UNVEILING THE SHADOW ECONOMY IN UZBEKISTAN’S HEALTHCARE: COMBATING CHALLENGES WITH DIGITAL SOLUTIONS

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UNVEILING THE SHADOW ECONOMY IN UZBEKISTAN’S HEALTHCARE:

COMBATING CHALLENGES WITH DIGITAL SOLUTIONS

Ramz Zoirjonovich Muhammadiev

Independent Researcher, PhD, Associate Professor

Contact: +999-94-660-48-07, ramziddin_09@mail.ru

Abstract:

This article delves into the ongoing challenges and opportunities within Uzbekistan’s

healthcare system, spotlighting recent strides in digital transformation and increased budget

allocations aimed at enhancing service delivery. It also examines the introduction of state

medical insurance as a promising step toward more sustainable healthcare financing. However,

alongside these positive developments, critical organizational and financial issues persist,

undermining the quality of care and resulting in funding losses essential for the growth of

medical institutions. A significant concern is the recurring financial and economic irregularities,

often perpetuated by those within the sector, which not only erode public trust but also fuel

widespread dissatisfaction. Despite efforts to modernize and digitize, these challenges remain

prevalent, underscoring the need for stronger regulatory measures and a renewed focus on

transparency to restore confidence in Uzbekistan’s healthcare system.

Keywords:

Medical services, digital transformation in healthcare, healthcare financing, medical

insurance, embezzlement in healthcare, misappropriation of funds, budget management in

healthcare, healthcare efficiency, paid medical services, shadow economy in healthcare,

healthcare transparency
Introduction
In recent years, Uzbekistan has implemented significant reforms in its healthcare system aimed

at enhancing human well-being and improving the quality and accessibility of medical services.

Key goals include expanding healthcare service coverage, ensuring timely diagnostics and

laboratory results, reducing bureaucracy, minimizing unnecessary expenses, and maximizing the

effectiveness of state budget allocations.
A well-supported healthcare system relies on skilled healthcare professionals, advanced medical

equipment, and a steady supply of essential medications. However, sustaining this sector requires

ongoing financial support to provide necessary resources and infrastructure. Whether sourced

from the state budget, dedicated funds, or patients’ personal contributions, it is crucial to account

for and manage these funds accurately and ensure their targeted and efficient use. This article

highlights the importance of consistent financial oversight and monitoring to address the

persistent challenges in the healthcare sector, with a focus on enhancing transparency and

efficiency to foster long-term sustainable development.
Literature Review
The concept of the shadow economy and its socio-economic impacts have been extensively

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explored by international and CIS researchers, including F. Schneider, A. Dreher, F. Smith, J.

Thomas, U. Mazar, P. Meon, M. Fleming, J. Roman, G. Farrell, J. Eilat [1], A. Cherepashkin, A.

Komleva, B. Raizberg, L. Lozovsky, E. Starodubtseva, Yu. Naumov, V. Latov, V. Burov, I.

Chursina, Yu. Kopylova, B. Rakhmatov, N. Chernenko, and I. Gromov [2]. In Uzbekistan,

scholars such as G. Alimov, B. Isroilov, M. Pardaev, N. Muminov, B. Turdiev, B. Ibragimov, U.

Abdunganiev, and A. Rakhmonov [3] have focused on theoretical and practical aspects of the

shadow economy, including its impact on economic growth and the tax base.
While these studies examine the shadow economy’s influence across various economic sectors,

they generally overlook its presence and implications within the social and healthcare services

sector. In the global context, research continues to examine the effects of the shadow economy

on public administration processes and national economic growth, with many scholars

highlighting the importance of digital technologies, information transparency, and strengthened

monitoring systems as effective strategies for reducing shadow economic activities.
Existing literature suggests that the shadow economy significantly disrupts state budgets and the

socio-economic landscape of countries. However, certain researchers—such as Matthew H.

Fleming, John Roman, and Graham Farrell—argue that some aspects of the shadow economy

may indirectly benefit other sectors, for instance, by contributing to market adaptation during

economic transitions and reinvesting shadow earnings into the formal economy [4].
Overall, prior studies on the shadow economy have largely concentrated on its effects within

broader economic structures, often overlooking the healthcare sector, which plays a crucial role

in public welfare. This study addresses this gap by examining the scope and implications of

shadow economic activities in Uzbekistan’s healthcare sector, aiming to contribute to a more

comprehensive understanding of the shadow economy’s impact on health service delivery and

economic stability.
Experimental Methods
This study investigates high-risk activities within Uzbekistan’s healthcare sector, particularly

those deemed suspicious due to their potential adverse effects on institutional performance. The

research examines these occurrences by integrating insights from a comprehensive review of

foreign and domestic literature and an in-depth analysis of the regulatory framework established

by the state to manage economic processes.
Data were collected from 841 state-funded healthcare institutions across Uzbekistan. Information

was gathered through training programs involving 2,106 personnel responsible for financial and

administrative functions within these institutions. These sessions addressed various operational

aspects, including procurement challenges, workflow organization, staff motivation, managerial

capacities, and long-term work experience. Participants responded to 9-11 targeted questions on

topics such as situational assessment, problem-solving approaches, and resource management,

with responses documented and relevant supporting materials reviewed. Due to the volume of

data and legal constraints on direct intervention in institutional operations, document sampling

methods were applied for in-depth analysis.

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The research employs a range of methodological approaches, including scientific observation,

comparative analysis, grouping, abstract-logical reasoning, induction, and deduction, as well as

tabular and graphical representation techniques. Open-source data from national statistical bodies,

government ministries, agencies, and business entities were also utilized to enhance the research

findings. This study is part of an ongoing effort to uncover and address hidden issues within the

healthcare sector, with plans to publish subsequent analyses as additional data are collected and

reviewed.
Results and Discussion
In order to effectively address the challenges faced by the healthcare system and reduce its

dependence on budgetary resources, the financial interests of medical organizations funded by

the state are regulated by several key legal frameworks. These include the Presidential Decree

No. PF-3923, dated September 19, 2007 [6]; Presidential Decree No. PF-5590, dated December

7, 2018 [7]; Presidential Resolution No. PQ-2863, dated April 1, 2017 [9]; and the Cabinet of

Ministers Resolution No. 414, dated September 3, 1999 [12]. These legal instruments grant tax

exemptions and similar benefits to private medical institutions, thereby fostering the expansion

of medical services. However, this has also led to the misuse of financial resources and

embezzlement of funds in some cases.
Leaders and responsible employees in the healthcare system must ensure the correct utilization

of these benefits. Instead of bypassing existing regulations or misusing funds for personal gain,

they should focus on strengthening material and technical support, encouraging ethical conduct

among staff, and maintaining compliance with the law. Instances of fraudulent activities, such as

falsifying documents, using budgetary resources for personal purposes, and employing advanced

methods to exploit funds, have contributed to significant financial losses.
Our analysis indicates that the underground economy in Uzbekistan remains substantial.

Estimates suggest that the hidden economy could account for 25–45% of the official economy.

This is particularly pronounced in sectors such as construction, trade, and services [15].

Additionally, research conducted by the Institute of Macroeconomic and Territorial Research

(MHTI) reveals that the share of the hidden economy may constitute 40–60% of the country’s

gross domestic product [16].
It is important to highlight that, according to the Agency for Combating Corruption, there has

been a significant shift in corruption trends. While bribery and related crimes previously

dominated, these have declined to less than 10% of corruption cases since 2019. Unfortunately,

new forms of corruption, such as embezzlement of state funds, fraud, and abuse of official power,

have seen a notable increase [17].
The primary objective of the healthcare sector is to preserve and restore the health of the

population. As economic entities, medical institutions perform both a constitutional function of

the state and activities typical of business enterprises. It is, therefore, essential to consider the

existence of hidden economic activities when evaluating their operations. This article aims to

explore the challenges posed by the hidden economy within the healthcare sector and propose

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potential solutions.
For instance, Presidential Resolution No. PQ-3953, dated September 27, 2018 [8], empowers the

Ministry of Health to directly procure medicines and medical supplies in accordance with an

approved list. However, the practice of entrusting the electronic digital signature (EDS) keys of

medical institution heads to chief accountants has led to regulatory bypasses. Through the

electronic state procurement system (kharid.uzex), necessary goods and services are sometimes

procured without adherence to legal protocols. Contracts can be initiated directly via the

“didox.uz” electronic procurement platform without the knowledge of organizational leaders,

resulting in inflated prices for goods and raw materials. This, in turn, leads to excessive

expenditure of both budgetary and extra-budgetary funds.
To ensure the effective use of available funds, medical organizations should first prepare a list of

goods and services based on their needs. This list must be approved by the head of the institution

before proceeding with procurement. However, in practice, irregularities often occur. For

instance, medicines and medical supplies are sometimes procured without oversight, with chief

accountants and pharmacy heads acting independently. Similarly, other goods and services (such

as construction materials and agricultural supplies) are procured through prearranged agreements,

enabling the misappropriation of funds. These purchases often include items that are either

unavailable, procured in insufficient quantities, or close to their expiration dates.
An analysis of such irregularities within the state procurement system reveals a lack of

proficiency among managers in using electronic digital signatures (EDS), inadequate skills in

handling new software, and a general misunderstanding of the system. Similar issues persist in

paper-based contracts with suppliers, where the organization of work, delivery of goods and

services (often of low quality), and monitoring of expenditures are handled directly by heads of

organizations or their representatives, leading to further inefficiencies.
Under the Law of the Republic of Uzbekistan “On State Procurement” No. ORQ-684 of April 22,

2021 [5,8], the identification and selection of specialized enterprises providing catering services

in medical organizations must be conducted through the electronic public procurement system

(kharid.uzex) under the “Selecting the Best Offers” or “Tender” procedures. However, the

procurement system contains certain loopholes, which officials often exploit.
In particular, the “Selecting the Best Offers” procedure allows medical organizations to form

internal commissions under the supervision of their leaders, creating opportunities to manipulate

outcomes. By contrast, the “Tender” procedure requires the involvement of external experts from

various ministries, agencies, and state organizations, ensuring greater transparency. To avoid the

stringent requirements of the “Tender” process, some managers divide annual catering service

budgets into smaller, quarterly amounts, bypassing the tender requirements and awarding

contracts to pre-selected service providers. These providers often have affiliations with the

organization’s management or receive directives from higher authorities. Ads for such services

are placed in the “Selecting the Best Offers” section to mask these arrangements.
In these manipulated processes, conflicts of interest are prevalent. For example, the Chairman of

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the Procurement Commission can influence commission members to award the highest scores to

prearranged service providers. This leads to poor-quality services, such as substandard food

delivery, insufficient quantities of food, or food prepared for fewer patients than reported.

Despite inflated pricing, cheap and low-quality food is often supplied. Superior service providers

offering better prices and quality are systematically excluded, creating monopolies of low-

quality providers. Furthermore, these favored enterprises are sometimes granted free use of

medical facilities, equipment, and other resources, compounding the inefficiencies.
Such conflicts of interest extend beyond catering services to other areas, such as the maintenance

and capital repair of medical facilities. For example, Presidential Decision No. PQ-425, dated

November 17, 2022, [10], mandates that construction projects should be managed transparently

through the Ministry of Construction’s “Transparent Construction” national information system

using electronic tenders. However, instead of adhering to this regulation, projects are often

shifted to the “Selecting the Best Offers” procedure, bypassing the intended transparency.
As a result, prearranged organizations are selected without regard for conflicts of interest or

affiliations. These organizations frequently overspend funds, perform less work than planned,

and fabricate documentation for uncompleted tasks. Up to 70% of allocated funds are often

disbursed before work is completed. Many of these organizations lack the financial resources,

legal manpower, or material and technical capabilities to complete construction and repair

projects.
If procurement processes were properly organized in accordance with existing regulations, and

construction and repair works were conducted through electronic tenders in the “Transparent

Construction” system, high-quality contractors could be selected to achieve better results.
Additionally, hidden economic activities in medical institutions extend beyond procurement

processes to patient care, service delivery, and related documentation. Addressing these issues

requires a comprehensive approach to ensure transparency, accountability, and adherence to

legal and ethical standards.
In medical institutions, the capacity for providing medical services, conducting diagnostics, and

performing laboratory analyses is clearly defined for outpatient clinics, day and night inpatient

services. However, in practice, non-compliance with these capacity plans or the concealment of

information about treated patients often leads to excessive allocation and misuse of budget funds.

Additionally, cash receipts from paid medical services are frequently unaccounted for,

exacerbating financial losses.
For instance, unregistered medical histories are sometimes maintained for patients, with

payments for services collected directly by treating doctors without being deposited into the

institution’s cash register. Consequently, funds intended for the renewal of medical and

laboratory equipment, purchased using state budget and special funds, are misappropriated,

leaving the organization unable to allocate resources for necessary upgrades.
Furthermore, fraudulent practices such as downgrading patients who have paid for high-quality

(deluxe) rooms to lower-quality accommodations, or underreporting the number of medical

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diagnostic services provided, are prevalent. In some cases, false entries are made in medical

records, including altering or removing diagnoses from external institutions, enabling the looting

of funds paid to the cash register. Alarmingly, such fraudulent activities often extend beyond

service departments to the organization’s financial accounts.
Similarly, caregivers’ payments for patients unable to act independently while admitted to

medical institutions are sometimes misappropriated by department heads without proper

documentation. Another malpractice involves using duplicate payment receipts—originally

issued to a patient paying by card—for another patient paying in cash. Such activities are

facilitated by the institution’s cashiers and accountants.
In some cases, cash payments made by patients for medical services are recorded as non-cash

transactions, using unregistered cash registers. Additionally, fake “Paid” stamps are applied to

outpatient medical cards, and funds collected from patients are illicitly withdrawn from cash

registers. Other violations include providing resuscitation and intensive care services to patients

or their relatives using forged documents, especially for paying customers or those with

connections to institutional management. These high-cost services result in excessive spending

from state budgets, while the payments made by these clients are misappropriated by department

heads and managers.
Such fraudulent activities are further exacerbated by the falsification of records to extend patient

retention periods, or by allocating expensive medications to certain patients while neglecting

others. Violations in cash handling are also rampant, with daily cash income from institutions

being withdrawn for administrative, operational, or construction expenses without proper legal

justification. These funds are often formalized with fake documents or remain unaccounted for,

raising the likelihood of personal misuse.
Additionally, extra-budgetary funds are frequently misused to cover personal expenses of

organizational leaders, such as long-distance travel, accommodations, and maintenance of

personal vehicles, including fuel costs. These expenses are often disguised as legitimate

institutional expenditures.
Another significant issue involves preferential medical referrals, which should be allocated to

district or city medical institutions for underprivileged patients. Instead, these referrals are often

sold to paying patients through prearranged agreements between the chief accountant and the

head of the reception department, depriving needy patients of their entitlements. Payments

received for such referrals are misappropriated, with cash register receipts often issued from

unregistered machines when patients request proof of payment.
Over-purchasing or acquiring expired medications at inflated prices is another common

malpractice in medical institutions. These medications are later written off after expiration,

resulting in substantial losses of both budgetary and extra-budgetary funds. Pharmaceutical

distributors often profit significantly from these transactions, receiving high commissions and

ensuring similar opportunities in the future. Studies reveal that funds obtained through these

“incentives” for purchasing medications are distributed among institutional officials in a

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structured manner.

Total amount

Head

of

the

Organization

Pharmacy Manager

(or Provider)

Chief Accountant of

the Organization

100%

50%

25%

25%

In medical institutions, the deliberate misuse of existing powers within accounting structures and

procedures has led to the manipulation of incentives, bonuses, financial assistance, and

allowances from extra-budgetary funds. These manipulations include altering the amounts

specified in orders that are signed and executed, and inflating fees for personal benefit.
Such practices are often conducted by groups of employees within the organization, with the

manager or their deputies frequently unaware of these activities. Violations in budget allocation

processes are also prevalent. For example, excessively high salary funds are allocated from

budgetary and extra-budgetary resources by inflating tariff rates in staffing tables and planned

expenditure estimates for the relevant year. These inflated funds are subsequently

misappropriated through mechanisms such as calculating exaggerated salaries for employees,

and reclaiming the “overpaid” amounts after recalculations without recording them in the cash

register.
Control activities conducted in medical institutions reveal numerous violations of current legal

requirements. Examples include the absence of employees listed on staff rolls (“dead souls”) or

the recruitment of personnel, such as doctors, nurses, and emergency drivers, in exchange for

bribes. Additionally, higher-ranking positions are sometimes secured for a fee, and department

heads are required to provide monthly contributions, often sourced from patient payments.
Those who comply with these unofficial systems are rewarded with career opportunities, such as

participation in rare surgical operations, access to high-paying clients, or inclusion in foreign

business trips. Meanwhile, non-compliant employees are relegated to remote locations or menial

tasks and are eventually dismissed under various pretexts.
According to Cabinet of Ministers Resolution No. 133, dated March 11, 1997 [11], the daily

working hours for medical workers in positions with special conditions are set at 5.5 hours. Most

doctors, particularly those on single-shift schedules, finish their workdays by 2:00 PM, enabling

them to work in private medical institutions on a temporary or contract basis. This dual

employment creates opportunities for abuse. For example, patients seen during working hours at

budgetary institutions are selectively referred to private facilities for high-value procedures, such

as laboratory examinations, surgeries, or therapies, where the physicians benefit from a 50/50

revenue-sharing arrangement.
This practice demonstrates the improper implementation of Cabinet of Ministers Resolution No.

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414, dated September 3, 1999. It results in significant losses to extra-budgetary funds, poor

distribution of available resources, and the misuse of restrictive artificial procedures by managers

and responsible employees of budgetary organizations. While funds from paid services in

budgetary institutions are supposed to be used for rewarding skilled and experienced specialists

after deducting operational costs, this process is often handled carelessly and ineffectively.
Medical institutions, due to their prime geographical locations in village, district, regional, and

urban centers, have facilities with high traffic and connectivity to various communication

networks. These features make such institutions attractive to business entities for renting vacant

spaces. However, irregularities in the leasing process, such as undervaluing rental areas or

issuing leases to social organizations at reduced rates, reduce cash inflows to extra-budgetary

funds.
The procedure for leasing state property is outlined in Cabinet of Ministers Resolution No. 660,

dated December 14, 2023 [13]. This resolution emphasizes the need for transparent, long-term

contracts. Yet, deviations from this process often lead to reduced revenue for budget

organizations.
It is important to note that these issues are not pervasive across all medical institutions in

Uzbekistan. However, the observations and information cited in this article are based on

documented cases and extensive research, which form the basis for the opinions expressed here.
Here’s a polished and grammatically improved version of your text:
Conclusion
Our research concluded that the involvement of leaders and responsible employees in medical

institutions in the “hidden economy” has serious negative consequences. These effects extend

beyond the medical sector to society at large, impacting the nation’s overall health and well-

being [14].
The hidden economy in the medical field not only results in the loss of revenue and hinders

development but also delays localization and growth in various sectors. However, the

consequences in healthcare are particularly dire, as they threaten public health, delay the timely

provision of high-quality and advanced medical services, lead to shortages in the supply of

essential medicines, and contribute to rising morbidity rates.
Therefore, it is imperative for government authorities and industry leaders to prioritize

addressing these issues. Measures should include developing indicators to ensure the efficient

use of allocated funds, identifying risk groups prone to engaging in the “hidden economy” within

each medical institution, and closely monitoring their activities.
Based on our analysis of the documents that enable covert activities in medical institutions, the

following recommendations have been proposed:

1.

Enhancing Accountability for Digital Signatures

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Increase the responsibility of medical institution heads for the use of electronic digital signature

(EDS) keys. Strict regulations should ensure these keys are used exclusively by authorized

personnel, and liability should be imposed for contracts signed without the knowledge of

responsible managers.

2.

Revising Procurement Regulations

Review and, if necessary, eliminate item 18 of the list of “Goods (works, services) purchased by

state customers under direct contracts” approved by Presidential Resolution No. PQ-3953 dated

September 27, 2018.

3.

Strengthening Procurement Norms

Establish strict regulations for purchases made through the state procurement system under

“Selecting the Best Offers” or “Tender” and ensure consistent compliance monitoring.

4.

Digitizing Financial and Economic Activities

Promote the full digitization of financial and economic operations in medical institutions, with a

focus on reconciling income and patient information.

5.

Implementing Online Cash Registers

Mandate the use of fully online cash registers in medical institutions. Introduce a system for

extraordinary inspections of entities that fail to adopt online cash registers, and impose increased

financial sanctions on those deliberately avoiding their use.
The implementation of these recommendations will help mitigate hidden economic activities in

the medical sector, ensuring greater transparency and efficiency.
Acknowledgment
This research was conducted as part of the Doctor of Science dissertation on the topic

“Organizational and Methodological Improvement of the Financing System of Medical

Institutions in the Context of the Digital Economy” (specialization code: 08.00.07, Finance,

Money Circulation, and Credit). The research was funded entirely by the researcher.

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