Vulnerability and chaos in the Hungarian healthcare system

The state of healthcare facilities and institutions is critical in some places, while public funding of the field falls way below the EU average. The Ministry of Health was dissolved into the new Ministry of Human Resources in 2010, thereby losing its power for advocacy. Institutionalized corruption is strongly present in Hungary, including within the healthcare system, while a unique concept of parasolvency (or ’compulsory’ gifts) has been deeply present in the collective consciousness of society since communist times, defining the doctor-patient relationship even today and strengthening discord between professional workers as well.

Highly skilled (mostly young) doctors are continuously leaving the country, while those medical workers who do stay are increasingly overloaded and unsatisfied. The division between public and private healthcare is further deepening the gap between the poor and rich levels of society.

Administration, resources, financing and structure

Let’s look into the most controversial measures since 2010 that have affected the Hungarian healthcare scene. First, a social insurance system based on risk pooling and nationwide solidarity was granted by the Constitution until 2010, when that document was replaced by the new “Fundamental Law of Hungary”. From that point forward the social insurance system lost its security. Instead of health insurance contributions, employers now pay a complex social contribution tax that the Government can use as it sees fit. However, employees are obliged to pay a health insurance contribution, and upon turning to a doctor, the validity of their social insurance is checked.

The responsibility for handling the national health insurance fund has been transferred from an independent body to an office under direct ministerial control. Today in Hungary, therefore, there is a unique healthcare system consisting of the mixture of state healthcare and social insurance.

In 2010, the second Orbán Government dissolved the Ministry of Health and melded it with the newly-created “Ministry of Human Resources” (EMMI), a mammoth ministry responsible for numerous fields including healthcare, education, culture, sports, social policies and equal opportunities, to list just a few. There is no minister of health since this change — in this new ministry the field of healthcare is overseen by a state secretary. This strong centralization also means a lack of lobbying power for these fields; healthcare has become a neglected field for this Government.

The fate of independent professional institutions is also informative:  Any institutions that were independent of national and local politics and had effectively controlled and inspected public health and epidemiological security have also been dissolved or replaced. Through such measures, the profession has gradually been removed from its controlling position. The ministry has also absorbed the previously-independent, country-wide patients’ rights organization, which held public authority power.

In 2015, the amount of public expenditure in Hungarian healthcare was 4.8% of GDP, while the EU average was 7.2%. It is especially important to note that while the state is spending substantially less than the EU average on healthcare, the burdens on the population for accessing care are disproportionately high, and these are usually “out of pocket” expenses not subject to risk management.

The financing of hospitals in the country is insufficient, which results in a debt of about HUF 40-60 billion (about EUR 120-200 million) each year. This shortfall is then “generously” settled or consolidated by the Government from time to time, but nothing is done to enable the sustainable operations of these institutions.

The state of Hungarian healthcare facilities and institutions is critically uneven. In the past 10 years, due to EU funding, hospitals in the country have been modernized, but the capital could not be included in those tenders. Since the government did not provide budgetary resources for this, Budapest hospitals have remained unrefurbished, and the quality of their services is unpredictable.

This might change in the near future with the announcement of the “For a Healthy Budapest Program” in 2018, which will focus on the modernization of both outpatient and inpatient services and the improvement and realignment of hospitals, including the creation of three central hospitals.[1] This step is crucial, as most of the hospitals in the city were built in the early 20th century and are not only in very bad condition, but also do not meet today’s requirements and are wasting financial and human resources.

However, these developments and modernization are not being implemented according to a well-designed, long-term strategic plan based on consultations with healthcare professionals. Rather, they are being realized in a haphazard manner, following momentary political and lobbying interests. 

Parasolvency – the system of ‘compulsory’ gifts

In the 1950s and throughout the socialist era, the intelligentsia in Hungary was systematically ripped from leading positions and their cooperation among themselves was also inhibited. However, doctors were not replaceable by party cadres, so the aim instead was to pit them against each other. The profession was grouped into two parts: those who meet the patients face-to-face regularly, and those working in the background, e.g., in the laboratories.

Wages were redistributed based on this division: the latter group, the “background workers”, was eligible for a higher salary. At the same time, doctors working in direct patient care were allowed to accept money from the patients in addition to their base salaries (generally called ‘parasolvency’, or ‘hálapénz’ in Hungarian, which translates to ‘gratitude-money’ and could be compared to a tipping system).

Unfortunately, this plan worked, and the division and dissention within the medical profession has lasted to this day. The phenomenon of parasolvency is deeply embedded in Hungarian healthcare. Today, patients are so distrustful of healthcare and so vulnerable to the lack of transparency in the system that they use parasolvency as an attempt to secure trustworthy service for themselves. This then generates further distortion of the system, creating a vicious circle.

The doctor-patient relationship thus becomes some kind of business transaction that at the same time violates both the real interests of the patient and the system of state incentives. Doctors became interested in treating their “grateful” patients for as long as possible, even if sending them to other colleagues would be medically indicated. This may also result in unnecessary examinations or interventions. It is not rare (and nowadays it is more like the general practice) that this money is expected, negotiated in advance, and sometimes even extorted—an everyday case of corruption. This is one of the reasons why the official wages of healthcare workers could be kept so low in the past decades.

The system of parasolvency creates a gap between practitioners of different medical fields and also between generations. It makes fair cooperation, collegial relationships and teamwork impossible, even though these are crucial. Let’s take the example of operations: the patients usually choose the surgeon themselves and they may also meet the anesthesiologist (even though not necessarily before the operation). However, what the patients may not know is that there is a group of pathologists working on the histological opinion that highly influences their survival, not to mention the other members of the healing team (nurses, physiotherapists and others). Who should receive the money? Who should the patients be thankful for?

Moreover, parasolvency is also sneaking its way into medical education, since instead of the mentor-student relationship, older doctors rather become the rivals of young ones. In order to keep their access to money, some doctors may just as well keep important information to themselves so as to make themselves indispensable in their profession.

Parasolvency anchors bad structures within our healthcare system, because those in power will not want to release their positions and privileges to others. As a result, a small group of people in the profession has emerged who hold strong lobbying power and for whom the survival of the parasolvency-system is essentially important, so they are determined to protect it.

The Hungarian Medical Chamber has played a crucial role in the fact that this system could survive until this day. As a professional public body, the most important role of the chamber should be to protect the profession’s reputation and to keep the trust of patients. However, the current leadership of the chamber does not step up against even very serious cases of ethical offenses, and fails to publish the decisions of its ethics investigations even though they are supposed to proactively examine each and every such case they are informed about.

The Hungarian Medical Chamber is the only organization in Hungary in which doctors are associated, and membership is obligatory for every practicing doctor. As such, it is a big mistake that this body fails to initiate the necessary professional and structural changes and merely obstructs them instead.

Lack of doctors and a divided healthcare system

Nowadays there is a general lack of doctors and medical workers everywhere. In Hungary this situation began to emerge after EU accession as a natural effect of the free movement of workers. It is rather difficult to measure the numbers in this regard, so let’s just look at a few facts about the lack of doctors:

In the first six months of 2017, 402 Hungarian doctors and 208 foreign citizens who have completed their medical studies in Hungary applied for permission to work abroad. However, this data does not show whether all of them actually moved abroad or not. It might sound unbelievable, but we actually do not know exactly how many doctors are working in Hungary. There are several parallel, independent databases for estimating their number; one of them is the above-mentioned Hungarian Medical Chamber’s list of members.

However, this number does not reflect those who are working abroad already and just keeping their Hungarian registration valid (or for that matter those who are on maternity leave, for instance). The other approaches (for instance the number of ‘active stamps’ that represent doctors writing prescriptions, or the number of active registrations for compulsory further trainings) also all fail to provide objective data on the actual number of doctors working in the country. There is no centralized database currently available, which results in the complete lack of a reliable method for keeping track of this.

However, the following facts are important to note nevertheless[2]:

• It is a fact that the number of doctors working in the country has been decreasing in recent years.
• It is mostly young professionals who are leaving the country.
• This sends a negative message to other medical students, who see no secure professional career prospects at home.
• It is also visible that the average age of healthcare workers in Hungary is rising: doctors working in the healthcare system are on average 49.31 years old, with every second doctor being over 50; the average age of other healthcare professionals is 44.08 years.[3]
• We do know that professional education does not provide enough new workers, as the number of fresh graduates more or less equals the number of doctors leaving the country. As a result, there is no replacement for those who are quitting the system for other reasons (e.g., death or retirement).
• It is important to highlight the phenomenon of a significant secession of doctors from the public healthcare system, partially towards working in the private healthcare sector only, but also many doctors are leaving the profession entirely.
•  The workload of each and every quitting colleague has to be covered by those who are staying due to the lack of replacement resources. For many, this is the last straw—and a domino effect of quitting starts.
• The lack of healthcare professionals not only results in inefficient service but also forces doctors to do the work of other professional staff, which in return reduces their capacity to care for their patients.

Based on my experience, the young generation’s main reasons for leaving the country are the inevitable involvement in the parasolvency system and the existence of a strong hierarchy in the medical profession — they simply refuse to work and live under these circumstances. Better career prospects and higher salaries elsewhere are also important aspects, as well as the promise of higher prestige for their profession and a better quality of life, better possibilities for professional development, sufficient equipment, a better state of hospitals to treat patients in, and a better work-life balance abroad.

In Hungary, the Government’s message is that there are no resources to increase wages in the healthcare sector, which is probably true in the current, wasteful system. However, money alone would not solve these problems. There is a need for a complete structural change in order to let the healthcare system become a patient-centered, transparent, clearly-functioning system meeting the requirements of the present day. The current system is nontransparent, corrupt and wasteful, one in which all the resources are lost.

The wages also need to be coherently thought over and restructured into a well-planned system. The hectic way this Government is approaching the issue, by highlighting a particular group of health care workers from time to time, is unacceptable. Just to mention one example: in order to motivate resident physicians to stay in the country, a scholarship scheme was developed for them. It is incomprehensible why professional, full-time, state-employed adults would need to be applying for ‘scholarships’, which they receive instead of a reliable monthly salary.

Moreover, in order to qualify for the scholarships, they need to commit to staying in the country for a specified number of years. These scholarships do not contribute to their pensions and are not considered as income for the purposes of assessing their eligibility for bank loans…

There is another, spontaneously-developing process that needs to be addressed here: the splitting of the Hungarian healthcare system into a rapidly- deteriorating public sector and an emerging, parallel public sector that is uncontrolled and only accessible by a minority of the population. As a study commissioned by the National Healthcare Service Center demonstrates, the total capacity of licensed outpatient care in privately-financed providers exceeds that of the public-funded service. [4]  

The following facts presented during a conference organized by the economic news portal Portfolio in October 2017 confirm this information: the proportion of people turning to private-service providers in the 20-60 age group was expected to be over 65% [in 2017], with an annual HUF 300 billion spent on healthcare services. These data only show the tip of the iceberg, since they are just sourced from the statistics provided by the legally-operating medical service providers.

There is, however another hidden path, the so-called “apartment-medical-stations”, where consultations or sometimes simple physical examinations take place in return for parasolvency money. These private medical stations are operated mostly by doctors (in many cases with a very high reputation) who otherwise work in the public healthcare system. As an example, the consultation preceding a planned surgery or birth would take place in this private office, but the surgery or birth itself takes place in a public hospital. Then the check-ups are again taken to the private office, but if there are any complications, the patient goes back to the hospital.

This setup is understandable, since nowadays the one patient – one doctor model no longer applies; there is a medical team and an expensive, complicated technical background for each case. However, it is not ethical, and to include undocumented visits and undocumented payments in this process is not acceptable, as they result in the lack of a guarantee and the lack of a right for the patient to claim redress should something go wrong.

It is revolting that such procedures endangering patients’ rights and avoiding professional and tax control can take place uninterrupted. Private healthcare is, of course, necessary, but a transparent, quality-assured, balanced system has to be created in which public and private healthcare can coexist, built on unified professional principles and on guaranteeing safe care for patients with strict, regular controls.

Today in Hungary the biggest danger posed to the healthcare system is the prospect of a complete split: Public healthcare services will be deteriorated and only treat the poor, while an expensive, better-quality, private service sector will emerge for the rich. There are techniques to prevent this scenario, but unfortunately the Government does not show any interest in stepping up to do so.

In our everyday work as physicians, the most critical aspects that always pose a danger to the safety of patient care are clearly visible in Hungary: lack of transparency, low quality of basic and outpatient care, overloaded outpatient care, lack of professionals in the whole system, and the structural fragmentation of healthcare institutions.

The whole system lacks correct professional regulation and protocols, lacks a process for updating the minimal standards for  conditions, or for that matter lacks follow-up by monitoring indicators of quality over time and publishing the results. These are the main reasons why the current healthcare system in Hungary is unreliable and chaotic both for the patients and for healthcare workers and is creating so much room for vulnerabilities.

This article is part of our ongoing special "Focus on Hungary".