Knowledge forms and interests in the Hungarian Health Reform

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Accountability has become a major issue in health care.

Accountability has become a major issue in health care. Accountability entails the procedures and processes by which one party justifies and takes responsibility for its activities. The domains of accountability—in health care, parties can be held accountable for as many as six activities: professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and community benefit; and the procedures of accountability, including formal and informal procedures for evaluating compliance with domains and for disseminating the evaluation and responses by the accountable parties. (Emanuel 1996)

A major characteristic of the health sector from the point of view of knowledge is that there is an extreme competition between three bodies of knowledge (1): economy–finance (rival economic theories!), natural sciences (medicine, biology), and social sciences (inequalities, etc.). The experts themselves represent these different disciplines while health policy is supposed to be implemented by the government seeking the common interest of citizens. Local and practical knowledge on the one hand, national, global and scientific knowledge on the other are also in conflict (2). However, short-term political considerations have the most profound effect on political decision-making (3).

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.

The territorialisation of knowledge and policy is supposed to invoke solutions (patient routing, cost effective forms of care, health care management etc.) that work.

The State is reluctant to give up its quasi monopoly of knowledge production (health indicators, morbidity statistics, etc.). 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.

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 conflicts between: …State routine and medical practice? …between national and international knowledge?... between one group of (liberal) experts and another group of (social-democratic) experts? … between “public interest” (and a given knowledge about it) and “corporatism”? ... between “Capitalists” and “the State”?... etc. We plan to study why this overwhelming discontent is perceived.

Indicators, as crystallised forms of knowledge about “reality” (e.g. mortality, inequalities, success rate of given operations in given health institutions) are important both symbolically and in practice. Knowledge and Policy are therefore linked and debated through the discussions on indicators. The role of the indicators in the studied PA is therefore a substantial object of the research.

Targeting is another form of knowledge which is policy at the same time. Targets are in this case defined in terms of risk-groups needing a higher level of per capita financing. Again, this is a symbolic, financial and political issue at the same time. Knowledge about “health risk” in different social groups mobilizes social sciences and public health sciences (incl. health demography) at the same time.

Stemming from the idiosyncrasy of medical knowledge and that of medical training it is often argued that the medical field has its distinct structure, such as being overcentralized, hierarchical and risk seeking. The PA is embedded in a domain, which is defined by the particularities of the medical field, i.e., not only the affected institutions are medical establishments, but also the politicians involved in the decision-making have been mainly recruited from medical professionals. It can be hypothesized that this linkage to the medical field has a direct impact on the PA, which should be untangled in the course of the research. For doing so the application of the medical metaphor can serve as a useful analytical tool, in the sense that narrow parallel can be drawn between the stages of decision making and implementation of the PA and the medical decision making and treating process (e.g. diagnostics, negotiations, decision, “treatment”, aftercare).

The health care reform has an accentuated significance in the Hungarian political context, as the health care system has been one of the last residuals of the pre-1989 system. For that very reason, the relation of the different actors to the reform, and to each other is not independent from their positioning in the post-communist setting. Thus, historical path dependency is an influential aspect of the research. Both knowledge production and appropriation related to the health care reform is steeped in this massive political self-definitional arena.

“Good practice” became an instrument, as a specific form of international knowledge in the context of the health care reform.

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, 34-37

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  • EMANUEL Ezekiel J., EMANUEL Linda L. (1996) What Is Accountability in Health Care?, JAnn Intern Med January 15, 1996 124:229-239,

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