May 5, 2019
Following my first event building public health capacity in Hungary in October 2012, an event about trans-fats organised by the Hungarian Permanent representation, supported by us in Brussels in April 2016 and a Chronic Obstructive Pulmonary Disease (COPD) focused visit to Hungary in October 2016, this time I am joining forces with the Hungarian Alliance of Patients Organisations as well as the National Patient Forum to organise an open debate and roundtable about the new Hungarian Public Health Strategy on 7th May 2019.
Hungary faces a public health emergency. Life expectancy at birth in Hungary was 75.7 years in 2015, up from 71.9 years in 2000, but still nearly five years below the EU average. The gap by gender and socioeconomic group is large: Hungarian men with the lowest level of education live on average nine years less than the most educated men.
The poor results of the population health is fundamentally because of the commercial determinants of health. In 2014, more than one in four Hungarian adults smoked daily. Smoking among people with a low level of education is more than two times greater than among the most educated. Obesity increased, and more than one in five Hungarian adults were obese in 2014. Harmful alcohol consumption among adolescents is another important risk factor: 38% of Hungarian 15-year-olds have been drunk on several occasions in their life (compared with an EU average of 25%).
In order to cope with the public health challenges, the Hungarian healthcare system is under serious pressure which faces structural difficulties. Health spending in Hungary is well below the EU average and the gap widened over the past decade. In 2015, Hungary spent EUR 1 428 per capita (7.2% of GDP) on health care, about half the EU average of EUR 2 797 (9.9% of GDP). Only two-thirds of health spending comes from public sources. The high level of out-of-pocket spending contributes to a comparatively high share of households facing catastrophic health expenditure.
The Health Consumer Powerhouse just released its “Euro Health Consumer Index” (EHCI) for 2018, and Hungary ranks near the bottom of the list of 35 countries in Europe. Sharing the place with Poland, the country is on 33th with a score of 565 out of 100. The 2017 EHCI report said about the Polish and Hungarian healthcare system that despite having good and plentiful medical education and a long tradition of solidarity-financed public healthcare there are still abominably long waiting lists. Pouring money into healthcare would not automatically produce a more efficient system. As EHCI puts it, there is “no correlation between accessibility to healthcare and money spent.” It is inherently cheaper to run a healthcare system without waiting lists than with waiting lists, they contend.
The crisis affects both patients and healthcare professionals. The Hungarian healthcare system is limping along in an unbusinesslike fashion, with patients waiting for hours or weeks, at the mercy of overworked doctors. Since the profession refuses to look upon their patients as consumers, the healthcare system is simply not geared to satisfying patients’ needs. As long as this attitude prevails, little will change.
The healthcare profession is facing an unprecedented brain drain where significant part of the professionals left the Hungary. The number of doctors in Hungary is lower than the EU average (3.1 per 1 000 population compared to 3.6), and so is the number of nurses (6.5 per 1 000 population compared to 8.4). Only a small proportion of doctors are general practitioners (GPs) (about 12% only in 2010, the latest year available), with most doctors being specialists. Furthermore, nearly half of GPs are over 60 years old, while only 10% are younger than 40 years. Hungary’s accession to the EU in 2004 also led to an increased mobility of Hungarian doctors, who have left in large numbers to work abroad. This mainly affected the public sector, resulting in a shortage of health professionals exacerbated by the growing private sector, which is attracting an increasing number of doctors and nurses.
As the State of the Health in Hungary OECD-WHO-COM report suggests, addressing the persistent underfunding of the health system is a prerequisite for improving access to good-quality care for all the population. Strengthening primary care, and prevention is are key challenges to improve population health and reduce health inequalities.
However, all of those challenges could be mitigated. It is possible even in a relatively poor country to achieve almost instantaneous and dramatic results. The example EHCI 2017 provides is Montenegro, which within one year moved to 25th (623 points) from 34th place by introducing their own system of an open, transparent real time e-Referral system, which radically reduced waiting times. Or there is Slovakia, which improved its score by 71 points in one year. One of the reasons for this marked improvement might have been the introduction of a system of private, add-on healthcare insurance.
Hungarian Health NGOs have the willingness and ability to contribute to the solutions. Among other factors, the public interest, non-for profit society has an untapped potential and can bring significant added value: by providing additional data and evidence, delivering services for underrepresented groups such as the Roma, providing constructive input to planned measures and making European connections to bring good practices from other countries are just a few of the many examples civil society can offer.Zoltán Massay-Kosubek