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14 February 2012
Imre Rurik MD, PhD, MSc
GP in practice, Head of Department of Family and Occupational Medicine, Faculty of Public Health, University of Debrecen
There are about 6800 primary care (PC) physicians in Hungary for a population of 10 Million. The 1,500 paediatricians are working mostly in big cities, caring children under 14y only, 1600 GPs are treating population of all ages and the rest of the primary care physicians treat only adults.
Earlier patients were allocated to the local providers, according to the place of residence, were allowed to visit only the official GP (panel doctor, district physician), who was employed by the municipalities or the local (state owned) hospitals. Since the new regulations in 1992, patients might choose their family doctors, and GPs were allowed to leave the employee status and to form their own enterprises.
Financing of PC
The financing is based on capitation mostly. There are other elements based on the number of inhabitants of the working area (higher when population is lower), type of settlements (lower in big cities, higher in remote areas), and there are other multipliers depending from professional qualification of GP (1-1.3), age of the patients (1=18-35y ; 2.5= above 60y). Recently small initiatives were introduced to improve the quality of care. Unfortunately they are based mostly on prescription and less on the real level of professional achievements. Nowadays, this sum altogether is cca. 2,200-3,000 EUR, monthly. This amount has to cover not only the salaries of doctor and nurse but all other expenditures of the practice as well. Many GPs also work part time as occupational health physician, or provide other type of medical services to increase their low income.
Very recently the government offered some extra payment (max. 170 EUR, monthly to cover purchases of new technical devices and investment in infrastructure.
General practitioners had to sign two basic contracts, one with the local municipality to supply care, the other with the National Health Insurance Found (NHIF) for financing. The financial rules are regulated by the government, there is no market based system with competition between providers.
According to the law of 2000, a legitimate title to practice was established; the new GPs have to pay for the practice to the predecessor physician who become retired or if/she dies, to the family.
Structure of PC, gate keeping
There are no group-practices in primary care. Actual financial regulations do not allow it. GPs are working in single handed practices, employing one practice nurse. Cooperation like locum constructions exists but only between practices within the same office or area.
Some type of secondary care specialists could be reached directly by patients, others only by referral (neurology, rheumatology, radiology, laboratory and admission to hospital), except emergency cases. Specialists within secondary care are mostly civil servants, with fixed salary, employed by the health services of local municipalities or hospitals, which are financed by the NHIF, based on fee for service. The same employment system exists in the hospitals as well.
In the former regime of socialism?s it was common, that patients gave some extra money to doctors for treatment (tipping), hoping some advantages in care. Amount of tip decreased in PC, but is yet of widely spread in the hospitals, to avoid waiting list and to honour the underpaid staff.
Health reform initiatives of the last years
In 2007 a health reform was planned and initialized in Hungary forced by the coalition of parties who were in power at that time. This reform was poorly communicated to the society and health professionals as well, and was attacked also by the parties, who were in opposition.
From February, 2007 patients had to pay a symbolic co-payment, as visit-fee (300 HUF, -cca.1 EUR), directly to the health care providers, for each consultations or days stayed in hospital. After a long political campaign where the parliamentary opposition was supported by civil movements, a national-wide referendum was allowed and co-payment was abolished in April, 2008. Previously planned private health insurance founds were not established.
Since January, 2012 according to new laws and regulations government takes over all hospitals from local and county municipalities. The declared goals of these reforms are:
- to rationalize the financing of the health care system,
- to decrease governmental expenses,
- to decrease existing overlaps between hospitals and specialities in the big cities,
- to establish a better centralized managing system, as it was practically impossible to coordinate the different interests of municipalities.
The restructuring process tries to face the problems of human resources, the shortage of doctors and experienced nurses.
Beside the enormous increase of administrative tasks, almost nothing happened in the primary care during the last years, despite promises in the election campaign and change of government in 2010.
A small increase of salary was promised for doctors preferably for young residents who are upset and outspoken. Many of them declared to leave the country when the salary of starting doctors remains unchanged (netto 300-400 EUR, monthly).
Problems of the Hungarian health system
- the lack of new financial resources for changes in the health system,
- private investment is not allowed into hospitals,
- besides low official salaries, existing tipping system disturbs a rational and economical use of financial and manpower capacities,
- there are no existing prevention programmes for people for expected lifestyle modification of patients,
- enormous amount of paperwork is expected from doctors, because a lack of other experienced staff members. Most of the administrative workload seems to be useless; reports for NHIF are shortening the time for consultations and curative performances,
- aged population of doctors, in almost all medical specialty (the average age of GP?s is over 57y),
- the lack of young doctors, who want to take over from the older generation. Many of the young and the middle aged doctors want to move abroad, hoping to get a better paid job elsewhere,
- lack of private investment in Primary Care.
In the recent economic crisis governmental support for Hungarian PC system probably will not increase and the near future seems to be cloudy.