Actors of the Health Reform Process in Hungary

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Since health reform has an accentuated significance in the Hungarian political context ever since 1988 the relation of the different actors to the reform thinking and to each other is not independent from their positioning in the post-communist setting. Thus, historical path dependency is an influential aspect in the process. Both knowledge production and appropriation related to the health reform is steeped in this massive political self-definitional arena.

1.1.1. Politicians

The need to change, the need to make reforms in the health field has been both on the political and on the health policy agenda ever since the 1980s. As a Central East European phenomenon on the political agenda health reform is articulated only in periods when the central budget needs consolidation, when it turns out that the treasury is empty (Kató et al 2009). Unless for fiscal reasons politics is reluctant to initiate any real change concerning the health system.

“There is a very interesting relation between health care and politics. The main problem is that the money invested in the health sector doesn’t ensure high “profit” for the politics. In fact the gains are very low. Therefore the actors in the sector are reluctant to co-operate with the political system, plus the health system in itself is structured in such a way that no matter how much money is spent on it there is hardly any visible change from a political perspective. This is because for people the normal status is when the system is properly running without any disturbance. So the political interest is to ensure this relative silence” (Frajna, I).

The “reform story” dates back to 1988 (i.e. before the democratic transition) when the Reform Secretariat commissioned by the Ministry of Social Affairs and Health published the first working paper on how the health care system should be reformed (See: Eröss-Koltai-Levendel-Fernezelyi, 2010) and a program on how the new financing system – with alternative sources could be introduced to the field. The initiative to work out the reform plans came from the Ministry of Finance and the National Planning Office. The deadline was December 1988. Accessibility, unequal quality, lack of standards and the problem of allocating the money and resources were the most important symptoms to be “cured”. The Reform Secretariat then was led by dr. András JÁVOR, a health professional, special expert in healthcare informatics.

“Soon the deputy minister came in and said that a Reform Secretariat is needed to be set up, work it out. I asked him how he thought it to be done. He said he doesn’t know, it’s my task to find the solution. This is how things went then. I asked and involved 15-20 colleagues to help throughout the work, Juli and I prepared a draft, which was discussed and debated. On the basis of it I wrote a conception and handed over by the end of the 80s. This document to my greatest surprise was banned. Weird enough this was the guarantee to be read by everyone. The reason for being banned was because I suggested that the Hungarian Medical Chamber (MOK) should be established when it was regarded as a fascist organization. Many things published in that paper had come about” (A, expert, forrmer and present secretary of State).

Throughout these years all sorts of reforms (or simple modifications) introduced to the Hungarian health care system were expected to change for the better.

The demand for changes are based on such common (both explicit and implicit) and supposedly evidence-based knowledges such as • while health care in Hungary is malfunctioning physicians are “great”

• the system simultaneously allows irrational overspending while it is underfinanced

• while gratitude payment disturbs and deforms the whole system salaries remain unfairly low

• life expectancy is low – major issue is the Central-Eastern European health paradox: so far unexplainable high mortality rate of middle aged men

• high territorial and social inequalities

• local autonomy (local authorities as maintainers, regionalisation, micro-regionalisation) is to be preserved once it regained in 1990

1.1.2. Reticent health professionals and experts specifying their ignorance

Ever since health reform is on the agenda the diagnosis of the “sick patient” is quite stable and alike, the debate is on its treatment. The answer to how and where the therapy should begin depends on the kind of the knowledge holder (health professional) who is either in charge/power or just an influential advisor at the time of the “operation”.

Throughout these years the three competing bodies of knowledge can be distinguished: economics – finance (including competing economic theories) , natural sciences (medicine, biology), and social sciences (sociology, social policy).

Health professionals themselves represent these different disciplines while health policy is supposed to be implemented by the government seeking the common interest of citizens.

When observing the relationship between two of the three above-mentioned bodies of knowledge, we can also formulate a parallel hypothesis: that of a sociologisation-process for the sake of creating political legitimacy. The communication and the knowledge production supporting decisions are more and more rooted in the discourse on territorial and social inequalities as a motive for change. At the same time, this is not necessarily true in the case of the decision making itself, which may follow state routine/ political logic/ financial objectives, etc. In this sense, sociology as a body of knowledge does not necessarily intervene in the formation of decisions, and may serve policy practices only as a legitimating factor, without really taking part in its creation.

Before introducing further actors the interaction of these two actors (politicians and experts) should be studied, i.e. to understand the relation between knowledge and politics.

Many of the actors (knowledge producers, lobbyists, experts, practitioners, professional organisations) share the impression that their knowledge is not used or even referred to in the policy formulation process. They often identify themselves as the silenced side in the debates such as: should medical practice be based on routine or protocols? Or the debates about national vs. international knowledge, liberal vs. social democracy, opposing understandings of “public interest”, etc.

“Basically politics decides everything. It was a terrible situation. Last summer (2009) an international conference - with experts from the countries of EU - was held on how the different health systems face the challenges during the economical crisis. In the course of the presentations at one point when I wanted to talk about Hungary and Mr Molnar (ex Minister of Health), the representative of World Bank kindly asked me to stop and sit down. He added that they are not interested in the Hungarian situation, because the politics’ control over health services is so much that there is no way to get an objective picture of the situation” (A - OEP).

“Unfortunately this is the essential point of our discussion: I think politics doesn’t need knowledge at all. This is what I experienced before, and even more during those four months while in power/in the decision making position. Shocking. Based on personal experiences I dare say that knowledge is at no level needed for the politics” (A – physician, leading decision-maker for a short period –four months- under the Liberals).

Knowledge and policy are also linked and debated through the discussions on indicators. Indicators, as crystallised forms of knowledge about “reality” (e.g. statistics on mortality, inequalities, success rate of given operations in given health institutions) are important both symbolically and in practice. The State is reluctant to give up its quasi monopoly of this kind of knowledge production. Standardized knowledge is produced by the State and non-standardized knowledge is used by other actors, where the first is responsible for sanctioning, but not for policy decisions, and the latter are responsible for concrete decisions.

For the HIR the Green Book published in 2006 was the basic knowledge base, “the book of to-do”, a list of measures to correct several dysfunctional points. The Green Book represented the kind of knowledge reform-oriented decision makers wanted the public to know about health care: a knowledge relying on socio-demographic data and international comparison showing the bad situation of Hungary. Data – on health, financial figures, international comparisons – in the Green Book appear indeed as the central element in legitimizing the necessity of reforms. Arguments come from sociology, economics, demography, but it does not use any medical explanations.

Right from the beginning this book was exposed to cross-fire from most experts and politicians in the health field. There was the critic of mixing three elements: the reform elements of the health sector, the instruments to reach the goals of the Program of Financial Convergence of Hungary and the practical tasks of the health administration. The problems and the present situation are shown in details, the measures to be taken are presented in a “shopping-list” form, but the achievable new situation is not defined (Kereszty, 2008, 64-65).

Other critics (both experts and physicians) refused to accept the validity of the figures and status report simply because they did not trust the statistics and data by NHIA. This is the process of contrsucting specified ignorance! See: the integration report (Bajomi et al, 2010) and the Comparison Zones, below.

“The main problem that the restructuring planned by them [social-liberal government] was not based on valid/reliable data. We didn’t say what they planned was ‘bullshit’ from the beginning but we knew that the data they referred to was not true. … then when we pointed out that certain basic figures are not correct because many important factors such as transport, morbidity, social problems are disregarded” (physician, president of a Regional Health Council).

“You know better than I that these figures [here the reference is made to financing by NHIA] quite often show no resemblance whatsoever to the real needs of the public health system, rather reflect the current political and economical interest of a given lobby. No wonder not one hospital was finally closed down when the situation was presented as the question of being dead or staying alive. This is because Hungary is exposed to/at the mercy of its politicians, and naturally it is the health system – the most fragmented and worst of all that suffers the most" (Leading surgeon).

1.1.3. Medical professionals – practising physicians

Some call it “reform fatigue” (Mihályi, 2007,17), others call it resistance – the fact is that the doctors are far from supporting the accountability measures in general and the HIR in particular.

Unless explained and properly communicated what the changes are doctors may deny the execution of these short-term legal pieces. Despite the overall consensus that reforms are needed resistance can easily generate a “reform burnout syndrome” or scepticism (Kereszty, 2008).

Scepticism and distrust once legitimized by the majority of physicians can lead to the total failure of any reform plans.

Partly separated from the general physicians the “physicians’ lobby”, or the “the corporative medical community” resist any kind of intervention (knowledge or policy) coming from outside: whether it is from the area of “new public management” and (health) economy or social sciences. The “intra-medical knowledge” is too prestigious to give space for others. Not even the directorate of health care institutions can be handed to managers, although there is an enormous pressure in this direction. Probably that is why the ministry tries to argue for change using consensual arguments: practical knowledge (about the bad state of health care infrastructure, the informal payments etc.) or sociological knowledge (about inequalities in access to health care). But the sector resists pretty well the tendency to sociologize, all the more so because they understand what is happening under this “cover”: “the” reform.

Their influence seems strong and effective: “The reform [HIR] didn’t affect this domain [accountability- protocols, expenditure]. They tried to make reforms without the least touching, intruding and disturbing these spheres of interest. Therefore the story was doomed to fail right from the beginning" (A. - NHIA).

ERÖSS Gabor & DAVID Bea (2010), They had a dream. Making health care providers accountable. Or not, Hungarian hospitals at the crossroad of knowledges and policies, KNOWandPOL Report, 9-13.

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