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PROJECT INFORMATION DOCUMENT (PID) 
CONCEPT STAGE 
Report No.:  AB5492 
Project Name 
Uzbekistan Health System Improvement Project 
Region 
EUROPE AND CENTRAL ASIA 
Sector 
Health (98%); Compulsory health finance (2%) 
Project ID 
P113349 
Borrower(s) 
MINISTRY OF FINANCE 
Government of Uzbekistan 
Implementing Agency 
 
Ministry of Health 
12 Navoi Street 
Tashkent, Uzbekistan 
Tel: (998-71) 139-1954  
office@jpib.uz 
Joint project Implementation Bureau 
Uzbekistan 
"office" <office@jpib.uz 
Environment Category 
[
]
A
[X] B   [ ] C   [ ] FI   [ ] TBD (to be determined) 
Date PID Prepared 
March 4, 2010 
Estimated Date of 
Appraisal Authorization 
February 2011 
Estimated Date of Board 
Approval 
June 14, 2011 
1. 
Key development issues and rationale for Bank involvement 
 
(a) Main Development Issues
.
Uzbekistan’s challenges in health are approaching those faced by 
industrial countries as demonstrated by the status of a few health indicators such as the rate of mortality 
due to chronic illnesses. According to WHO (World Health Statistics, 2009) life expectancy for a person 
born in 2009 is 68 years on average, which is 11 years below the Eur-A average of 79 years. Over the last 
several years, the greatest 
burden of disease
 in Uzbekistan has been attributed to non-communicable and 
chronic diseases, counting cardiovascular diseases and neuropsychiatric conditions among the highest 
causes for both males and females. According to the same source, non-communicable diseases (NCDs) 
accounted for about 90% of all deaths in 2004.  
 
Diseases related to the circulatory system are the most common cause of death accounting for 65.6% of 
age-standardized mortality in 2005 (WHO, 2009).
 
The mortality rate from diseases of the circulatory 
system has increased from 39.1% in 1998 (WHO, 1999) to 56.4% in 2009, a development that mirrors the 
trends in other countries of Central Asia and the Commonwealth of Independent States (CIS). About half 
of all cardio-vascular related-mortality is due to ischemic heart disease, with one-quarter attributed to 
cerebro-vascular related diseases. Malignant neoplasms are the second most prevalent cause of death in 
the country while respiratory diseases account to about 7% of total mortality. Mortality from digestive 
diseases has increased notably in the country, much of which is due to chronic liver disease and cirrhosis. 
These indicators of mortality are greatly affected by poor access to high-quality professional care, 
especially in the rural areas. 
 
Despite this, 
current public health measures
 are largely focused on sanitary-hygienic surveillance and 
infectious disease control. Aspects of a modern health service provision, such as the increasing 
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importance of non-communicable diseases for the health of the population and integration of public health 
services with other areas of the health care system, have not yet been addressed in a comprehensive 
manner. 
 
Uzbekistan has a 
large, inefficient and fragmented network of hospitals
 and specialized clinics, 
characterized by multiple vertical programs and many single-specialty facilities. There is a lack of clarity 
regarding the specific roles and linkages between the numerous hospitals and specialized care facilities. 
Despite the fact that over the last 10 years, the Government has undertaken measures to reduce the 
hospital bed capacity from 5.3 beds/1000 people to 4.8 beds/1000 people, this ratio remains high 
compared both to other LMICs and upper income countries. The gradual reduction in hospital capacity 
since independence has not been part of a planned, comprehensive package (as was the case in primary 
care reform) and therefore with most physical structure and staffing remaining unchanged, there have 
been limited savings and efficiency gains.  
 
Inefficiency
 is evident in the oblast hospitals network and within rayon medical unions (RMOs). At 
oblast level in particular, there is fragmentation and duplication of services across too many separate 
facilities. For example, a patient may be referred to three separate otorhinolaryngologists after referral 
from a General Practition
er (GP): one in the policlinic, another in the hospital’s outpatient specialist 
consultation department, and another in the inpatient department. Duplication of diagnostic departments 
and laboratories in the same city is also evident. In some areas of the country, there is an emerging lack of 
specialized staff to fill all of the positions, while others areas continue to have high staffing relative to 
workload. Additionally, the organization of buildings and departments within each hospital is usually 
very inefficient: existence of multiple buildings on hospital site with poor functional layout and 
connection. These are also characterized by an inefficient management system due to the many 
disconnected vertical chains of command and reliance on vertical, technical routes for oversight. 
 
Poor infrastructure and outdated diagnostic and medical equipment
 at the rayon, city and oblast-
level secondary facilities add on obstacles for provision of quality in-patient care. Except in the upgraded 
Emergency Medical Centers (EMCs), equipment is typically 30 years old or more, and much of it is not 
functioning. Technical maintenance of the medical equipment is absent and facilities often lack needed 
reagents for diagnostic tests. Sustainability is compromised by proliferation of laboratory and diagnostic 
departments across the fragmented facilities network. There is also lack of on-going quality improvement 
programs at the facility level, targeting oblast, rayon hospital, PHC and individual health worker. 
 
Furthermore, the existing specialized inpatient-treatment network is 
oversized, and expensive. 
The 
current hospital staffing structures are based on norms issued by the Ministry of Health, which are not 
aligned with the services offered by the hospitals. Expenditures on hospitals account for around two thirds 
of total public expenditure on health (as of 2005), 85% of which is reportedly accounted for sub-national 
expenditures. 
 
One of the major adverse effects of the current fragmentation for healthcare outcomes is a lack of 
institutional and managerial focus on prevention and management of chronic illness and non-acute 
services for middle-aged and the older population, compounded by a lack of coordination of services for 
patients with multi-system diseases that are mostly related to non-communicable diseases (NCDs). Figure 
1
highlights an unusually low use of medical care by older people who would be expected to be among 
the highest users of care, according to the burden of disease. Care for these conditions often requires 
occasional hospital admissions, periodic specialist outpatient consultations and good coordination with 
primary care. Clinical services in many hospitals, which are delivered around a disconnected vertical 
delivery system, are not evidence-based and do not necessarily address the population health needs. Case 
management fonded on quality improvement techniques, evidence-based medicine and up-to-date clinical 
practice protocols and standards is largely absent. 
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Figure 1: Consumption of Medical Care in Uzbekistan by Age and Gender
 
Source: Edward Frid and Ilkhom Maksudov, 
Per Capita Financing Study
,
World Bank, 2005. 
 
The quality assessment of pediatric inpatient care conducted by WHO in 2008, has revealed a number of 
shortcomings in clinical management (diagnostic, treatment, and monitoring): for 35 % of the 87 cases 
observed, children did not require the hospitalization; in 76 % of the cases observed confirmed that the 
therapy prescribed was noted as ineffective and unsafe; in 81 % of cases observed, clinical management 
was considered suboptimal, and in 94 % of cases observed, health workers did not have clinical protocols, 
guidelines and/or clinical standards. 
 
Resource allocation and payment methods
 are based on input-based norms (bed and staff numbers) and 
reflect ad hoc changes to capacity, resulting in geographic inequity and perverse incentives against 
improved efficiency.  
 
Urgent interventions are needed to address the
 
principal health care problems 
of
the country. Those 
would aim at: (i) supporting preventive measures and health promotion programs for NCDs with high 
mortality rates; (ii) increasing the role of primary health care in prevention, diagnosis and treatment; (iii) 
improving the quality of hospital services by addressing the fragmentation and inefficiency found in 
health care delivery, especially in rural areas; (iv) substantially repairing the many regional hospitals, and 
replacing the depreciated equipment (over 20 years old); (v) developing an appropriate referral system 
while adopting quality management principles; (vi) developing motivation mechanisms, improving human 
resource management and work standards, and providing training to health service providers (at all levels); 
(vii) improving health budget spending (total budget for health sector is a relatively small 2.5% of GDP); 
(viii) addressing the current input-based norms for resource allocation and payment (based on bed and staff 
numbers) with a view to reduce geographical inequity and perverse incentives; and (ix) providing 
affordable, transparent, and accountable hospital services for the older age population. 
 
(b) Rationale for Bank Involvement
.
The Bank has included the proposed project in the CAS for the 
period FY09-FY11 (Report No. 43385-UZ, May 14, 2008), which responds to two of the CAS four pillars 
specific to (a) enabling environment for shared growth (under “increasing the efficiency of public 
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financial management for more effective service provision”); and (b) improving human development and 
social protection through improved basic services delivery. 
Since the mid-1990s, Uzbekistan has undergone reforms in the health sector that focus on restructuring 
primary health care and on establishing an emergency medical care network. The country has 
implemented a standard approach to training GP, upgrading PHC infrastructure, allocating equipment for 
GP in rural clinics, and in improving the provision and scope of health services. The Primary Health Care 
reforms supported by the World Bank through two investment projects - Health 1 and Health 2, are nearly 
completed.  Assessments indicate that the projects’ investments resulted in increased satisfaction of 
population with the improvement of primary health services and increased motivation of service providers 
as a result of improved working conditions, retraining and availability of bonus incentives. However, 
considerable challenges remain with respect to governance, in particular financial and management 
accountability, efficiency in public resource management as well as quality of service provision. 
 
Government’s Interventions
.
The Welfare Improvement Strategy 2008-2010 and the Decree of the 
President of Uzbekistan (PP-
700
as of September 19, 2007), “On main directions on further deepening of 
reforms and implementation of the State Program on Healthcare Development” identifies inpatient and 
specialized care as important areas of focus for the next stage of health sector reforms with the aim of 
improving the performance of medical establishments. The Government’s goal is to improve the quality 
of secondary care in rayons/cities and make tertiary care available in oblast facilities, to increase access 
and to reduce self-referral and referral to specialized hospitals in Tashkent. The Government intends to 
improve the provision of specialized care through making substantial investment for upgrading rayon 
medical unions, oblast multi-profile hospitals and multi-profile children’s centers, and diagnostic centers. 
The MOF has budgeted US$500 million for civil works investment over 2008-2012 for this program, and 
is seeking financial support from development partners/donors for equipment and training costs. The 
investment plan, which has already been formulated, is based on a comprehensive inventory and bottom-
up proposals from rayons and oblasts. The GOU is interested in improving the functional efficiency 
within
 the Rayon and City Medical Unions (RMU and CMU respectively), and within the referral chain 
from SVPs through rayon, oblast and Republican facilities. 
 
Current and planned support from Donors and International Agencies
 
mainly focus on the policy front 
and on financial and institutional reforms.  Bank’s involvement would complement the current and 
planned support from Government and other donors and international agencies by addressing in a more 
systemic way, the challenges of non-communicable diseases, general public health education and 
promotion, and behavioral change of the population.  This project would aim at bringing together the 
various interventions among donors while focusing on integrating and scaling up major public health 
action through deepening ongoing health sector reforms within the context of the Government Welfare 
Improvement Program.  
 
2. Proposed 
objective(s) 
The overall objective is improving health system performance in delivery of efficient and quality essential 
health services and its ability to address the pending epidemic of chronic non-communicable diseases. 
The specific objectives are: (i) improving quality of medical services in rayon medical unions; (ii) 
ensuring financial sustainability of upgraded rayon medical unions; and (iii) supporting health promotion 
and prevention programs targeting NCDs and improving the epidemiological surveillance of 
communicable diseases through piloting reorganization of the public health laboratory network. 
 
3. Preliminary 
description 
 
Component 1: Improving
 
Health Service Delivery. 
This component is aimed at improving the quality 
of care within selected priority clinical conditions responsible for the highest burden of diseases according 
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to quality management principles. This involves the use of comprehensive clinical and public health 
approaches aimed at reducing the impact of these conditions on the health status of the population while 
improving outcomes.
 
Sub-component 1.1: Hospital Services Improvement  
 
This sub-component aims at improving quality of medical services in  rayon medical unions and access to 
specialized inpatient and consultative outpatient care in rayon hospitals through: (i) the provision of 
medical equipment for central rayon hospitals; (ii) the development and implementation of systematized 
medical equipment  maintenance for these hospitals; (iii) the development, review and implementation of 
the new clinical standards and protocols of the MoH; (iv) the functional planning of health service 
delivery for participating RMUs/CMUs, (v) the development of health service referral guidelines and 
mechanisms. The Government will finance under parallel financing (i) upgrading of buildings and 
fixtures of the central rayon hospitals and laboratory facilities; and (ii) recurrent operating costs. The 
estimates amount of Government contribution is UDS 300 million.  
 
Sub-component 1.2: Primary Health Care Development  
 
This sub-component aims at providing further support to general practice-based Primary Health Care 
established and supported under the IDA-financed Health I and II projects.  It will finance: (i) the 
expansion of urban primary care model through investment in medical personnel and equipment in urban 
PHC facilities (all policlinics) in three oblasts: Fergana, Syrdarya and Samarkand; (ii) the extension of 
training/retraining programs to an additional number of PHC providers from rural Primary Health Care 
Clinics (SVPs, 
Selski Vratch Punckt
)
and reformed polyclinics; (iii) establishment of well designed and 
sustainable equipment maintenance system for PHC facilities developed through Health 2 project; and 
(iv) provision of energy security technologies to the selected PHC facilities (SVPs and polyclinics). 
 
Sub-component 1.3: Human Resource Quality Enhancement  
 
The key aim of the component is to strengthen the quality of care at primary and secondary health care 
levels through improvement of the clinical skills and competence of health personnel. This includes: (i) 
completion of GP re-training for rural health facilities and urban polyclinics; (ii) training of RMU and 
CMU pediatric and internal medicine doctors and nurses in new Clinical Practice Guidelines (CPGs); (iii) 
training of trainers in clinical case management; (iii) the development and introduction of up to date 
relevant and practical guidelines/treatment standards for RMU/CMU internal medicine and pediatrics 
staff. 
 
Component 2: Strengthening Health Financing and Management Reforms 
 
This component aims at: (i) solidifying and institutionalizing per capita based rural Primary Health Care 
Financing and management reforms that were rolled out nationwide within Health 2, including changes in 
oblast fiscal allocations; and introducing results-based provider payment system in the hospitals and PHC 
facilities. It will finance : (i) the development of appropriate regulatory measures to ensure lead role of the 
oblast/rayon health organs in health budget planning; (ii) staff training in financial management of 
reformed PHC and hospital facilities; (iii) design and implementation of performance-based incentive 
scheme for the reformed PHC facilities; (iv) implementation and evaluation of a pilot case-based payment 
system for the multi-profile hospitals in one oblast: Fergana; (v) the review of the current system of user 
fee exemptions and a study on the causes for the low utilization of hospital services by middle aged and 
older population. 
Component 3: Improving Public Health Service Delivery  
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This
 
component
 
is aimed at improving selected essential public health functions related mainly to NCDs 
and also for which there is strong counterpart buy-in and support.  The proposed activities could include:  
Sub-component 3.1: Health Promotion and NCDs Prevention.
 This sub-component would build on 
current efforts to improve health promotion. Specifically it would support the development and 
implementation of a comprehensive national level Health Promotion program focused on the promotion 
of healthy lifestyles and prevention of NCDs.  
Sub-component 3.2: Strengthening Health Surveillance Systems.
 The sub-component would 
encompass the strengthening of surveillance systems and of the capacity of the Institute of Health to use 
data for policy making and program planning, and for monitoring NCDs.   
Component 4: Project Management 
 
This component would finance project’s administrative and fiduciary requirements such as project 
coordination, monitoring, evaluation, procurement and financial reporting.  
The Project would be implemented over a five year period and would finance goods, consultant services, 
training, and incremental operating costs. The Government would finance cost of upgrading the physical 
condition of hospitals and laboratory facilities, recurrent operating costs and taxes. 
 
4. 
Safeguard policies that might apply 
The project would not present any significant environmental concerns and will not finance civil works.  
The project does not deal with disposal of medical waste.   Nevertheless, an environmental expert has 
been recruited under Health II project to help Government prepare the environmental assessment for this 
operation.  He is currently in the field and his draft report should be made available by December 2010.   
 
5. Tentative 
financing 
Source: ($m.) 
BORROWER/RECIPIENT 0.0 
International Development Association (IDA) 
93.0 
 Total 
93.0 
 
6. Contact 
point 
Contact: Susanna Hayrapetyan 
Title: Sr Health Spec. 
Tel: 5251+250 
Fax:  
Email: shayrapetyan@worldbank.org 
Location: Yerevan, Armenia (IBRD)