6.1. Analysis of recent reforms

This chapter considers in detail the major reforms and policy interventions that have taken place since the previous HiT profile on Hungary was published in 2004. It sets these within their context and explains their impact on health and health service provision. The chapter considers the major reforms already implemented, as well as those that failed or were passed but never implemented, and provides an overview of future developments. For more details on older reforms and related policies, the chapter refers where appropriate to other sections of the present volume.

In the area of health system governance and organization, the chapter focuses on a third (and ultimately unsuccessful) attempt made to introduce managed competition to the health insurance system; the HISA; capacity regulation; the ownership and management of health care providers; coordination in health care; and intersectorality and public health. In the area of health system financing, the chapter describes important reforms made to revenue collection; the pharmaceutical market; provider payment methods; and user charges. Section 6.2 concludes the chapter by providing a brief outline of future developments.

6.1.1. Reforms of health system governance and organization

Third attempt to introduce managed competition to the health insurance system

Starting in 2006, one of the highest priorities of the government was to introduce managed competition to the SHI system by replacing the NHIFA/HIF with multiple health insurers that would be under partial private ownership. The stated aim of this change was to reduce inequities in the use of health care services, to improve efficiency and to ensure financial sustainability and transparency (2008/7). This was the third and most elaborate attempt since the early 1990s to introduce a system of multiple, competing health insurers to Hungary. (For details on the two previous attempts, see section 2.2.)

A bill introducing managed competition to the SHI system was approved by the National Assembly in December 2007, but vetoed by the President shortly thereafter. In February 2008 the National Assembly overrode the presidential veto and passed the bill in the face of widespread public protest. At the same time, the main opposition parties initiated a referendum, which was held in March 2008, on user charges for physician visits and hospital stays and on tuition fees in state-funded higher education. By an overwhelming majority of more than 80%, voters approved a measure revoking both measures. In the meantime, the opposition parties had signalled their intention to hold a referendum on the legislation for managed competition in September 2008. Expecting that this would have the same outcome as the referendum held in March of that year, the National Assembly repealed the act in May 2008. This created what is most likely an unprecedented case in the history of the Hungarian lawmaking, with the same parliament approving a law twice and then repealing it within the space of six months. This situation caused the Alliance of Free Democrats to leave the governing coalition, leading to a break-up of the government and the formation of a minority government by the Hungarian Socialist Party.

If the managed competition model had been implemented, the NHIFA/HIF would have been replaced with 22 joint-stock companies. In each company, 49% of the stocks would have been sold to private investors and 51% would have remained in state ownership. The minority private stockholder, however, would have nominated the CEO and had deciding power to influence daily management. It would have been possible for a single investor to have a stake in more than one company, but only if the total number of individuals insured by these companies did not exceed 2 million. Insurers would have been expected to compete for enrolees through the quality of their services, and they were to form joint commissions at the national level to advise the government in purchasing decisions.

Administrative costs would have been limited to 3.5% of the revenue, which is approximately twice the percentage currently incurred by the NHIFA.

The HISA

With the stated aim of increasing accountability and transparency, a plan to establish the HISA was presented in June 2006 (2006/10). Doing so was considered by the government to be a precondition for introducing managed competition to the health insurance system (Government of the Republic of Hungary, 2006). The HISA was to supervise private and public actors within the health care system, including new entrants to the health insurance market. In this capacity, it was also to oversee and evaluate the outcome of health services delivered by providers and to protect patient rights. No separate discussion paper was presented, and no formal health impact assessments were conducted, however, before the HISA was established and went into operation in January 2007.

After the repeal in 2008 of the bill that would have introduced managed competition to the health insurance system, the new authority did not play any supervisory role with regard to the NHIFA, but rather focused on monitoring waiting lists and the quality of services, as well as on examining patient complaints. In February 2009 the HISA published an activity report, which showed that only 1350 complaints had been submitted to the authority in 2009, which is very low compared to the total number of services provided within the health system. Most complaints were about care provided improperly and in a manner contrary to professional standards, insufficient patient information, and waiting lists. The HISA conducted some useful research to inform the public and policy-makers on quality issues and access to care (HISA, 2009).

Following the elections in April 2010, the new government eliminated the HISA (2010/10) with the stated aim of improving the efficiency of the health system. Some functions of the HISA were preserved by the government and distributed to other actors in the health system, such as the NHIFA and NPHMOS.

Capacity regulation

A stated goal of the governments in power from 2002 to 2010 was to make health care provision more equitable, increase the quality of care and improve the efficiency of health care delivery by adjusting the capacity of providers more precisely to the needs of patients (2006/12). In 2006 the government argued that (a) the structure of the health care delivery system (the ratio of acute, chronic and nursing care capacities) and its relationship with morbidity and mortality patterns were distorted and (b) the geographical distribution of the capacities was unequal, resulting in unfair disparities in access to care.

To address this issue, the government aimed to reshape the system so that treatments for emergencies and common diseases would become accessible in as many places as possible – preferably within the framework of outpatient care – while more serious and costly interventions would be limited to facilities where all necessary conditions were available. A new law to this effect was approved by the National Assembly in the second half of 2006 (2006/12) and implemented starting in April 2007 (NISHR, 2007). This took place without the government having previously published a discussion paper or special policy paper for wider consideration, and several experts at the time criticized the law for its lack of transparent methodology (Ágoston et al., 2009).

In the wake of this legislation, the total number of acute hospital beds was reduced by 26% (to 44 215), some of which were transformed to increase chronic, rehabilitative and nursing care capacity by 35% (to 27 169) (Vas et al., 2009; NISHR, 2007). Five hospitals were closed down along with the acute-care departments of another twelve hospitals. Moreover, four hospitals were merged in a single state central hospital. The level of the acute care provided by the hospitals was split into categories, such as priority hospitals (39 in total) and territorial hospitals (77 in total) (NISHR, 2007). The priority hospitals, which consisted of a heterogeneous group including large university clinics, county hospitals and small municipal hospitals, accounted at the time for approximately 50% of all hospital beds in Hungary (Vitrai, Kiss & Kriston 2010). They were intended to work with the most advanced technology and with the best-trained physicians and to function as emergency centres providing urgent care around the clock every day of the year. In contrast, the territorial hospitals were intended to provide general acute care. In addition, 50 institutions were allowed to provide only rehabilitative and nursing care (NISHR, 2007), and the new regulation reshaped the catchment areas of all providers as well. The capacities of outpatient care were frozen at the level of 31 December 2006 (Ágoston et al., 2009).

Capacity regulation of the providers had already been reorganized twice since the mid-1990s (see section 2.2). The new regulation (2006/12) returned to the pattern of the capacity regulation legislated in 1996 in two important respects. First, the new system was introduced in both cases along with deep downsizing of the hospital beds. Second, implementing and managing capacity regulation was left to the stakeholders – that is, the county consensus committees after 1996 and the regional health councils after 2006. Furthermore, the decrease in the total number of beds seen in 2006 was 11%, which mirrored the reduction that had taken place in 1996 (Ágoston et al., 2009).

The regional health councils are convened by the NPHMOS and consist of representatives of the most important stakeholders, such as hospitals and the NHIFA. By establishing this mechanism, the government aimed to give more of a role to the stakeholders in monitoring unused capacity and to restructure this capacity through systematic negotiation. The councils are also entrusted with compiling regional health development plans. Unfortunately, the new system does not have a clear process of health needs assessment, and the councils lack the proper policy capacities and authority (Tótth, 2008). Furthermore, no monitoring process has been put in place to evaluate how far the objectives of this reform have been achieved. Some observers have stated that the government’s measures did not lead to a more equal distribution of capacities (Vas et al., 2009). Moreover, the impact of the reform on efficiency has not been analysed. Several projects to evaluate the impact of the reform on quality and on financial protection have been initiated, with the involvement of WHO experts, as part of the Biennial Collaborative Agreement through the WHO Country Office in Hungary. These studies are expected to be completed in the second half of 2011.

Regarding the impact of capacity regulation on the financial sustainability of the system, however, it seems clear that the health system has not been strengthened. Indeed, the system of prospective payment, which has served as the cornerstone of the Hungarian health financing system since 1993 (see subsection Specialized ambulatory/inpatient care in section 3.7), had almost collapsed by 2009, and the protest by hospitals against the financial restrictions of the government has intensified greatly. A new lobby organization, the Strategic Alliance for Hungarian Hospitals, was created to increase pressure on the government to improve health system financing. Moreover, Hungarian hospitals initiated a “green flag movement” in 2009 to inform patients of their financial situation and to put pressure on the government to ease the financial restrictions.

Ownership and management of health care providers

With the stated aim of increasing the efficiency of health care providers, the government announced in June 2006 that it would introduce measures to encourage the conversion of providers from public to other forms of ownership that would entail more private involvement (Government of the Republic of Hungary, 2006). The government also pledged that regulations affecting public providers would be modified so that their business operations would more closely resemble those in the more competitive business sector (Government of the Republic of Hungary, 2006). The link between the reform plans and general health objectives, however, was not clarified.

Previous attempts at creating transparent regulations governing the involvement of private providers had failed for a variety of reasons. The government in power from 1998 to 2002 chose to take a corporatist approach, preserving the public hospital system and allowing health care providers more discretion in their allocation of resources. The first law to this effect was crafted in such a way that it encouraged the corporatization of public providers while restricting their privatization (2001/12). The government that came into power in 2002, however, suspended some of these restrictions (2002/16, 2002/17) and replaced the 2001 law with a new one that gave decision-makers more room to facilitate private investment in the health care system (2003/5, 2003/6). To support changes in the ownership of health care facilities, the government even offered subsidized loans to employee groups that intended to privatize public providers (2003/12) – a clear signal that the government preferred private investors to take a more active role in the health sector. The 2003 law was later annulled by the Constitutional Court, however, as the National Assembly had not devoted enough time to discussing the objections raised by the President of Hungary (2003/23).

Increasing privatization of many health services has actually been taking place since 1990, when dialysis services were privatized, following by diagnostic imaging (CT-MRI) services in 1994 and laboratory services in 1998. This was followed by a second wave of privatizations in the area of hospital background services, such as laundry, meals, energy and accounting. Subsequently, in 2004, a third wave of privatizations, involving the entire management of public providers, began in 2004 with the outsourcing of the management of a public hospital in the city of Kiskunhalas to Hospinvest, a company established in 2000. By the beginning of 2009, there were eight private companies running sixteen health care institutions (including hospitals and outpatient centres) in this manner (NISHR, 2009).

In the second half of 2008, the National Assembly approved a law regulating the legal status and financial management of public institutions, making it possible to corporatize hospitals (2008/8). According to a report published by the NISHR, 36 of the 126 state and local hospitals in Hungary had been transformed before the 2008 law was repealed by the government brought into power in April 2010 (2010/12) (NISHR, 2009).

In 2009, Hospinvest, which by that year was managing five local government hospitals and five outpatient care facilities, filed for bankruptcy and was forced to return the management rights of these facilities to the local governments. The company had played a leading role in the privatization of management in health care facilities owned by local governments and, as a result, its activities had led to intense public and media debate across the country. The European Bank for Reconstruction and Development, which had invested €4 million in 2007 into the company and owned 30% of its assets (NISHR, 2009), had already sold its share in March 2009, just half a year before the bankruptcy of the company and despite its original plans for five to seven years of business cooperation. At the same time, more and more local governments with similar outsourcing contracts were reported to be lending significant amounts to their health care providers to maintain their operations.

The failure of private companies in running public providers has meant a serious failure of the business model whereby local governments retain ownership of a facility but outsource the provision of services or management to private individuals or companies – otherwise known as “functional privatization” in Hungary. In 2009, the State Audit Office published a study on the outsourcing of hospital services and management, which followed an earlier study on the privatization of secondary and tertiary care health services published in 2006. One of the conclusions of the 2006 report was that a lack of health policy guidance and regulation had resulted in the privatization process being governed by private companies rather than by public authorities (State Audit Office, 2006). The 2009 report confirmed this finding (State Audit Office, 2009b). The role of private capital in the provision and management of services in the Hungarian health care system remains an unsettled policy issue.

Coordination in health care

During the past decade, the most comprehensive measure in the area of health care coordination in Hungary was the CCS, which was launched as a pilot program in 1999 and was in operation until late 2008. The CCS was launched to address the shortcomings of health system monitoring and the various payment systems by employing new financial incentives. The content of the reform, however, was not developed in discussion papers or in a detailed policy proposal, and no specific regulation was prepared. Rather, the National Assembly approved the launch of the CCS by passing a brief amendment to Act XCI of 1998 on the Social Insurance Funds’ Budget of 1999, which was the same law that shifted the responsibility for collecting HIF contributions to the Tax Office.

In essence, the CCS offered health care providers the opportunity to take responsibility for the whole spectrum of care for a population group, initially up to 200 000 people (1998/26). The idea behind the pilot was to provide financial incentives to health care providers to coordinate their activities across levels of care for a population living in a geographically defined area, using the health care utilization data accumulated at the NHIFA.

Although the CCS showed some similarities with managed care in the US and general practitioner fundholding in the UK, it had the following innovative features:

• The care coordinator (that is, a group of family doctors, a polyclinic or a hospital) had no financing/budget-holding responsibilities. Retained at the central level, the financing and payment functions continued to be carried out by the NHIFA.
• The budget-holding function was virtualized. Although care coordinators were assigned a budget on the basis of an adjusted capitation formula, the budget amount was not transferred to the care coordinator’s bank account, but rather served only a basis for comparison: if the actual spending on the patients of the population to be cared for was lower than the virtual budget, only the difference (that is, the savings) was transferred to the care coordinator, which could subsequently use the money to remunerate doctors (or other health care providers within the model), or to improve working conditions, etc.
• Family doctors and not individual inhabitants chose whether to join the CCS, minimizing the possibility of risk selection.
• Patients retained the right to choose providers freely and could utilize health care at providers outside the system, but all the payments made to these providers were deducted from the care coordinator’s virtual budget. In short, the financial responsibility for all episodes of care of a patient in the population to be cared for lay with the care coordinator. This limited incentives to maximize savings by undertreating patients.
• Incentives to undertreat patients were also limited by the fact that providers within the model still had to generate enough revenue by treating patients to survive month by month till the end of the year, when the income from the savings could be realized.
• The NHIFA provided access for the care coordinators to the health care utilization data of patients in their respective populations to be cared for. This database provided the unique opportunity to analyse practice patterns, protocol compliance, patient pathways at the level of individuals, and to evaluate the impact of interventions implemented by the care coordinator retrospectively.
• The pilot did not change how the system operates. If anything went wrong, the care coordination function could be withdrawn, without any risk of people remaining without adequate care.

By design, the CCS assumed the cooperation of local health care providers, that is, the establishment of a functional network of primary care doctors, outpatient specialist clinics and hospitals. When family doctor groups served as a care coordinator, the population receiving coordinated care automatically consisted of the people who were registered with the family doctors within the group. When other providers, such as polyclinics or hospitals, served as a care coordinator, they first had to contract with local family doctors to bring their registered patients into the model. Naturally, all three types of care coordinators had to contract with other health care providers in their region in order to realize maximum efficiency improvements. These contracts were based on the sharing of these savings among providers within the model. Importantly, provider networks were formed only within the health care system, as social care was not part of the initiative.

The first wave of the CCS project was launched in July 1999 with nine care coordinator organizations. The largest organization, the Misszió non-profit-making corporation (a polyclinic) based in the city of Veresegyház, covered a population of 240 000 in 2003. The part of the total population of Hungary that could be drawn into the pilot was expanded gradually. By 2005 the project covered more than 20% of the Hungarian population, or some 2.2 million inhabitants, and the system was regulated in detail (2005/12).

After plans were introduced in 2006 to privatize parts of the SHI system and entrust competing private health insurance companies with the care coordination function, the CCS was assigned low priority. Although the privatization plan was ultimately unsuccessful (see subsection A third attempt to introduce managed competition to the SHI system in section 6.1.1), the CCS remained a low priority and was eventually eliminated in December 2008 (2008/9). Although ample data were available considering that the CCS had been in operation for 10 years, this decision was not based on the results of a scientific evaluation. Moreover, there was no evidence of worsening health outcomes, of problems with access to care, or of inefficiencies or any malfunctions in general. On the contrary, published assessments of the CCS show that many care coordinators employed a range of case and disease management techniques, none of which were enforced, prescribed or suggested any way by the Ministry of Health[21] or the NHIFA. Rather, the application of these techniques appears to have been motivated by the financial incentives inherent in the system – that is, the ability to take the savings resulting from improved coordination in care and use these to remunerate providers.

Intersectorality and public health

In 2001, a 10-year public health action programme was launched with the aim of increasing the life expectancy of men and women to 70 and 78 years, respectively (2001/9). Coordinated by a project unit within the NPHMOS, the programme was continued and later expanded by the government after 2002. Known as the Johan Béla National Programme for the Decade of Health, it was accepted by the National Assembly in April 2003. Still in effect today, the programme has ambitious targets in four main areas – social environment, lifestyles, avoidable mortality and public health institutions – and focuses on cardiovascular disease, cancer (e.g. national screening programmes in breast, cervical and colorectal cancer), mental health, locomotor diseases, HIV/AIDS and risk factors such as smoking, alcohol, drugs, unhealthy diet and lack of exercise (2003/1). National screening programmes for breast (2002), cervical (2003) and colorectal cancer (still a pilot programme) were introduced within its framework (2003/8). Compared to previous plans, the novelty of the new programme was that it focused on the wider environment and determinants beyond the health sector.

After the National Assembly stressed the importance of intersectoral, multilevel national collaboration, with a particular focus on non-communicable disease, in its resolution on the NPHP (2003/1), the Ministry of Health[22] set up an Intersectoral Public Health Committee, which was led by the State Secretary of the Ministry in 2003 and 2004, and subsequently by a Government Commissioner (Vokó, 2009). The necessity to incorporate the priorities of the NPHP into policy-making in all sectors was reinforced by the National Assembly once again in 2004 (2004/11).

6.1.2. Reforms of health system financing

The lack of a stable and predictable flow of resources is arguably the most serious shortcoming of the Hungarian health system. The funding of the health system is strongly influenced by policy goals unrelated to health, such as labour and broader economic policy objectives. Moreover, the large deficit of the HIF, especially since 2004, has been a major driver of health system reforms, most of which have focused on cost-containment and on broadening the revenue base of the system.

Revenue collection

Various government programmes between 2002 and 2010 have focused on establishing a registration and monitoring mechanism to check whether patients had actually paid the necessary HIF contributions and were thus entitled to obtain health care services (Government of the Republic of Hungary, 2006). The system that was ultimately introduced in 2006 is located on site with the providers, who have thus assumed the monitoring function. Importantly, even if they have not paid their HIF contributions, patients cannot be denied necessary care; instead, the patients and the Tax Office are notified about the case for further proceedings (for more details see subsection Breadth of coverage in section 3.3.1). Despite problems related to delayed communication between the NHIFA and Tax Office, several reports published by the NHIFA and the State Audit Office show that the share of the population with an unclear registration status has declined to 3% (State Audit Office, 2008a).

In 2005 a new type of hybrid tax/contribution called a “simplified contribution payment” was launched. It applies to individuals and small entrepreneurs working in media or in the arts and earning below a certain income ceiling (2005/6). Instead of paying regular HIF contributions or income tax, the employees and, when applicable, employers in these occupational groups pay a preferential contribution rate (see subsection General government budget in section 3.3.2). The stated aim of the measure was to support free debates of public issues in the media and arts, and to promote freedom of artistic activity. The HIF collects 1.8 billion HUF (around €6.5 million) from this source annually, which amounts to about 0.1% of its total expenditure. This measure well characterizes the fragmentation of revenue collection in a system in which the government applies policy measures that have little to do with overall health system goals.

Since 2006, deep cuts in the HIF contribution rate paid by employers have led to a shift towards funding through general taxation, as has a redefinition of the central government contribution to the HIF using a new formula to account for non-contributing social groups (2007/11) (see section 3.3). Whereas in the late 1990s employer contributions accounted for 73.6% of HIF revenue (versus 11.3% for employee contributions), they accounted for only an estimated 16.1% (versus 29.6%) in 2010. Furthermore, the lump-sum component of the hypothecated health care tax was eliminated in 2010. At the same time, the total transfer from the central government budget, including deficit financing, is estimated to be almost five times higher in 2010 than it was in 1997. In short, general taxation has become as important as wage-related contributions as a source of revenue in the Hungarian health care system (see section 3.2).

One of the stated goals of successive governments has been to foster the creation of jobs by deeply reducing the contribution rate of employers. This goal has been pursued since the mid-1990s, but data from the employment database of the HCSO show that the employment ratio for the population between the ages of 15 and 64 years increased only slightly, from 53.6% in 1998 to 56.0% in 2000 and to 56.7% in 2008 (HCSO, 2010c). Although the economic situation in Hungary has been complex in this regard, these data indicate, at the very least, that lowering the employer contribution rate is likely not the panacea it has so frequently been portrayed to be. As this is a particularly expensive policy tool, it would be helpful to elucidate its impact on employment with more evidence.

Pharmaceuticals

In its programme presented in 2006, the government indicated that its chief goal would be to contain expenditure on pharmaceuticals (Government of the Republic of Hungary, 2006). Several new measures were introduced to this effect in 2007, such as inciting competition in the generic market by fine-tuning the reference pricing system (2006/20); using NHIFA-certified IT tools to support and monitor the cost–effectiveness of physician prescribing; imposing a 12% tax on pharmaceutical companies, a 2.5% tax on wholesalers and a solidarity tax on pharmacies based on the reimbursed value of pharmaceuticals; and introducing an annual tax of 5 million HUF (around €19 700) to be paid by pharmaceutical companies for each marketing agent they employ (2006/8). Moreover, as had been done by previous governments, the level of reimbursement for pharmaceuticals paid by the HIF was reduced significantly, that is, user charges were increased (2006/20). Altogether these led to a sharp decrease in public expenditure on pharmaceuticals in real terms.

Also, before 2004 there was no systematic and elaborated process for deciding which services should be included in or excluded from the statutory benefits package and the final decisions were made in a non-transparent way. With accession to the EU in May 2004, the adoption of the Council Directive 89/105/EEC, laying down harmonized provisions to ensure the transparency of measures adopted by national authorities to regulate the pricing and reimbursement of medicinal products, was used to establish the process (2006/8) of HTA. The new appraisal process aimed to strengthen the active purchasing of the NHIFA with proper evaluation of the application of the pharmaceutical companies (see more detail in 2.7.2 and in 3.3.2). This was done successfully, and since then, the usage of HTA was extended for other medical technologies and equipment in 2010 (2010/3).

Provider payment methods

As a part of cost-containment efforts, and in addition to the existing DRG-type system in place in inpatient care and the fee-for-service payment methods used in outpatient care, a limit on the volume of billable services was introduced in 2004. Known in Hungarian as a “performance volume limit” (teljesítmény volumen korlát) – “performance” here meaning “output” rather than “outcome” – this artificial limit was calculated as 98% of a hospital’s or outpatient department’s total output in 2003. Until June 2006, a degressive scale was applied for services delivered beyond the limit (see subsection Specialized ambulatory/inpatient care in section 3.7.1). After July 2006, the baseline volume was reduced to 95% of the 2003 output total, and the degressive scale was eliminated completely. This meant that when a hospital or outpatient centre provided health care services beyond the ceiling, they did not receive additional reimbursement. Because this led small hospitals to refer their “over the limit” patients to bigger hospitals, this put the large university clinics (university teaching hospitals) at a disadvantage.

This strict limit led to a difficult financial situation for hospitals and forced hospital management to introduce measures, such as increasing the length of waiting lists, to reduce expenditure and the volume of services provided. In April 2009, the government decided to eliminate the aforementioned limit, albeit only for inpatient services and for specialist outpatient services. For these two groups of providers, the previous payment mechanism was replaced with one that combined a predetermined national base rate and a floating fee based on the volume of services provided (see Specialized ambulatory/inpatient care in section 3.7.1). This change was likely the main reason that provider payment system almost collapsed in mid-2009. A plan to introduce a predetermined global budget was scrapped after weeks of discussions with representatives of the providers. Instead, the previous system, with its strict limit on the volume of billable services, was reintroduced in October 2009.

Private expenditure on health

Although the government programme presented in 2006 did not mention user charges for the health care services by name, it did declare the intent of the government to determine which services would be excluded from HIF coverage and made available for a fee (Government of the Republic of Hungary, 2006). In the summer of 2006, the government presented, as an alternative option for debate, the introduction of user charges on a wider scale as a way to reduce the magnitude of informal payments in the health system. This alternative was published in a discussion paper along with many other reform options (Ministry of Health, 2006).

Until 2007 the main rationale for using and increasing the level of OOP payments was not so much to increase allocative efficiency in the provision of health care as it was to raise additional revenue for the HIF. In February 2007, the allocative efficiency argument came to fore with the introduction of a flat user charge per outpatient visit and a per diem payment for inpatient care (2006/9). Revenue from these OOP payments amounted to HUF 13.3 billion (around €52.5 million) in 2007, which was the equivalent of about 0.7% of total health expenditure that year (see also section 3.4).

These new measures quickly became a hot button issue, proving to be extremely unpopular even among the government’s traditional supporters. The situation was capitalized on by the opposition parties, which organized a national referendum both on this topic and that of tuition fees in state-funded higher education. The outcome of the referendum, which led to the repeal of both measures, is described in more detail in section 6.1.1.