The Socialist-Liberal coalition government in Hungary has promised to tackle what it describes as widespread corruption in the health service. It proposes to restructure healthcare finance and discard the 50 year old state monopoly provider of medical insurance.
The cabinet will publish draft legislation early this autumn, after a month long consultation period just ended. It blames the problem of corruption on the low pay of medical staff and the insurance structure inherited from the bygone communist regime.
Dr Lajos Molnár, the health minister, described the dependence of healthcare provision on ubiquitous “gratuity” payments for supposedly free services as “a minefield of explosive conflicting interests.”
Patients make such payments to medical staff to purchase privileged treatment at the expense of other patients, he says, with most people paying for fear of losing out. He calculates that such payments total as much as 100bn forints (£250m; €370m; $470m) a year.
Several recent academic studies have examined corruption in the service. They describe various practices, such as nurses ignoring the discomfort of patients unless they are given gratuities of about 1000 forints and GPs being paid two to three times as much for home visits to patients.
A register identifying individual physicians and quantifying the gratuities they allegedly charge appeared on the internet two years ago (www.halapenz.hu). It was shut down at the instruction of the parliamentary commissioner for human rights to protect the privacy of doctors.
At the same time, the Hungarian Chamber of Physicians instigated disciplinary proceedings against Dr Molnár, the then director general of a Budapest hospital, for asserting in the Financial Times newspaper of London that most of the untaxed corruption money enriched just a fifth of the profession (www.ft.com, 9 Mar 2004, “Hungary’s patience running out”). The hearings concluded with the vindication of the doctor.
Dr Molnár, a Liberal member of the cabinet, claims that the Hungarian medical elite “derives its money and power from the control it exercises over vital healthcare resources.” He declares, “I don’t want to leave my grandchildren a future in which they can only obtain decent healthcare by illicitly stuffing euro notes into their doctors’ pockets.”
The government wants to open the health insurance market to competition and replace gratuity payments with regulated charges.
Most of the insurance market, now worth 544bn forints a year, has been liberalised already as a condition of Hungary’s joining the European Union in 2004. One exception has been free universal medical insurance provided by the National Health Fund, which costs a total of 1000bn forints a year, which is raised from taxation.
The law is intended to restrict free healthcare to the means tested poorest population groups plus children younger than 6 years old. Most people would contribute towards the cost of their medical expenses by meeting “copayment charges,” set at 300 forints for a visit to a doctor or a day spent in hospital. Luxury care, above the basic standard provided to all citizens by the national health service, would be financed from private health insurance.
Dr Molnár is already talking to several insurers in preparation for an early market launch, according to Népszabadság , a Budapest newspaper (www.nol.hu, 8 Jul 2006, “A biztositókat is bevonnák az egészségügyi reformba”; 5 Aug 2006, “Üzleti biztositók a reformbizottságokban”). It says the government is hoping to exploit the experience of the companies in commercial healthcare finance abroad, while the insurers—most of them Hungarian subsidiaries of foreign companies—want assurances that the authorities can stop corruption.
Neither side is prepared to publicly comment. The government’s public consultation document has expressed hopes for a fully liberalised insurance market in a little more than a year.
Judit Csehák, a former Socialist health minister and now the director of Jogvédök, an organisation for the protection of the rights of patients, has declined to comment on the proposals because, she says, “the government has still not come around to sending us a copy” of the consultation paper.
Several eminent doctors have stated, on condition of anonymity, that the success of the proposals would depend on questions still unanswered by the government. These include the nature of a proposed regulation authority in charge of the commercial health insurance market, the number of insurers allowed to compete, and the value and availability of basic healthcare still to be financed from taxation. Many doubt the ability of the government to protect the interests of patients in a commercial healthcare environment planned for this post-communist society, where human rights are still relatively new concepts.
Dr Ferenc Falus, the director general of Budapest Gyula Nyirö Hospital, says that the consultation document lacks the long term vision essential to planning the development of health care.
Dr András Jávor, director of the Institute of Health Informatics at Semmelweis University, considers the document incomplete in the absence of proper cost-effect analyses that evaluate the relative usefulness of alternative reform scenarios.
The document says that Hungary has 40 000 physicians for a population of 10 million, whose life expectancy lags six years behind the EU average. The average gross legal monthly income of a junior hospital doctor is 257 000 forints; that of a specialist at the height of a career is less than 300 000 forints. The Hungarian Chamber of Physicians reckons that the remuneration of healthcare staff must be quadrupled to support a workable system.