ABSTRACT
This chapter reviews the main measures introduced by successive governments since 1990 to bring about a transformation of the health care system in postcommunist Hungary. It lays special emphasis on changes to the financing of health care; the issue of citizen and interest group participation; and the ownership of hospitals. A recurrent theme in the making of health policy has been its highly contested nature and the perceived ineffectiveness of several of the measures that have been introduced. The paper explores this problem through an analysis of key characteristics of the Hungarian polity as it has emerged since 1990, and the relations between policy actors in the making of health policy in Hungary. Drawing on documentary and interview-based research with a wide range of different state and social actors, including government ministers, civil servants, political parties, consultants and representatives of doctors and other health care workers, the chapter examines debates and competition between them in their attempts to influence policy-making. Twenty-two years after the regime change in Hungary, the situation of the
health sector is rather ambiguous. On one hand, a series of institutional reforms has resulted in major changes: health care has been opened up to the market, to the influence of globalisation on its economy, and to private ownership. The roles of purchasing, service provision and financing have been separated; regulatory, monitoring and supervisory bodies are in place; a new system of financing has been established; patients’ rights have been enacted; consultative bodies have been set up; and representation of professional and patient organisations has been institutionalised. On the other hand, the management of the health sector and the operation of health institutions are subject to widespread criticism from health professionals and the public alike. Discontent has focused in particular on poor levels of public health; a limited emphasis on health promotion and the prevention of illness; extensive hospitalisation and growing waiting lists; corruption; and the apparent failure of successive post-communist governments to resolve the key issues of finance and ownership. In certain areas, such as gynaecology, dentistry and kidney dialysis centres, private service providers play an outstanding role, while private owners and operators either have remained
insignificant or have failed entirely in the running of hospitals. What is more, recent decisions suggest that the ownership of a wide range of health institutions will be transferred from the municipal governments to the central government and its county representatives. The interconnected issues of finance and privatisation have been particularly
intractable. For most of the period since the regime change, the provision of health care has been in deficit, and attempts to reduce the deficit have entailed severe cuts in expenditure that have been extremely unpopular. Between 1990 and 2002, the central budget had to pay HUF 30-80 billion annually to cover the deficit of the Health Insurance Fund (HIF), and after 2002 the deficit increased considerably to a figure in excess of HUF 300 billion. Only in 2006-07 did government policies succeed in removing the deficit so that the balance of the Fund turned into a slight surplus for the first time. This effective deficit reduction was achieved through bureaucratic control mechanisms and the weakening of incumbent interests in the sector. However, the reform package also involved severe cuts in health expenditures.2
The Hungarian electorate tends to have strong feelings on health issues and is generally opposed to cuts in public health expenditure. This has posed a serious dilemma for successive governments. While higher revenues could have reduced the size of the cuts, the already high levels of taxation did not make a significant increase of health contributions possible politically. Thus governments generally have avoided painful interventions unless budgetary constraints left no room for escape. In this context, privatisation of health services has been seen by government
at national and local levels as an important part of a solution to the problem of financing the system and, in theory, it could have provided the best possibilities specifically for generating revenues. Successive governments have made attempts to privatise hospitals and other health care institutions, but in the fierce bipartisan context of a strongly polarised party system until the 2010 elections, this has not been feasible politically.While private actors are already present in the health sector, under the prevailing financial regulations neither contracting out further services nor privatising entire health institutions has been regarded as an attractive option. In 2010, the Hungarian Civic Union (Fidesz) won a major electoral victory
and obtained a qualified two-thirds majority in parliament. As a result, the current government enjoys nearly unlimited legal freedom in the formulation of health policy. However, the fierce public opposition to privatisation and co-payment during the previous government’s term has made it politically difficult for Fidesz to incorporate such ideas into its policy mix. In fact, the new government intends to tackle the country’s financial difficulties partly by reinforcing the role of the state in delivering public services. Thus the first drafts of a new bill on local government advocate that responsibility for secondary and tertiary care and the ownership of the respective institutions should belong to the state.
