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21 November 2023 | Country Update
Public centralization of CT and MRI diagnostics -
27 July 2023 | Country Update
Changes in the organisation of mother-and-child health (MCH) nurse services -
21 March 2023 | Policy Analysis
The background to the current tensions between the government and the Medical Chamber -
12 March 2023 | Country Update
Legislative changes to the role and responsibilities of the Hungarian Medical Chamber -
30 December 2022 | Policy Analysis
Will further centralization solve the performance problems of the Hungarian health system? -
13 January 2016 | Policy Analysis
Recent changes of the organizational structure of the Hungarian health care system (2010–2015)
2.4. Decentralization and centralization
In the early 1990s, health reform in Hungary sought to move the sector from central government control. Decentralization was the dominant tendency throughout the restructuring process, and the health care sector became decidedly more pluralist, with responsibilities divided among several players. For example, the responsibility for the provision of certain public services was devolved to local governments in 1990, along with the ability to raise and spend revenue. As part of this process, the ownership of most health care facilities was transferred to local governments, which became the dominant providers in the health care system.
The role of the central government as the direct provider of services has continued to decrease since the mid-1990s, but its role as a funder (see subsection Revenue collection in section 6.1.2), purchaser and regulator has grown. Indeed, successive governments since that time have gradually restored more central control, mainly focusing on the NHIFA as a way to limit health spending. For example, whereas the supervision of financing for health services and the control of the NHIFA were delegated to the Health Insurance Self-Government in 1993, these duties were reassumed by the central government in 1998. Another example is the regulation of the medical profession, which was partly delegated to the Hungarian Medical Chamber in 1994, but partly centralized again in 2007 when the government abolished compulsory membership in the Chamber for practising physicians and withdrew some of the Chamber’s disciplinary rights (2006/7). Similarly, the consultation rights of the Chamber of Pharmacists in the licensing of new pharmacies was curtailed with effect from 2007 (2006/8).
However, there have also been developments in the opposite direction. Successive governments between 2002 and 2010, for example, have revitalized the idea of regional planning and development, providing the legal basis and financial support for regional health councils entrusted with the elaboration of regional health plans on a voluntary basis (2003/4) (see section 2.3.9 and subsection Capacity regulation in section 6.1.1).
With regard to health care providers, although the legal background for the different types of privatization was created in the early 1990s, significant privatization has taken place only in primary care (section 5.3) and among pharmacies (section 5.6). A few hospitals have been given back to their original church owners and are run on a non-profit basis, but the majority of providers of specialist health services remained in local government ownership. In secondary outpatient care, many physicians offer part-time private clinics in addition to their public sector employment. In addition, some private polyclinics have been established, where patients pay for services out-of-pocket. The role of private capital in inpatient care remains controversial in Hungary and is described in detail in subsection Ownership and management of health care providers in section 6.1.1.
On 4 July 2023, the Hungarian Parliament adopted an amendment to the Act LXXXIII of 1997, specifying that, from 1 November 2024, the state will provide publicly funded CT and MRI examinations as part of the public benefits package.
Contracts for financing or contributions between private providers and either the Hungarian National Health Insurance Fund or the state, along with lease contracts for equipment or premises, will be terminated. Affected service providers will be compensated and can choose to sell their devices to the state. This measure specifically affects privately owned CT and MRI machines in state-owned hospitals.
During a government press conference, the minister emphasized that the state’s decision will enable the operation of these machines, reducing waiting lists. The government believes this will improve public patient care, as the devices will operate at full capacity.
Professional organizations, including the Hungarian Medical Chamber, have a different opinion. They argue that the changes might lead to longer waiting lists, as there will not be enough health professionals to carry out the examinations. Further, industry players highlight that private companies contributed by mitigating certain system-level issues, like hospital debts, and the new rules will cease these contributions.
References
https://net.jogtar.hu/jogszabaly?docid=99700083.tv
http://medicalonline.hu/eu_gazdasag/cikk/elfogadtak_a_2024_es_koltsegvetest_megalapozo_tovenyt
https://medicalonline.hu/cikk/gulyas__jozanesz_szerint_tortenik_a_ct__es_mr_vizsgalatok_allamositasa
https://medicalonline.hu/eu_gazdasag/cikk/a_maganelatoknak_kedvez_a_ct_vizsgalatok_allamositasa
https://medicalonline.hu/eu_gazdasag/cikk/a_nagy_ct__es_mr_atalakitas_hattere
https://www.valaszonline.hu/2023/08/21/rekordszamu-ct-es-mr-gepek-vizsgalatok-maganegeszsegugy-tb
https://mfor.hu/cikkek/egeszsegugy/erthetetlen-miert-allamositjak-az-mr-es-ct-gepeket--mondja-az-egyik-erintett-cegvezeto.html
https://telex.hu/belfold/2023/07/05/egeszsegugy-ct-mr-allamositas-magyar-orvosi-kamara
https://hvg.hu/itthon/20230706_CT_es_MRvizsgalatok_allamositasa_egeszsegugy
Authors
The elimination of mandatory membership in the Medical Chamber in February 2023 is not the first time that the role and responsibility of the Chamber have been changed. In 2006, similar to today, the government wanted to introduce substantial healthcare system reforms and also faced opposition from the Chamber. The mandatory membership in the Chamber was abolished as part of those reforms and reinstated again following a change in government in 2011. In this sense, the current situation parallels the historical example. The newly passed amendment can be viewed in light of the reform package from December 2022, which aims to transform the healthcare system (see Policy Analysis from 30 December 2022).
The Medical Chamber objected to the reform package and the further centralisation of the health system; it believes that the new regulations would result in a command-based, inflexible system, which would decrease the availability of publicly funded services and drive patients to the private sector. Thus, it called for the government to withdraw its initiatives and urged drafting a long-term strategy for the health sector with the involvement of political parties, professionals, and patient organisations. Furthermore, the Chamber also formulated a set of immediate demands, including specific steps to strengthen primary and dental care services, ease specialised medical doctors’ working conditions, and increase wages for allied health professionals from January 2023. Although the reform package contains plans to increase wages, it will start in July 2023, and not sooner, as proposed by the Chamber.
As the demands had not been met, in February 2023, the Chamber decided to pursue a pressure campaign, leveraging another piece of the reform package, the progressive reorganisation of out-of-hours services (see Country Update from 20 January 2023). Until the demands are met, the Chamber called on its members not to sign their new contracts to provide out-of-hours services and deposit a notice of termination of their contracts establishing voluntary overtime work. The resulting tension between the Chamber and the government triggered the presentation of the amendment proposal.
The rationale for the proposal has been what the government estimated to be “an abuse of power” on the part of the Chamber, which, in the government’s view, used its position to exert pressure on its members and thus threatened the right of citizens to healthcare. However, the Chamber refuted these claims in an open letter, contending that the government politicised a professional disagreement.
The current situation may have implications for the ongoing dispute between the European Commission and the Hungarian government regarding the rule of law and access to EU funds. To resolve the dispute, last year, the government made a series of commitments, one of which was to ensure that – with certain defined exceptions – public consultation would precede the passing of new legislation. However, according to the Chamber, no such consultation took place. Thus, passing this amendment might constitute a hurdle in accessing EU funding.
Authors
References
https://mok.hu/a-kamararol/tortenetunk
https://24.hu/belfold/2022/12/07/egeszsegugy-atalakitas-torveny-parlament-megszavazta-ugyelet-korhaz-szakrendelo/
https://magyarkozlony.hu/dokumentumok/931d90151e4218a98b64de8c0f7af2af09372925/megtekintes
https://mok.hu/hirek/mokhirek/orvosi-beremeles?fbclid=IwAR0S8fICP2eUvaxDGJ8pJU0672nbdBhGpg3MqZ7BRJykOdoEd_qovCNxq1s
https://mok.hu/public/media/source/nyomasgyakorlas/L%C3%A1tlelet.pdf
https://www.parlament.hu/irom42/03065/03065.pdf
https://mok.hu/public/media/source/Guly%C3%A1s_Gergely_%C3%BCgyeleti_rendszer_0227.pdf
Following Parliament’s approval of an amendment proposal to Act CLIV of 1997 on Health and Act XCVII of 2006 on the professional chambers in healthcare during a special legislative session in February 2023, it is no longer mandatory for Hungarian healthcare professionals (HCPs) to be members of the Hungarian Medical Chamber to practice their profession. Following the amendment’s entry into force, HCPs need to make a written declaration for continued membership within 30 days (until 2 April, midnight). Otherwise, membership is automatically discontinued.
Furthermore, the amendment also transferred the responsibility to formulate the professional ethical code and to conduct disciplinary proceedings from the Chamber to the Medical Research Council, a body working under the minister responsible for health. The Council’s further responsibilities include setting research priorities and coordinating research activities in Hungary. It formulates professional and ethical opinions on research projects and questions about medicine and represents the country in European clinical research fora.
Authors
After the 2022 general election, the shift of the governance of the health system from the Ministry of Human Capacities to the Ministry of Interior was not an unexpected move. Yet, it created uncertainties about the future directions of health care reforms.
The performance problems generated by the COVID-19 pandemic are no way disappeared with the easing of the burden that the pandemic placed on the public sector. On the contrary, implementing the measures related to the new employment status, the salary increase, the criminalization of informal payment, and the regulations to separate the public and the private sectors have worked against normalization and sustained the performance decline, access problems, and increased mass exit to the private sector. The apparent shortage of health services in the public sector, manifested in increasing waiting times and other access problems, called for an intervention, but it was not clear how the government would perceive and react to these problems with the Minister of Interior now in the driving seat.
The fall of 2022 has provided the health sector with the answer in the form of a reform package whose main direction is further centralization. While the problems the reform package aims to address are valid, there are doubts about whether further centralization is the right answer to these problems, especially since the previous centralization measures hardly improved the performance of the health sector. It seems that there is not enough administrative capacity and competence available centrally to manage the health system well. Throughout the centralization process, the existing administrative capacities were eroded rather than developed (for which the erosion of the purchasing function is a good example). Now, this weak and continuously eroding governance capacity, with which it was impossible to manage the already centralized functions adequately, will be further burdened with additional tasks. This is unlikely to lead to the necessary performance improvement. Instead, it will more likely lead to a further deterioration of the public sector and a strengthening of the private sector, driven by the increasing demand from those who can afford it.
The Hungarian Medical Chamber has already expressed concerns regarding the new reform package, but the move has not generated a significant public debate. Nevertheless, the government seems to be at least aware of the conflicts the partial implementation of the policy of the separation of the public and private sectors has already created. A good example of this is the plan to make it compulsory for physicians working in the private sector to practice 20 hours per month at public providers to keep their license. This measure was originally part of the reform package, but the government postponed its introduction following wide-scale protests from various professional organizations. The opposition parties have pointed out that such a measure goes against the earlier government policy of the strict separation of the public from the private sector and indirectly acknowledges the shortage in the public system, which was generated, or at least aggravated by the policy in the first place. The government is to make the final decision in early 2023.
Authors
The government of Hungary, led by the center right party, Fidesz, implemented substantial recentralization in the organization of the Hungarian health care system, but its outcome in terms of health system performance is not fully known.
Parallel to the change of regime, the integrated, state-socialist system model, characterized by the almost exclusive dominance of the central government in the financing and provision of health services, was transformed into a purchaser-provider split model, as a reversion to the earlier, social health insurance tradition of the country, which was broken by the establishment of the communist dictatorship after WWII. In the frame of the new social health insurance system, the single payer, National Health Insurance Fund Administration (NHIFA), had to contract with the dominantly local government owned health care providers to provide publicly funded health services for the population, which in turn had been reimbursed on the basis of new payment methods, such as capitation in primary care, fee-for-service in outpatient specialist care, and DRGs in acute inpatient care. In terms of organizational changes, the direction of reforms was mainly decentralization, as a reaction to the inefficiencies and inequities generated by overcentralized, communist health care model.
The government, which took power in 2010, however, has implemented significant recentralization, by taking over the ownership and management of previously local government owned hospitals. The initial plan was to take over all specialist care providers, including local-government owned polyclinics, but that was not carried through by the government, because of protesting mayors and local government representatives, who formed a powerful coalition within the governing party, Fidesz, against the announced plan. It is important to note, however, that with the nationalization of local-government owned hospitals, the government has also become the dominant provider of outpatient specialist services, since roughly 70% of these services have been provided by various organizational units of hospitals, anyway.
The ownership and management tasks had originally been entrusted to a new mega background institution, the so-called National Institute for Organizational and Quality Development in Healthcare and Medicines (GYEMSZI), which was established in 2011 as a result of the merging of several, previously separate institutes of the ministry, including the National Institute of Quality Development and Hospital Engineering (EMKI), the National Institute of Pharmacy (OGYI), the National Institute of Strategic Health Research (ESKI) and the Institute of Health Care Professional Training and Continuing Education (ETI). Apart from being the focal point of the nationalization process, GYEMSZI was also responsible for care coordination, in line with the new regional division of health administration.
The expectation was that the state ownership of inpatient care providers would facilitate the needed restructuring of capacities, but also to achieve better deals by centralized procurement of medicines, supplies and utilities. Some efficiency gains have, indeed been realized, such as the savings on utilities and the cut of the pharmaceutical sub-budget of the HIF by almost 25% from 2011 to 2012, but only a small part of this latter could be attributed to savings on centrally procured hospital drugs. Overall the estimated total savings for the initial years do not exceed 10 billion HUF, which is less than 3% of the annual acute inpatient care sub-budget of the HIF. It is important to note, however, that bulk of the efforts of GYEMSZI went to the establishment of the centralized administration and management systems, which was (and still is) an enormous task in itself. More importantly, the expectations regarding the easier restructuring of the inpatient care sector, have only partially been realized. Paradoxically, the fewest achievements could be realized in Budapest, where the diverse hospital ownership structure had indeed hampered coordinated investments and rationalization before.
While the reform, in many respects, is still under implementation, the government has decided to reorganize GYEMSZI, after the 2014 general elections. The tasks and responsibilities of GYEMSZI has been streamlined to the ownership, supervision and management of state hospitals, and GYEMSZI has been renamed to Center of State Health Care Provision (ÁEEK) as of 1 March 2015. The tasks related to health information management and partially to care coordination have been transferred to the NHIFA, while the registration and licensing of pharmaceuticals is carried out by the reestablished National Institute of Pharmacy.
In the area of health financing, some analysts consider the changes in the revenue structure of the HIF by increasing the tax sources to over 50% of the total HIF budget, and its reintegration into the central government budget as the other main direction of centralization. While a diverse revenue structure could be beneficial in terms of long term sustainability, it is true that less earmarking increase the influence of the government over the level of overall public spending on health. Indeed, one of the main targets of the fiscal stabilization program of the government of 2010-2014, was public expenditures on health, and the remarkable savings, which were realized on the pharmaceutical sub-budget of the HIF during this period, were not reinvested, but taken out of the health sector.