Hungary: a health system in transition - International Health Care

Access

Authority--Health care coverage is considered a right for everyone.

Population Covered--prior to World War II, there was limited access of the population to health care. After World War 11, care was slowly extended to everyone along the lines of a socialist system. In 1960, 85 percent of the population was covered. This increased to 99 percent by 1972 and the entire population was covered by 1975.

Shortfalls--Geographic access is limited, with 17 percent of the population located in rural areas with no access to adequate care. Although all citizens are covered for care, the resources to accomplish this coverage are lacking. Lower income individuals receive a lower quality of care than those in higher income levels.

Buildings (Hospitals)

Present System--In 1992, there were 166 inpatient general, psychiatric, and long-term care facilities. Eighteen institutions and 5 medical university hospitals are operated by the Ministry of Health. Counties operate 115 institutions; 9 long-term facilities are operated by other health care entities. There is a hierarchy of local hospitals, county hospitals, regional hospitals, and national hospitals that refer more complicated cases to the next higher level. Typical hospital wards are 6 beds, with little privacy. Specialty hospitals exist for children, psychiatric care, maternity care, senior government officials, and sanatorium facilities. Hospital medical directors are physicians. In 1990, consensus management was introduced to the hospital system. An executive team of the medical director, the nursing director, and the economic director, each with equal voice, directs the hospital. In the future, these positions will be appointed by local governments. Hospital organizational structure is a combination of the Russian and an models.

Clinics--There are separate clinics for adult services and pediatric services. Services have national programs with local treatment dispensaries. In 1980, there were 171 tuberculosis dispensaries, 124 dermatological and venereal disease dispensaries, 73 oncological dispensaries, and 180 specialized psychiatric consultation units.

Hospital Beds--In 1970, there were 8.21 beds per 1,000 population, which increased to 9.2 beds per 1,000 population in 1992. In 1990, there were 72,551 beds in short-term facilities, 29,403 in long-term facilities, and 12,785 in psychiatric facilities. Regional health authorities have control of 77.5 percent of the beds.

Admissions/Length of Stay--Hospital admission rates are higher than those in other European countries or in the United States. In 1982, the hospital admission rate was 20.5 percent. Average length of stay, 9.9 days in 1989 in acute care hospitals, is comparable to Europe and the United States. In 1987, the length of stay in chronic care hospitals was 32.4 days.

Inpatient Care/Occupancy Rates--Hospital bed days are comparable to those in Europe and the United States. Per capita use of inpatient care in 1982 was 2.8 days. In 1990, there were 19,605,076 inpatient days in short-term facilities, 8,894,622 days in long term facilities, and 4,003,817 days in psychiatric, facilities. Occupancy rate is 84 percent.

Costs

General--In 1983, 14 percent of the health care dollar was spent on primary care services. In 1990, total health expenditures were U.S. $1.838 billion.

Hospitals--The long-term financing plan is based on morbidity factors. The budget is based on bed capacity, the number of physicians and other personnel, the cost of an inpatient day, the number of the most expensive surgical procedure, the number of the most expensive diagnostic tests, and the number of inpatient days. Preliminary budgets are allocated in the first quarter. A mid-year review reallocates revenues according to performance. Some expensive procedures--i.e., perinatal intensive care units, dialysis centers, heart surgery, etc.-usually receive a separate allocation from the Ministry and the local Council. Half of hospital costs are salaries. In 1986, a DRG-based system, modified for Hungary, was introduced and was in use in 10 hospitals by 1989. Extra revenues may be generated by a hospital by providing services to other institutions and attaining certain targets set by the Ministry. In 1990, 1.9 percent of the GDP was spent on hospital services. Hospital services were 33.6 percent of overall health care expenditures.

Insurance--Employees pay 10 percent of earnings through a payroll deduction while employers pay 43 percent of wages into the fund that covers health benefits, retirement benefits, workers' compensation, unemployment benefits, and other social benefits. One third of the collected premiums are dedicated to health care. In 1993, the National Health Insurance Foundation was put in control of distribution of health care finances.

Medications--Annual drug consumption is $50 per capita. Pharmacists who receive postgraduate qualifications and the title specialist pharmacist" are entitled to monetary benefits above the usual monthly salary.

Patients--There is a copayment of 15 percent for medications purchased outside the hospital and other specified copayments for spa treatments and nursing home care.

Physicians--New medical school graduates receive U.S. $125 monthly (minimum wage in Hungary is U.S. $110), which increases to U.S.$185 over a 10-year period. Salaried government physicians receive low wages. Beginning engineers earn more than beginning physicians. Monetary incentives are given for increased patient load based on the number of health cards in a practice, the age distribution of the patients, and the experience of the health care provider. Unfortunately, there are 14 million health cards for a population of 10 million. Patient tipping can account for significant monetary rewards. In some cases, salaries will be augmented three- to fourfold through tipping. Private practice is allowed after the physician has worked six hours for the national health service.

Drugs (Medications)

Approval Process--The National Pharmaceutical Institute (OGYI) has role similar to that of the FDA in the United States in approval of experimental preparations. Research activities are coordinated between the different institutes and clinics through this agency. VI Pharmacopoeia not only controls internal products, but also evaluates imported preparations. Twenty county pharmacy centers manage pharmacies in their sectors both administratively and financially.

Availability--the pharmaceutical industry is highly developed and is engaged in many joint ventures with drug companies from western countries. More than 80 percent of the country's needs are met with internal production. The national formulary has 1,200 products. Hungary is a net exporter of medications, with 5 percent of the world's exports. It ranks second in the export world to Switzerland and exports to 90 countries. There are 1,400 public pharmacies (gyogyszeresz) and 70 state institutions, all controlled by the state. More than 10 percent of the pharmacies are privately owned. Most medications are prescribed in unit doses supplied by the manufacturer. Pharmacists do very little patient counseling. Many previously prescribed medications are now available as over-the-counter preparations.

Equipment (Technology)

Approval Process--New technology introduction is government controlled. Although spending is tightly controlled, decision making on equipment purchases is highly influenced by health care providers. Financing is highly influenced by the budget of the appropriate council.

Availability--Past postponement of investment in hospital structures and equipment has produced significant deterioration in building structures and scarcity of equipment. With scarce hard currency, there is a limited amount of technology that can be purchased. Two thirds of the equipment used in the country is internally manufactured.

Funding (Financing) Care

In 1990, social insurance accounted for 58.3 percent of health financing. Personal out of pocket payments accounted for 16.4 percent. Government at all levels provided 25.3 percent of the financing. The state distributes the finances to the county councils in a block grant-type of distribution.

Health Care Provision and Providers

Long-term Care Facilities--Day care homes are for those unable to care for themselves who have no relatives to help. Pensioners must share costs for meals, medical attention, social activities, and entertainment. If a member who gets care has family members, they must share costs. The 1,086 day care homes served 30,183 individuals in 1985. A family practitioner referral is usually given to the director of the elderly center, who supplies services according to need and availability of resources.

Home social care is done by home visitors. Benefits included are personal care, meals, cleaning services, and medical errands, such as medications obtained from pharmacies. In 1984, 24,469 individuals received "meals on heels," meals delivered by people on foot. The care is provided half the time by nurses and half the time by trained volunteers. In 1985, 40,000 individuals received home health care.

The final care available is in 279 nursing (social) homes, which served 36,327 individuals in 1984. The elderly occupied 59.4 percent of the beds, with the remaining beds occupied by mentally ill, mentally retarded, and handicapped individuals; alcoholics; etc. Staff for these individuals is only 4,000 skilled nurses. There is a nursing shortage despite the local training programs established to mitigate against it. Funds are from the local municipal council. A waiting list is kept at the Department of Health of names referred by local family practitioners, who make daily visits to the home. Accommodations are available according to ability to pay, with base accommodations of seven to a room.

Emergency Services--Transportation of the sick is by the National Ambulance Service, which is under the supervision of the Ministry of Health. There are 165 ambulance stations with 1,800 ambulances equipped for on-site treatment of the severely injured. Ambulances are linked by radio-telephones to the national headquarters and to each other. There is a back-up system of emergency departments and trauma centers. A system of air transport vehicles assists the ambulances. No area in the country is more than 25 kilometers from a health care center.

Home Health Care--Visiting nurse services are a supplement to hospital care and care for the aged. The public health system has visiting nurses for child and maternal health services. The rural district nurse provides bedside nursing to those unable to attend clinics. In 1985, the 4,595 primary health nurses made 5,965,106 home visits. There were 27,608 elderly participants who received care. Only 40 percent of clinic time is spent in direct patient care.

Present System--Since the break-up of the Soviet Union, the system has evolved into more of a market economy type. There is a separate system for care of the governing, academic, managerial, and scientific elites. Their care is in a closed system of hospitals and clinics.

Vertically integrated, autonomous systems have been slowly transformed into an integrated system of primary care, preventive and curative services, polyclinics, and hospital services serving regional populations. Polyclinics in many areas will be climinated, with ambulatory care provided in either the outpatient department of the hospital or the Primary Care Center (PHC). Health centers have 1,000 to 2,300 beds and I to 3 polyclinics. Doctors in the hospital rotate through the polyclinics and as factory doctors.

The system has continued to evolve, with hospital outpatient departments and polyclinics developing into community outpatient service centers complete with specialty care. Patients are now free to chose their own physicians within their communities.

Physicians, General--In 1970, there were 297 physicians per 100,000 population, which increased in 1992 to 339 physicians per 100,000 population. In 1949, there were 9,468 physicians, which increased to approximately 33,000 physicians by 1985, half of whom were women. The range of physician saturation is great, with 580 per 100,000 population in Budapest, 400 in country towns, and 80 in villages. Physicians cannot engage in private practice unless they are full-time employees of the county council and get council approval. Patients are seen in the doctors' homes. A private practice cannot exceed two evenings per week, and practice earnings are heavily taxed. With the change in the system, private practice has become a large part of the health care system.

Primary Care Physicians--Primary health care includes the district physician and district pediatrician, school health services, occupational health services, maternity and infant care, district dental services, ambulance services, public hygiene, environmental and food services, epidemiology, and health education. Care is territorial through a countrywide "patch" system. Each family practitioner is assigned a care area (patch) that does not overlap with any other patch. Groups of general practitioners have a larger patch. Patients who live within the patch may go only to the general practitioner who empanels the patch. Special arrangements are made and published that enable patients to bypass the general practitioner for certain. General practitioner panels average 2,500 patients. In 1985, there were 4,248 district general practitioners and 1,204 pediatricians providing primary care on a full-time basis; 1,280 occupational medicine physicians provided primary care services on a part-time basis. In 1970, there were 36 general practitioners per 100,000 persons, which increased to 45 per 100,000 in 1992. With the lifting of restrictions, 40 percent of primary care physicians were private by 1994.

Primary care is available 7 hours a day, 7 days a week in the office and on home visits. Family practitioners usually take their own night calls and rotate weekends. On the average, 300 patients are referred to the polyclinics a year and 40 to 50 are admitted. In 1965, general practitioners made 4 million home visits, with an increase to 4.44 million in 1985. There is geographic maldistribution, with many small villages not covered by primary care providers. One in eight family practice doctors is elected as an auditing representative to monitor health services, monitor the environmental problems, and supervise preventive care. This individual acts as a public health director.

Specialists--In 1985, 75 percent of practicing physicians were specialists. The greatest variability between Budapest, the towns, and the villages is seen with the specialists. Obstetrics is provided by obstetricians and maternity nurses and not by general practitioners. The separate pediatric services are staffed by pediatricians in clinics, polyclinics, hospitals, and rehabilitation services that only treat pediatric patients.

Insurance

History/Establishment--In 1931, 31 percent of the population was covered by health insurance. There was no insurance for the rural agricultural worker or the urban poor. In the '50s, coverage was 56 percent and, by the early '60s, was extended to 96 percent of the population. In 1972, the system was changed to employer mandated payments, with all citizens covered. The program in place at the time of the launching of the republic was still employee/employer mandated funding of a social security package. After the country became a republic in 1988, it launched a National Health Insurance Fund separate from the other social insurance funds.

Administration--Since 1992, funding of new insurance has been shared by employers and employees, with tax financing for those unable to pay. Pension funds from pensioners, unemployment funds from the jobless, and local government revenues to supplement care of those unable to pay will support the health insurance program.

Health Benefits Package--Prior to the fall of the Soviet Union, benefits were available to all individuals. There was a greater benefit to those who worked. The present health benefits package is to be determined by the new National Insurance Fund. Benefits will be available only to insured individuals. Local governors will deal with those in their jurisdiction who require assistance. A small percentage of the population will fall between those eligible for assistance and those who are insured. Benefits included in health care expenditures are institutional domiciliary care of the physically and mentally handicapped, sickness benefits relating to loss of income, and public health programs. Maternity benefits include 20 weeks of maternity leave.

Workers' Compensation--In 1985, 33 percent of the 8,000 primary care physicians were employed in the industrial sector, full or part time. Every business with more than 500 employees has a full time physician. One percent of the country's general practitioners work in the industrial sector. The industrial sector is still not well policed and there are hazardous working conditions. Accident data are, in many cases, unpublished or false. Many disability claims are dubious but difficult to prove false. A person on disability collects 75 percent of his or her previous salary even while employed elsewhere.

National Health Care Structure

General National Structure--Parliament is the highest level of government. The Cabinet is the highest administrative body to manage and control ministerial work. A parliamentary multipartisan committee controls health care laws and their implementation. The Ministry of Social Affairs and Health plans and implements health care policy based on these laws. The council of ministers and parliament distribute funds to health and to other social and economic programs.

National Medical Structure--As with most socialist countries, after World War II the health care system was patterned after that of the Soviet Union. In 1986, the Ministry of Health was replaced by the Ministry of Social Affairs and Health to give emphasis to the fact that social conditions affect health. The Ministry of Social Affairs and Health is charged with health care planning, priority setting, standard development, and coordination of the system. It is a part of the Council of Ministers. A Scientific Council with many medical consultants advises the Council of Ministers on matters of health. There are more than 40 National Institutes for specialty care, e.g., the National Institute of Children's and Infant Care, the National Institute of Cardiology, the National Institute of General Practitioners, etc. The National Institutes care for patients referred from lower level hospitals.

After the fall of the Soviet system, the name was changed again, this time by the freely elected Parliament, to the Ministry of Welfare. Monies are distributed to county councils as block grants on the basis of population, development, and previous allocations. Hospitals all have a similar organizational structure, with a hierarchical top down, strong central control with rigid rules.

State Medical Structure--There are 19 counties (regions) and the city of Budapest. This is the next level of care and is analogous to a state structure. Regional centers are Level IV care. Local authority is in the county or district council (in the case of Budapest), with administration from the executive committee. Each entity is governed by an elected council that has an executive committee. Funds are from block grants and local taxation. Each county has a health department for standards and health policy implementation. The county health department has dual control responsibility to the executive committee of the county council and professional responsibility to the Minister of Health. Institutional care is usually begun at the county level. Medical university clinics and certain departments of major county hospitals provide very specialized care for patients from two or more counties and routine care for geographically associated populations. Hospital care is a county function. County general hospitals have 1,000 to 2,000 beds, most of the specialties needed for routine specialty care, and lower technology than the larger regional institutions but more than the community facilities and accept the 20 percent of patients who require referrals from the local hospitals.

County Medical Structure--County structure is seen mainly in the urban areas. Budapest is divided into 22 districts, each of which has an autonomously elected council with local authority. County and city councils have dual responsibilities for administration and financial management. The city and county councils are known as level Ill care. Budapest has integrated the hospital and polyclinic systems. The polyclinic system is known as level II care. In 1955, there were 2,872 medical districts, which increased to 4,050 by 1980. Many of the districts have no physician coverage. The average district is intended to serve 5,000 to 6,000 people. Level 11 hospitals, county or specialized care hospitals, have 1,500 to 2,000 beds. All specialties are represented. Many patients bypass level I hospitals and go directly to level II without a referral. Polyclinics, dispensaries, and PHC services are available at this level. An average polyclinic has 2 general practitioners, one pediatrician, one dental officer, one factory doctor, 2 district nurses, 4 health visitors, 9 clinic nurses, and 3 social workers. Part-time specialist services may be provided.

City Medical Structure--The typical city structure is in rural areas. The next higher level is the state (county) level. There are typically three levels of health structure, not four. There are 109 towns and 2,957 villages. In towns, the PHC functions as part of the hospital outpatient department, with the hospital director also acting as the chief of service. There is local supervision by the town council. The county and city councils have dual responsibilities for administration and financial management. The village PHC is controlled, staffed, and supervised by the town council, not a hospital director. The primary care physician is known as level I care.

Towns and villages have an elected structure similar to the county level that is administered by the executive committee, which is responsible for short-term planning. The health department (village administrative body) at the municipal level is responsible to the county health department at the county level and is controlled by the local executive committee. Accountability to county, municipal, and village councils is stronger than vertical responsibility to the next higher health department.

Population

Of the 1990 population of 10.6 million, 20 percent was in Budapest. In 1985, 15.7 percent of the population was between the ages of 60 and 79, and 2.2 percent of the population was more than 80. The percentage of the population over 65 has increased from 7.3 percent in 1950 to 13.3 percent in 1990, with a projected increase to 14.6 percent by the year 2000. The dependency ratio, population age 60 and over compared to the population in the 15 to, 59 age group, was 18 percent in 1950, increase to 28 percent in 1980, and is expected to increase to 31 percent by the year 2000.

Quality

Each hospital is surveyed every 4 to 5 years for adherence to standards. Unfortunately, there are no sanctions imposed on those that fail. The principal indicator of quality prior to the collapse of the Soviet system was quantitative measures. The increase in actual numbers, not the substance or quality within the numbers, was the benchmark. The European Community's Medical Health and Research Coordination Program resulted in a Concerted Action Program on Quality Assurance in Hungarian hospitals.

University System (Medical School/Training)

Medical Schools--There are four medical schools with faculties in medicine, stomatology, and pharmacy and one postgraduate medical university. Forty national institutes are part of the university system. Previously, training during the first three years was general, with clinical training in the last three years. Since 1982, medical education has changed dramatically. There are now two years each of basic science education, preclinical training, and clinical education.

Financing and management of medical schools is a direct function of the Ministry of Health and Social Affairs. The funding amount and spending regulations are a function of the Ministry of Finance. Free education has been replaced by a U.S.$185 monthly stipend to offset the costs of books, instruments, and licensing fees.

Postgraduate Training--Five years' training after graduation is required to become a specialist. Family practitioners require no extra training. The Primary Care Institute in Budapest was established to address this shortfall. There are 60 places per year available to supply two years' training in family practice. The Postgraduate School of Medicine trains specialists and provides continuing medical education.

Edward M. Mendonza, MD, MBA, FACPE, is CEO, Augusta Medical Managers, Augusta, Ga., and Professor, Department of Medicine, Morehouse School of Medicine. Bryn Henderson, DO, JD, is a management consultant, specializing in health care issues, in Orange, Calif.

COPYRIGHT 1996 American College of Physician Executives
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