Charlotte L. Rosen, Professor Walter Whipple, Psychology
“Hungarians, rise, your country calls you! Meet this hour, whatever befalls you! Shall we freemen be, or slaves? Choose the lot your spirit craves!”1 This was proclaimed by the famous Hungarian poet, Petrofi Sandor, during the Hungarian Revolution of 1948. This battle cry is a taste of the deep-rooted spirit of the Hungarian people that has persisted throughout their tumultuous history. Because of its strategic location in Eastern Europe, Hungary has been conquered and ruled by other countries numerous times. Most recently Hungary was under Communist control until the Iron Curtain fell in 1989. Hungary has many social, economic, and political problems stemming from their transition from a socialist to a capitalist society. These problems are particularly visible within their health-care system. This summary will touch briefly on the history of Hungarian medicine, including its former structure under Communist rule. However, it will mainly focus on current reforms, and, most importantly, opinions of Hungarian health-care workers taken from a survey sent to Hungary. The purpose of my paper is to encourage informed discussion of Hungary’s health-care conditions through which improvements can be made.
The first information found on the structure of Hungarian health-care deals with the period after World War 11. It was then that Soviet troops “liberated” Hungary from Fascist Germany, in an attempt to establish socialist development and, thereby, raise the standard of living. Their three dimensional approach to health-care was “universal access to care, adequate attention to public hygiene, and elevation of living standards through the redistribution of wealth.”2 A new healthcare system was created in line with this Soviet policy.
Since the early 1990’s, the health-care reforms introduced have largely pertained to the organization rather than the increase in funding to the health-care sector. They have been largely directed towards cutting costs, and not towards elevation of standards or the establishment of new priorities.3 Hungarian health-care has been free of charge since the establishment of Communism in 1948. One of the main health-care reforms since then has been the cessation of that privilege. On July 1, 1992, comprehensive free health care to all citizens of Hungary ended. Automatic health insurance was given to employed citizens, students, registered unemployed, juveniles, and senior citizens; all others paid for the same health care benefits. Those covered by insurance were issued a card which they were to give to a physician of their choice. These card holders are only eligible for basic health services. These primary care physicians are paid according to the number of cards they are given, or in other words, the number of patients they have. This system is called capitation. Hospitals are paid according to an entirely different system than the family doctors. Under Communism, hospitals and clinics received money according to their connections with the Medical Superintendent, without regard to their actual need or performance level. In 1993 a new “fee-for-service” or “point system” was established. According to this system, a hospital still received 70 percent of their previous socialist income. The other 30 percent was provided according to their performance. Most recently, the income of hospitals has become entirely dependent upon performance. Their model is the Diagnosis Related Groups (DRG) system used in the United States.3
The previous sections were a report on the conditions and reforms in the Hungarian health-care system. However, it is necessary to also consider the opinions and suggestions of the Hungarian health-care workers themselves. To this end five hundred questionnaires were mailed to Hungary—250 were sent to random hospitals (15 hospitals were sent 15 questionnaires each), and 200 were sent to health organizations in Hungary. The remaining fifty were sent to friends of the author who are health-care workers in Hungary. Also, the same questionnaire was submitted to five Hungarian news groups on the Internet accompanied by a request for a reply. Questionnaires were returned via FAX, E-mail, and Airmail. Twenty-four questionnaires were returned from those mailed to Hungary. Many of them came individually. Twelve questionnaires were received by E-mail. Thirty-six were received back in all. The questionnaires included four questions in Hungarian. Each question and its answers will be discussed individually.
** IN YOUR OPINION, IS THERE A NEED FOR HEALTH-CARE REFORM? WHY OR WHY NOT? -The reply was a unanimous, resounding, “YES!” ** HAVE YOU FELT ANY POSITIVE (OR NEGATIVE) INFLUENCES FROM REFORMS YET? IN WHAT WAY? -Only one-tenth of the replies mentioned any kind of positive influence that reforms have so far had. Two of them mentioned the “positive” changeover from assigned district family physicians to self-chosen family physicians. The other two mentioned the point system of hospital payments. One said that the point system has shown differences in the performances of various hospitals, and the other said it has prompted them to re-examine treatment strategies and cut expenses and nursing time. All the other replies either said they haven’t felt any influence from reforms yet or that the influences have been negative thus far. Some of the negative influences mentioned were hospital closures, medical employees being fired, withdrawal of research money, and relatives having to bring in medicine for patients in the hospitals, because hospitals have no money to buy them.
** IF YOU HAD THE OPPORTUNITY, WHAT WOULD YOU CHANGE OR REFORM IN THE HEALTH-CARE SYSTEM? -The top five answers were: 1) Improved wages for healthcare workers (30% of the replies mentioned this) 2) More attention to prevention in health care (14%) 3) Stop the reduction of hospital beds (11%) 4) Change the doctor training system (8%) 5) Switch power from the self-government to doctor quorums in hospitals (8%)
** WHAT ARE THE THINGS THAT DON’T NEED TO BE CHANGED? -There were a variety of answers, but the top three answers were: 1) Everything needs to be changed. (16% of answers) 2) Hungary already has good preventative services- prenatal checks, chest x-rays, school physicals. (14%) 3) Hungarian medical schools are of high quality. (11%)
While these questionnaires were meant to provide inside information on the condition of Hungarian health care, they also had another, perhaps more important, purpose. It was hoped that while the health-care workers wrote down what they would change in the health-care system, they would seriously think about it and actually change something-anything-for the better. While foreigners can provide valuable advice, the actual implementation of the reforms must be done by the workers that will live with them daily. As they do this, Hungary will rise again as a nation free from, not only political, but financial chains as well.
References
- Sisa, S. (June 1995) The Spirit of Hungary. The Rakoczi Foundation. Toronto, Canada.
- Csazi, L., & Kullberg, P. (1985) Reforming health care in Hungary. Social Science Medicine, 21 (8), 849-855.
- Makara, K. (1994) The difficult rebirth of health care. The Hungarian Quarterly, 35 (133).
- The aid of the Hungarians that shared their time and opinions is gratefully acknowledged.