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THE ROLE OF PUBLIC–PRIVATE PARTNERSHIP IN ENSURING
CITIZENS’ RIGHT TO HEALTHCARE
Safarova Khulkar
Doctor of Philosophy (PhD) in Law, Acting Associate
Professor, Tashkent State University of Law
Tashkent, Uzbekistan
https://doi.org/10.5281/zenodo.16977723
In the Concept for the Development of the Healthcare System of the
Republic of Uzbekistan for 2019–2025, priority tasks were identified such as
the improvement of national legislation in the field, increasing the efficiency,
quality, and accessibility of medical care, expanding private healthcare,
introducing mechanisms of public–private partnership (PPP), promoting
medical tourism to attract investments, as well as the widespread
implementation of electronic healthcare systems.
The development of market relations in the healthcare system is reflected
in the transformation of the economic structure of medical institutions, their
privatization, and withdrawal from exclusive state ownership. Alongside state
institutions, the establishment of medical joint-stock companies, non-profit
entities, and private medical organizations based on diverse forms of ownership
is envisaged.
Currently, the number of private medical institutions in Uzbekistan
continues to increase day by day. This fosters healthy competition in the
healthcare sector, enhances the quality of medical services provided to the
population, and contributes to the reduction of prices.
Pursuant to the relevant decisions of the Head of State, private medical
organizations have been granted the opportunity to obtain licenses in 129
medical specializations. The legal foundations for public–private partnership in
healthcare have been established, with particular emphasis on attracting
foreign investments, expanding access for the population to high-tech medical
services and equipment, and stimulating the participation of the non-state
sector. Moreover, private medical institutions have been authorized to perform
complex surgical operations such as organ transplantation. Conditions have also
been created for the development of “Nursing Practice” and “Mobile Medicine.”
As a result, the number of private medical organizations increased from
3,000 to 8,500; the number of licensed medical specializations granted to
private healthcare providers expanded from 50 to 129; the range of products
manufactured by domestic pharmaceutical enterprises grew from 2,644 to
3,600 items, including an increase in the number of medicinal products from
2,556 to 3,096, medical supplies from 49 to 419, and medical equipment
products from 29 to 85.
In his report, the former Minister of Health of the Republic of Uzbekistan, A.
Inoyatov, emphasized that systematic efforts are being undertaken to gradually
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transfer the functions of state medical institutions to the private sector. It was
highlighted that the share of private sector participation in healthcare services
is planned to increase from the current 20 percent to 35 percent by 2025, and
to 60 percent by 2030, with the introduction of purchasing medical services
from the private sector within the framework of guaranteed medical care
1
.
For the successful development of this sector, it is necessary to foster the
emergence of medical institutions based on various forms of ownership
competing with each other, to form and advance the medical services market, as
well as to encourage the establishment of joint medical institutions on the basis
of foreign investments.
The system of public–private partnership (PPP) is considered one of the
most effective mechanisms in the development of the private sector. Therefore,
the number of facilities established in different spheres on the basis of PPP has
been steadily increasing year by year.
For the successful development of this sector, it is essential to encourage
the establishment of medical institutions based on various forms of ownership
competing with one another, to form and advance the medical services market,
and to promote the creation of joint medical institutions on the basis of foreign
investments.
The system of public–private partnership (PPP) is regarded as one of the
most effective mechanisms for developing the private sector. Consequently, the
number of facilities established in various fields on the basis of PPP has been
steadily increasing from year to year.
The Presidential Resolution of April 16, 2019, “On measures for the
development of public-private partnership in the healthcare sector”, as well as
the Law of the Republic of Uzbekistan of May 10, 2019, “On Public–Private
Partnership”, serve as important legal foundations for regulating activities in
this sphere and for the introduction of PPP mechanisms in the healthcare
system.
According to Article 3 of the Law on Public–Private Partnership, PPP is
defined as “a legally formalized cooperation between a public partner and a
private partner, established for a specific period of time and based on pooling
their resources for the implementation of a PPP project.”
The interpretation and application of this concept in the healthcare sector
has been the subject of research not only by national scholars but also by a
number of foreign researchers over the past decade.
A group of scholars (Ahadzi M., Bowles G., Bennett J., Iossa E., Chen B.R., U.S.
Chiu, Engel E., Fischer R., & Galetovic A., Greco L.) advance the notion of PPP
within the framework of contract theory. In this interpretation, PPP emerges as
a complex project, for instance, an infrastructure project encompassing multiple
specific issues (such as the construction of a facility and the provision of
1
uza.uz/uz/posts/sogliqni-saqlash-sohasida-xususiy-sektor-faolligini-oshirish-davr-
talabi_498682?ysclid=meqt08lxjw973901175
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technical services). In such cases, the state decides whether to transfer all or
part of these issues to a private company and selects the most suitable
contractual model for operation. This implies that the project is divided into
distinct components.
Meanwhile, another group of scholars (Hernandez-Aguado I., Zaragoza G.A.)
propose interpreting PPP as a form of joint implementation of a specific project
2
.
Turning to international experience, the development of public–private
partnership (PPP) in the healthcare sector in developed countries dates back to
the late twentieth century. As noted in an article by M. Torchia and A. Calabrò
devoted to the Italian experience in this field, “Over the past decade, healthcare
systems have been undergoing rapid changes due to the increase in healthcare
expenditures and the reduction of state budgets. Nevertheless, management
and project-planning challenges in this sector remain evident in Italy”
3
.
It should also be noted that in recent years national scholars have
conducted research on the issues of public–private partnership in the healthcare
sector. Among them, one may highlight the works of Y. Aliev
4
, B. Ochilova
5
, A.
Khojanazarov, S
6
. Allamuratov, S.S. Ghulomov and others.
In the healthcare sector, as well as in all other designated areas, the
fundamental principles of public–private partnership (PPP) are as follows:
equality of the public partner and the private partner before the law;
transparency of rules and procedures in the implementation of PPP;
competitiveness and impartiality in the selection of a private partner;
prohibition of discrimination;
prohibition of corruption.
It is well known that the public and private partners are equal parties. The
rules and procedures of PPP must be open, transparent, and comprehensible for
all stakeholders. The public partner is obliged to ensure free access to
information concerning the rules and procedures of PPP as stipulated by the
relevant legislative acts.
One of the fundamental principles ensuring the successful functioning of
PPP is the principle of non-discrimination. This principle is guaranteed through
the following:
equality of rights for participants in tender procedures;
impartiality in the selection of a private partner;
openness in the process of selecting a private partner.
2
Hernandez-Aguado I., Zaragoza G. A. Support of public
–private partnerships in health promotion and
conflicts of interest //BMJ open.
– 2016. – Т. 6. – №. 4.
3
Torchia M., Calabrò A. Increasing the governance standards of public-private partnerships in healthcare. Evidence
from Italy //Public organization review. – 2018. – Т. 18. – №. 1. – C. 93-110.
4
Aliyev Y. Минтaқaвий туpиcтик-pекpеaциoн мaжмуaлapни тaшкил этишдa дaвлaт-хуcуcий шеpикчилик
тизимини pивoжлaнтиpиш //Apхив нaучных иccледoвaний. – 2020. – №. 19.
5
Ochilova B., Nazarqosimov S. Ўзбекиcтoндa “дaвлaт дacтуpлapи” ижтимoий coҳacини pивoжлaнтиpиш
oмили //Apхив Нaучных Публикaций JSPI. – 2020.
6
Khuzhanazarov A. Z., Allamuratov S. A. Look at medicine attention: problems and solutions //Ўтмишгa
нaзap жуpнaли. – 2019. – Т. 24. – №. 2.
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Furthermore, the requirements concerning the rules and procedures of PPP
must exclude corruption-related offenses and ensure the implementation of
preventive measures against corruption and its underlying causes, which,
beyond doubt, contributes to the prosperity of society.
In their research, A. Ballantyne and C. Stewart identify four distinctive
values as the fundamental principles of public–private partnership in the
healthcare sector: public interest, governance, transparency, and collaboration
7
.
Turning to the specific principles of public–private partnership (PPP) in the
healthcare sector, we may refer to paragraph 3 of the Regulation on Public–
Private Partnership in Healthcare, annexed to the Presidential Decree of the
Republic of Uzbekistan No. PQ-4290 of April 16, 2019, “On Measures for the
Development of Public–Private Partnership in Healthcare”. According to this
provision, the main principles are:
the primacy of public interest;
legality;
openness and transparency of information regarding PPP, with the
exception of information constituting state secrets and other secrets protected
by law;
non-discrimination and equality of rights of the parties to the PPP
agreement;
and others.
In the context of healthcare, the primacy of public interest implies that
every project or proposed concept must first and foremost correspond to public
needs and bring social benefit. This is because the implementation of services
such as designing, constructing, reconstructing, organizing, equipping,
modernizing, financing, and maintaining healthcare infrastructure is directly
linked to the protection of citizens’ health, i.e., to the interests of society as a
whole.
In Europe, PPP projects have been applied in various sectors of
construction as well as in the realization of large-scale national projects. For
instance, in France, cooperation between the state and the private sector on the
basis of concession was first implemented in 1552 in the construction of a canal.
However, such partnerships became particularly widespread in the 18th–19th
centuries.
In Germany, public–private partnership (PPP) projects are implemented in
various forms. In the construction of public facilities such as hospitals, schools,
administrative buildings, sports complexes, and prisons, the state organization
— as one party to the PPP agreement — often retains ownership rights over the
immovable property, while transferring to the private investor, as the other
party, the rights to construct and operate the facility for public purposes
8
.
7
Ballantyne A., Stewart C. Big data and public-private partnerships in healthcare and research //Asian Bioethics
Review. – 2019. – Т. 11. – №. 3. – C. 315-326.
8
This model is known, generally, as a build-transfer-operate model. In many cases, the public authority will already be
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In Japan, 80% of hospitals are privately owned, while a unified medical
service fee schedule, set by the state once every two years, applies nationwide.
As a result, citizens covered by compulsory health insurance are free to choose
between public and private hospitals. In order to attract patients, hospitals
strive to operate in a competitive environment by ensuring the availability of
highly qualified personnel and equipping facilities with modern technologies.
Based on the above, it can be concluded that it is necessary to transfer
certain functions or services of state medical institutions to entrepreneurial
entities on an outsourcing basis, as well as to implement effective mechanisms of
public oversight over the activities of non-state medical institutions.
the owner of the real estate and does not require the private investor to acquire title. See
Jacob/Kochendorfer/Drygalski/Hilbig, ‘Ten years of PPP in Germany’, Management, Procurement and Law Volume
167, p. 180 et seq.
