’, which outlines steps to create a new system of medical care in Uzbekistan. It is planned to reorganise the financing of medical institutions of all instances, the system of supplying them with medicines and medical equipment, as well as the principles of management.

According to the draft strategy, the exact amount of guaranteed medical services for each level will be determined annually. Financing of polyclinics will be transferred to the insurance model: for hospitals - per patient, for polyclinics - per each attached citizen.

The strategy also envisages the expansion of paid medical services and a gradual increase in the financial independence of medical centres. It is planned to increase the contribution of medicine to GDP to 5 per cent. It is planned to implement up to 200 projects on the basis of public-private partnership. Multidisciplinary hospital clusters with a minimum of 1,000 beds will be opened in all regions. Mechanisms will be introduced to support non-state medical institutions. It is planned to increase the share of the private sector in healthcare up to 50 per cent by purchasing services from them and transferring state clinics to private sector management.

Maternal and child health

There is nothing more important in the health care system than maternal and child health care, as it is of great importance in the formation of a healthy gene pool. That is why our country pays special attention to the development of this area, including improving the quality of perinatal care, improving the infrastructure of medical institutions for maternal and child health care, equipping them with modern medical equipment and providing them with personnel.

In particular, antenatal (prenatal) screening rooms are now operating in primary health-care facilities. At present, 8,500 obstetricians in medical teams are working to fully cover about 900,000 pregnant women and more than 9.1 million women of reproductive age with the patronage service and to register them in a single electronic database in the antenatal clinics of 209 multidisciplinary central polyclinics.

In the regions, each district (city) polyclinic has established children's departments and girls' health centres, as well as round-the-clock paediatric posts and paediatric intensive care units, and mobile intensive care teams for children and pregnant women.

As a result of the reforms, the maternal mortality rate decreased from 21.0 ppm in 2017 to 13.9 ppm in 2022 and the infant mortality rate from 11.5 ppm in 2017 to 8.7 ppm in 2022.

Introduction of health insurance

In 2023, the WHO report ‘Transforming the health system in Uzbekistan: a two-year review of implementation’ was presented. WHO reviewed recent health system reforms in Uzbekistan and makes recommendations related to primary health care, health financing and eHealth solutions - the areas of focus of this report. This report was developed by the WHO Barcelona Office for Health Systems Financing and the WHO European Centre for Primary Health Care.

The report presents Uzbekistan's main achievements in the field of health care, including:

• establishment of the State Health Insurance Fund as a single purchaser contracting with medical centres and pharmacies;
• improving the organisation of primary health care (PHC) in Syrdarya province;
• new mechanisms of payment to suppliers and contracts with health facilities;
• advanced electronic health (e-health) information systems used by pharmacies.

WHO recommends a tax-financed health insurance system as the most appropriate model for Uzbekistan and advises that the impact and effectiveness of new payment systems be carefully monitored.

In September 2024, the President of Uzbekistan, Shavkat Mirziyoyev, highlighted key measures aimed at strengthening the primary health care system and introducing national health insurance mechanisms. In presenting these initiatives, President Mirziyoyev emphasised the importance of strengthening primary health care to improve public health outcomes, promote early detection of diseases and ensure effective treatment.

As part of health sector reform, the Government has rolled out a state health insurance system from 1 October 2024 in Tashkent and Syrdarya province. The system is expected to be extended to the Republic of Karakalpakstan from 1 January 2025. Preparations for the insurance system include the introduction of the ‘Electronic Polyclinic’ and ‘Electronic Hospital’ information systems by the end of 2024. These systems will improve administrative efficiency and support the training of medical staff.

Within the framework of the public health insurance system in Tashkent:

• A guaranteed package of free medical services and medicines provided by the State is being introduced;
• A system of referral of patients to specialised specialists or hospitals is being organised through the family physicians assigned to them;
• medicines are provided free of charge to the population within the guaranteed package through pharmacies on the basis of an electronic prescription for the treatment of the most common diseases.

To support the implementation of the health insurance system, health facilities will be provided with the necessary technological upgrades and network infrastructure. This includes equipping facilities with modern technology and providing qualified staff to utilise the new systems.

A key feature of the new health insurance system is its emphasis on results-based financing. Medical services and pharmaceuticals covered under the insurance plan will be financed from the state budget, eliminating the need for additional costs for patients.

It is planned that by the end of 2026 the health insurance system will be widely implemented in other regions of Uzbekistan. The phased introduction is aimed at ensuring a smooth transition and comprehensive coverage of health care needs in different regions.

Development of private health care facilities

One of the main advantages of involving the private sector in health care is its ability to innovate. At the same time, the private sector can significantly expand the range of health services available to the population. Private clinics and hospitals operating on the principle of competition provide a wide range of medical services to patients. This, in turn, improves the accessibility and quality of health services.

Today, foreign investors in our country are granted the same privileges as domestic entrepreneurs, which undoubtedly increases their interest in Uzbekistan. In order to develop private medical institutions in our country, such clinics were granted tax and customs privileges, cancelled the mandatory tourist tax for medical tourists and allowed to provide medical services at the expense of state funds.

It is worth noting that the number of private hospitals in Uzbekistan has increased in recent years. In 2017, the number of private hospitals was 3454, in the current 2024 this figure has reached 9200. At the same time, the annual increase averages 500-600 new private clinics. The range of medical specialities represented in the non-government sector is also expanding - from 50 to 225 types. The private sector already owns 35% of all places created in the country's medical organisations.

The share of the private sector is increasing due to high-tech diagnostic and treatment services provided in state institutions on the principles of public-private partnership. According to the draft Strategy ‘Health of the Population - 2030’, mechanisms to support non-state medical institutions will be introduced. By purchasing services from the private sector and transferring the management of state clinics to the private sector, it is planned to increase the share of the private sector in health care to 50 per cent by the end of 2025 and 80 per cent by 2030.

Further steps to improve the health care system of the population

By the end of 2024, the existing 40 sanitary rules, norms and hygienic standards will be fully revised and brought in line with international standards.

Modern management methods and high standards of safety and quality of medical care will be introduced into the activities of the republican specialised scientific and practical medical centres for surgery, cardiology, endocrinology, dermatovenerology and cosmetology, the National Children's Medical Centre and the National Medical Centre, and their international accreditation will be carried out.

Financing and infrastructure

Over the past seven years, funding for the health care system has increased from 5.9 trillion soums to 33.5 trillion soums, which is six times higher than previous expenditures. This has made it possible to significantly improve the material and technical base by equipping hospitals with modern equipment and opening new medical centres.

Primary health care

Important attention is being paid to primary health care. The new model of medical teams includes the assignment of one family doctor, a nurse practitioner and additional midwives per 2,000 inhabitants. This allows doctors to spend more time with patients and to carry out preventive measures more effectively.

Emergency medical care

The one-stop emergency medical service was created to provide high quality care. Innovative technologies have reduced response time to calls, which is critical to saving lives. Today, doctors and nurses work in conditions that meet international standards.

Digitalisation of health care

Healthcare modernisation is impossible without the introduction of digital technologies. Electronic systems, such as Electronic Polyclinic and Electronic Prescription, help optimise the work of medical institutions and make services more accessible to the population. The Situation Centre ensures the integration of all information systems in healthcare.

Education in health care

Equally important is the development of the educational system. Uzbekistan has many medical institutions of higher education, which are internationally recognised. Success in the educational sphere is a guarantee of future achievements in health care.

Conclusion

Despite the successes achieved, there are still problems that require further attention. The task of increasing the availability of specialised care, ensuring an adequate level of staffing and improving the material and technical base of medical institutions remains an urgent one.

In the long term, Uzbekistan aims to achieve a high level of medical care for its citizens. The introduction of health insurance, the development of high-quality medical education, the expansion of the private sector in health care and the digitalisation of all processes are becoming cornerstones of the strategy to improve the health care system. Importantly, health-care reform is oriented towards ensuring equal access to quality medical services for all segments of the population, regardless of place of residence or social status.

It can be noted that Uzbekistan is on the right track towards the creation of a modern, accessible and efficient health care system that will meet the needs of the population and meet the challenges of the time. The reforms that are ongoing and planned for the next decade create prerequisites for the sustainable development of health care in the country, raising the living standards of citizens and creating a healthy society as a whole.