Bitter Medicine

In the first six months of Hungary's health care reform, more harm has been done than good

Already six months into Hungary's so-called health care reform, it has become quite clear that not only are the reforms not really working, but some of the measures implemented have done more harm than good. For example, in only the first two months of this year organ transplants have fallen back by around 50%. The reason for this sharp decline is that much of the administration associated with organ transplants has now become unnecessarily burdensome.

It's not so much that there are fewer organs for transplant. Indeed, Hungary has a system known as "passive consent" whereby everyone's organs are potentially transplantable unless they specifically request not to allow their organs to be used. Unfortunately, hospital officials nowadays don't have the time or the resources with which to refer a potential organ for transplant. A decrease in staff numbers coupled with extra administrative burdens have made the system more difficult to manage. As a result, the situation is such that those waiting for an organ will now have a longer wait; meanwhile, those who have been lucky enough to have already received a transplant have to make sure they take very good care of it.

The problem with Hungary's health care reform not only has to do with the restructuring of hospital administrations and budgets, however. A very contentious issue also has been the closure of many hospitals. Most of these institutions are located on prime real estate, and there have been accusations that these closures have been motivated entirely for reasons of profit and not for reforming the health sector.

Most experts in the field of health care agree that there appears to be no valid reason for the closures, and that these closures will cause more problems than they allegedly solve. An excellent example of this is the Svabhegy Children's Clinic in Budapest. The hospital treated approximately 50,000 children a year, mostly those with asthma and allergy-related illnesses. The clinic was located in the Buda hills overlooking Budapest where the air is relatively clean compared with the rest of the city, one Europe's most polluted urban areas. Considering the types of patients it handles, its location can be described as ideal.

Unfortunately, it's also ideal for property speculators. Given the neo-liberalist agenda of the present government, the golden rule of capitalism has been ruthlessly applied: he who has the gold makes the rules. As a result, although the hospital is technically still open to walk-in patients, it's already in the process of shutting down. Most of the pulmonary equipment has been removed and the hot water and heating have already been turned off. Meanwhile, although the health minister, Agnes Horvath, stressed that all children suffering from pulmonary diseases are guaranteed treatment, she was unable to say how or where this treatment will be done, only that they hope to somehow solve the problem. In the meantime, both parents and health professionals have no idea what will happen next. Many speculate that neither does the Ministry of Health.

Hospital Inc.

The government has made it perfectly clear that its solution in dealing with the country's health care burden is to apply a large (and perhaps lethal) dose of corporate governance. Some of this has led to episodes of absurdity. In one instance, the Hungarian government attempted to forego the payment and delivery of medical helicopters from Austria claiming that they weren't needed as the ones already in operation were under-utilized. The Austrians would have none of this, and ultimately Hungary was forced to fulfill the conditions of the contract.

The fact that parts of Hungary’s health sector are "under-utilized" is often used as the justification of the need for "reform". A similar claim was made in terms of the number of hospital beds throughout the country; an estimated 70% were under-utilized. Thus, instead of looking at the positive side of things, that there aren't as many sick people as beds available, the government simply felt that there were too many empty beds, and so cuts had to be made.

There is an obvious danger in over-optimizing public resources. This should have been made very clear to the government last year during the August 20th national day celebrations, when five were killed and hundreds hurt during a freak storm. Prior to the catastrophe, the ambulances on hand "just in case" were woefully inadequate even under supposedly "normal conditions". Thus, when disaster struck, had there been enough ambulances on hand as should have been the suffering and injuries sustained perhaps would have not been as bad.

Despite lessons of the past, the government appears intent on reducing what it sees as "bloat" in the health care sector -- and then some. Hence, a large part of the government program is to provide health care throughout the country within a maximum radius of 50 km. This regimented policy has been used to justify a massive reduction in the number of hospitals and clinics throughout the country, especially in rural areas.

As a result of this, patients now have to travel longer distances for care. In turn, this has led to some alarming situations. For instance, people in the town of Keszthely now must go to the city of Veszprem in order to receive medical assistance -- more than fifty kilometres away and over hilly countryside. On several occasions, pregnant women had to give birth in the ambulance for they couldn't make it to the hospital in time. Likewise, two seriously hurt victims of a car accident last month weren't able to be operated on for almost an entire day because they were unable to find a hospital that was able to look after them.

Regardless of such obvious problems, the number of beds available together with the number of hospitals and clinics (along with their funding) has all been regulated by a cold and strict view of the bottom line. While such form of fiscal discipline and austerity may be appropriate for the private sector, it's totally counter-productive in the public sector.

A prime example of this is the quota system now in place. Hospitals are given a strict quota of how many patients they can handle on a daily basis; if they go over this limit, the cost for treatment isn't reimbursed by the government but shouldered by the institution.

In essence, what the government is forcing health professionals to do is compromise their Hippocratic Oath. The predicament many institutions find themselves in is best illustrated by the following scenario: a clinic in Budapest for organ transplants is allowed to treat about 50 patients; if this quota has been met, and a former patient who has suffered a rejection arrives at the clinic, what are the doctors to do? Refuse the patient until a place becomes available; accept the patient and discharge someone else who isn't in such bad shape; incur the wrath of the government and treat the patient, thereby overstepping the quota and take on the costs of the treatment, or perhaps charge the patient for the cost of the treatment either in whole or in part?

It's easy to say that hospitals should simply stick to their Hippocratic Oath, but in doing so they may end up going bankrupt and have to shut down. If so, what will then happen to those in need of care? Such a situation has already developed with Budapest's largest children's hospital, Paul Heim (Heim Pal). The hospital caters to 80% of the children in Budapest, and is losing approximately 45 million HUF (180,000 EUR) per month and soon will be unable to continue without additional funding. The same situation is faced by most other institutions; in fact, many experts and health professionals have warned that if something isn't done soon, Hungary's entire health care system could collapse by the autumn.

In the meantime, institutions are doing the best they can with what little they have been given. Some have resorted to closing down a portion of their services for the summer. This, however, is playing with fire. In 2003, about 15,000 died in France as a result of an unprecedented heat wave. Many have attributed the deaths to not only the fact that many health professionals were on vacation, but that many clinics and hospitals were closed or understaffed in order to save money.

Unexpected calamities aside, the situation is made worse by the fact that many people are being made to suffer unnecessarily. For example, because of the chronic shortage of funding and available beds, hospitals throughout the country have been forced to put non-emergency operations in a queue. As a result, relatively long queues for surgery have suddenly become a lot longer, making many otherwise non-emergency cases into serious ones. A case in point is hip replacement therapy, where the long wait results in a worsening of the condition.

Finally, the government program has not only put the health and well being of society at risk, but has created a brain drain of talent westward. As a result of hospital downsizing and closures, many health professionals have found themselves looking for work. With fewer hospitals to absorb the growing number of positions made redundant many -- especially younger professionals -- have chosen to seek work abroad. Estimates have put the number of doctors and nurses seeking employment abroad at about one thousand. In the modern times, this is unprecedented. Most countries have a shortage of medical professionals and are doing their best to keep them, not make them unemployed. Not only this, but looking at it from a purely economic standpoint, such a policy makes no sense, because the cost basis of each individual (in terms of the costs for their training) is an unrealized gain which can never be cashed in. In other words, Hungary is spending vast amounts of money training health professionals which end up working in other countries, namely richer western countries in Europe and North America, where there are shortages of such professionals. Thus, in a twist of irony, those who stand most to gain from Hungary's health care reforms are not Hungarians but Germans, Scandinavians, the British, Americans, and Canadians, among others.

Another World

Many view the present health minister, Agnes Horvath, as living in another world. This seemed to be confirmed when she was once quoted as saying that the status of the country's health care system can't be regarded as bad as there are mobile operating theatres to handle such things as gall bladder removal and the like. No-one as of yet has seen such mobile operating rooms, nor does anyone have a clue of how to get a hold of one.

Such outlandish statements aside, the fact that the government is living in a dream world is apparent by their preoccupation with private insurance. Whereas in most countries -- including the US -- the debate is on providing government-sponsored, universal health care, Hungary appears to be running in completely the opposite direction. As a FAIR media advisory in late June pointed out, 64 percent of Americans support the idea that government should provide a national health insurance program and guarantee health insurance for all, even if this would mean higher taxes (FAIR Action Alert, "CBS's 'Sicko' Spin"). The Hungarian government's argument of looking to the US as an example, with an emphasis on less taxes and better coverage through private insurance, is misplaced to say the least.

It's a widely acknowledged fact that a corporate health insurance system, and the ideology that underlines it, seeks to defeat the essential insurance function of public health care -- of everyone helping to take care of everyone else. Indubitably, the much taunted health care systems of countries such as Canada and the UK have some serious shortcomings which their respective governments are grappling to deal with. Still, these systems do far better than what private insurance companies can deliver; they provide universal coverage, are far more cost effective, and statistically their health indicators are better, evidenced by everything from infant mortality rates to life expectancy.

Even so, despite the dire warnings and present horror stories, after six months of so-called reform the government proudly points out that the country's health insurance finances have never looked better. In many ways, however, this surplus has already been spent. The money which has so far been saved won't necessarily be reinvested into the health sector, as a large portion of it has been diverted elsewhere. Much of the remainder, meanwhile, will be used to help bail out some of those institutions which had their finances so drastically cut.

In the end, not much will have actually changed. If anything, it has become worse considering the suffering and the extras which had to be paid by hospitals in terms of interest and penalties. In effect, the entire health care reform process appears to be much ado about nothing and more of a public relations stunt for EU finance ministers to make it look as if something has been done. Perhaps it would have been better if nothing was done at all. Naturally, this isn't really a viable alternative either.

It goes without saying that forcing people not to use the health care system, either by dissuading them through user fees and other direct costs, or by handicapping hospitals so that they are unable to deliver the care necessary, doesn't make for a healthy society. Indeed, it raises the risk of a looming pandemic, among other things. Meanwhile, the savings generated are merely costs shifted elsewhere, for instance in terms of a decrease in productivity and a rise in disabilities (especially among the young) brought about by largely preventable diseases, such as Type2 diabetes.

The final irony is that in the 20th century Hungary had braved many more problems than what it is now facing. Then, not only was there the Great Depression, but the depressions at the end of two catastrophic world wars and vindictive peace settlements. Yet through it all, not only was the country's health care system and network of hospitals able to survive, they were even able to expand. Thus, it remains to be explained how something can be considered "reform" when it actually takes away, makes less, and destroys. Put in another way, how is increasing the cost of medication and cutting back on the number of beds improving health care?

Hungary is in danger of losing some of the advances it has made over the past decades, advances that has put it ahead of some countries which are considered to be "advanced" in terms of health care. A case in point is in the area of kidney transplants, where passive consent and, until recently, a quick and easy administrative regime had made Hungary a much better place for kidney transplants than places like Canada. In fact, it's fair enough to say that Hungary was among the best in terms of specialised medicine such as organ transplants, brain operations, and the like; where it's in dire need of reform is patient after-care, general practice, and nutrition.

By not investing more in health care - in particular, preventive strategies aimed at children -- the overall cost of health care is actually going up. This problem is further compounded by the fact that the government no longer supports physical education in the schools. Unless a change in policy and attitude isn't forthcoming, Hungary will continue to be the sick man of Europe -- in more ways than one.