No. MINISTRY OF HEALTH REPUBLIC OF UZBEKISTAN BASIC DESIGN STUDY REPORT ON THE PROJECT FOR IMPROVEMENT OF PRIMARY MEDICAL AID IN THE TASHKENT AND DJIZAK REGIONS IN THE REPUBLIC OF UZBEKISTAN OCTOBER 2006 JAPAN INTERNATIONAL COOPERATION AGENCY UNICO INTERNATIONAL CORPORATION GM JR 06-198 MINISTRY OF HEALTH REPUBLIC OF UZBEKISTAN BASIC DESIGN STUDY REPORT ON THE PROJECT FOR IMPROVEMENT OF PRIMARY MEDICAL AID IN THE TASHKENT AND DJIZAK REGIONS IN THE REPUBLIC OF UZBEKISTAN OCTOBER 2006 JAPAN INTERNATIONAL COOPERATION AGENCY UNICO INTERNATIONAL CORPORATION PREFACE In response to a request from the Government of the Republic of Uzbekistan, the Government of Japan decided to conduct a basic design study on the Project for Improvement of Primary Medical Aid in the Tashkent and Djizak Regions and entrusted the study to the Japan International Cooperation Agency (JICA). JICA sent to Uzbekistan a study team from February 28 to March 24, 2006. The team held discussions with the officials concerned of the Government of Uzbekistan, and conducted a field study at the study area. After the team returned to Japan, further studies were made. Then, a mission was sent to Uzbekistan in order to discuss a draft basic design, and as this result, the present report was finalized. I hope that this report will contribute to the promotion of the project and to the enhancement of friendly relations between our two countries. I wish to express my sincere appreciation to the officials concerned of the Government of the Republic of Uzbekistan for their close cooperation extended to the teams. October 2006 Masafumi Kuroki Vice-President Japan International Cooperation Agency October 2006 Letter of Transmittal We are pleased to submit to you the basic design study report on the Project for Improvement of Primary Medical Aid in the Tashkent and Djizak Regions in the Republic of Uzbekistan. This study was conducted by UNICO International Corporation, under a contract to JICA, during the period from June 2005 to October 2006. In conducting the study, we have examined the feasibility and rationale of the project with due consideration to the present situation of Uzbekistan and formulated the most appropriate basic design for the project under Japan’s grant aid scheme. Finally, we hope that this report will contribute to further promotion of the project. Very truly yours, Wataru Shiga Project manager, Basic design study team on the Project for Improvement of Primary Medical Aid in the Tashkent and Djizak Regions, UNICO International Corporation SUMMARY SUMMARY Uzbekistan in Outline The economic base of the Republic of Uzbekistan is cultivation of cotton and other cash crops but the nation is relatively well endowed with mineral and energy resources. Since attaining independence in 1991, Uzbekistan has accomplished its distinctive pattern of economic development, by adhering to a policy of moderatism while attaching importance to three core objectives for structural reform of the economy, namely stabilization of the macro-economy, transiting to a market economy, and attraction of foreign direct investment. During 1998-2003, growth of the GDP was stable, averaging 4.2%, a performance that owed much to progress in restructuring the large state enterprises and facilitating dynamism among private corporations. Following a record-setting performance of 7.7% GDP growth in 2004, the high growth of real GDP of 7% was achieved in 2005, and rapid progress was evident in the movement toward a market economy. A high literacy rate -- 99% -- is a characteristic of Uzbekistan, indicating that the nation is also endowed with a labor force of high quality. The structure of employment in Uzbekistan is about 32% of jobs in agriculture, about 13% in industry, about 8% in construction, and about 14% in all other sectors, so that non-manufacturing and other services account for about 32%. The sectoral composition of industry, in fiscal 2005, in terms of shares of GDP, indicate that agriculture contributes 25%, industry 20.7%, construction 4.9%, services 38.4%, and net tax collection 11%. Irrigated farming is the basis of Uzbekistan’s agriculture. In addition to the traditional cultivation of cotton, a major crop is wheat but there is also considerable production of other grains, vegetables and fruits, and in the mountainous districts there is a vibrant livestock sector, producing meat and dairy products, and eggs. The industrial sector is dominated by extraction or recovery and processing of natural resources on a scale significant in global perspective. Natural gas and coal are the most important in this regard, but Uzbekistan also continues to occupy an important position as a producer of raw materials for the textile industry. In terms of the value of industrial production, energy resources (fuels) account for 27.2% of the total, light industry (textiles, leather processing, others) 16.9%, nonferrous metals 16.9%, machine-building 12.9%, and food processing 8.4%, leaving 17.7% provided by other sectors. Overall, the industrial sector is characterized by natural resources including in particular mineral resources, by cotton production, and by foodstuff production, whereby the processing of agricultural resources is the dominant characteristic. During the decade and a half since attaining independence, coupled with the development of the economy that has largely taken place in the urban areas, economic disparity between the urban and rural areas has emerged, and disparities have become evident and have enlarged, with regard to the environment for education, access to safe drinking water, and social services such as health and S - 1 medical care. In terms of the UNDP Human Development Index, whereas the score for Uzbekistan was 0.737 in 1996, by 2005 it had fallen to 0.694 (111th out of 177 countries), signifying that the fruits of economic growth and development were not being recycled so as to improve the lives of the people on an equal and fair basis. In order to deal with the challenges that these conditions represent, further development of the market economy, and improvement of the economic infrastructure, are indispensable requirements, as well as the reduction of poverty as an effect of achieving solid economic growth over the long run. Further, necessity also exists for improvement of social services that function as a safety net for the poor people in particular, so that it will be possible to stabilize the livelihoods of the people in a manner that is balanced in regional comparisons. The Uzbekistan government, from this viewpoint, has taken up the challenges of structural reform of the economy, agricultural reform, education reform, health services and medical care reform, judicial reform and other development objectives, among which improvement of the system for providing health care and medical services to the rural areas has been recognized as being a particularly urgent issue. Background of the Project More than 63% of the 26 million people making up the national population of Uzbekistan live in rural areas and 28% of the population is considered to be living in poverty but of them more than a third are said to be living in conditions of absolute poverty. Because of a skewed distribution of medical institutions that places the rural areas at a disadvantage, the residents of those areas are in a position of inferiority with regard to maintenance of health and access to medical care. There is s clear regional disparity with regard to this aspect of public services. There has not been evident progress in achieving the nation’s Millennium Development Goals (MDG) in terms of reduction of the infant mortality rate and the under-5 mortality rate, and improvement of maternal health. Thus, the health and medical care sector face a challenge of great magnitude and equally great significance. Steps that the Uzbekistan government has taken against this background include the guarantee provided in the Constitution, promulgated in 1992, that the people of the nation have the right to equal medical services, and since 1994 there has been a swift succession of presidential decrees that have been announced and laws that have been passed, with intentions of reforming the system for health care and medical services, providing the system with fiscal support, and promoting privatization. With assistance from the World Bank, the United Nations Development Program, the Asian Development Bank and other providers of assistance, the Uzbekistan government has formulated a program that has the overriding objectives of improving the livelihood of the people and reducing poverty, and in March 2005 released the Interim Welfare Improvement Strategy Paper of the Republic of Uzbekistan for 2004-2010 (I-WISP). The report gives among interim goals for the period 2004-2010 the strengthening and expansion of primary health care service system for residents of rural areas. Prior to this, in 1998 the government adopted as a priority concern the improvement of health care and medical services and augmenting the regional allocation of medical resources, in the State S - 2 Program of Health Care Reform (1988-2005). As one part of this program, the government has embarked on reform of the primary medical services system that had been a leftover from the Soviet Union days, and began to reorganize the rural feldsher posts (FAP), small rural ambulatory posts (SVA) and small rural hospitals (SUB), that had not been organized in a unified manner, by creating rural medical centers (SVP). The Uzbekistan government is now in the process of creating and improving SVPs in over 2,800 locations, so that primary medical care of a certain level can be accessible to the entire rural population. Most of the facilities for this are existing, and are being improved so as to be usable by the SVPs, with progress being made as budgetary allocations permit. Most of these facilities, however, are structures that had been built during the Soviet era, and very many of them are in need of reconstruction or major repair.