Vol 1, No 16
11 October 1999
C S A R D A S:|
Operation Successful, Patient Dead
The crisis in the Hungarian health service
Casting a glance at a recent survey on patient satisfaction with the hospital care they have received (where the results were in line with the EU average) might lull the casual reader into a false sense of security (Magyar Nemzet, 2 October 1999). Where 93% of these patients claim that they are happy, is there any point in quibbling? Only 62% of respondents, however, were satisfied with the work of doctors and 60% with that of nursing staff.
For one in three patients there was no access to a telephone, in two thirds of hospitals there is no opportunity to seek spiritual succour in the form of religious services in a chapel, in half it is not possible to purchase snacks or food in the buffet, in 71% there is no postal service. Two to four percent complained that they had been made to appear in front of strangers in a state of varying degrees of undress, and the organisation of the daily routine came under fire from 25% of patients who could not understand why they were forced to get up before five am or wait 30 to 40 minutes on arrival before being seen by anyone. Conditions on overcrowded wards also gave rise to misery: noise and anti-social habits of fellow unfortunates being the most frequent laments.
Earlier this year, the 29 clinics of the Semmelweis Medical University (SOTE - the country's most prestigious teaching hospital) organised a two-hour strike, with nurses and doctors treating the most critical cases wearing a blue ribbon or badge to indicate their support of the action (HVG, 10 July and 7 August). They were not alone. The Health Minister, Arpad Gogl, had stated only a month previously that if workers had not received the 13% pay rise promised to them by 1999 they were entitled to take industrial action.
At SOTE, the average increase had been a pathetic 4.3%, the real value of which had been eroded by the withdrawal of staff allowances and the changes to income tax rules. The Ministry of Education had transferred the full 13% and the National Sickness Insurance Fund (OEP) had increased funding for patient care by 16 to 17% compared with last year. This had all gone towards paying off a debt to the hospital's suppliers, which had been steadily accumulating for years and which the hospital could not hope to settle without an injection of outside funds.
These problems are by no means confined to the capital, as the example of the St George Medical University of Szeged shows. Doctors from all walks of life supplement their meagre incomes by working as pharmaceutical salesmen in their spare time. Professor Thurzo, Secretary of the Trade Union Committee at the University, paints a gloomy picture of realities, with the calibre of prospective undergraduates dropping with each intake since their more successful peers head straight into the rival professions of stockbrokering or becoming economists. Even once they have qualified, young doctors no longer queue up for clinical posts at the University, which once guaranteed them a career in scientific research.
According to Professor Thurzo, the financial straits in which clinical workers find themselves could be alleviated if they were paid the same as their counterparts in two of the EU's poorest countries, Greece and Portugal. Their earnings would be five times greater than they are now. The Professor does not consider this to be too much to hope for, particularly in the light of the fact that Hungarian clinics do not lag behind Western European clinics in terms of the quality of teaching and the qualifications of their graduates.
The Szeged University is currently under investigation by the police because, along with five other hospitals from the same county, it spent HUF 540 million (USD 2.2 million) from the sickness insurance fund on investments aimed at improving the quality of care for patients, by replacing obsolete equipment. By law, this money ought to have been spent on primary health care.
The financial woes of over 180 hospitals and outpatients clinics were compounded by an OEP bungle, which meant that they were paid HUF 4.2 billion (USD 17.5 million) more than they were actually entitled to and they now have to pay it back. Since 1 July new weightings have been introduced under a points system for what are known in technical parlance as "homogenous disease groups" adopted by the government to regulate health care funding. Although each point has a greater value, increasing from HUF 68,500 (USD 285) to HUF 75,500 (USD 315), other alterations to the way the system works mean that, in practice, hospitals have to sustain a ten per cent cut in their revenues.
At the Saint Rokus Hospital, the response has been to find new ways of economising. If the temperature of bathing water is allowed to exceed the optimum by one or two degrees Celsius, millions literally disappear down the plughole. The corridors are no longer brightly lit in the evenings and in the long hours of the night. A three-stage plan exists to keep costs within closely defined limits. Stage three, by which only patients are permitted to consume warm meals whereas staff are not, has not yet been implemented. No doubt the managers of one of the few hospitals in Hungary not crippled by debt are keeping their fingers crossed.
Tip of the day
The trials and tribulations described thus far are familiar from elsewhere, but doctors in Hungary are confronted with an awkward ethical dilemma all of their own:
64. The expression of gratitude that accompanies the healing of a patient, the saving of a patient's life and bringing a new life into the world is based on a decision freely taken and without any compulsion having taken place.
65: Gratitude money is a benefit paid on a voluntary basis to the doctor once treatment has been completed by the patient or the patient's relatives.
66. One of the causes of the phenomenon of gratitude payments is the humiliatingly low level of salary paid to doctors. Behind this in turn lies a breakdown in the health care system. At the present juncture both law and social attitudes tolerate gratitude money within certain limits. It is often linked to special fields, ranks, means of treatment alongside numerous subjective factors. This creates tension within the medical profession. Gratitude money is humiliating because it also jeopardises the doctor's independence.
67: Doctors must behave in such a manner as to assure both the patient and his relatives that the quality of the health care provision required medically does not depend in any way on the benefits paid.
68. Workers in the health care sector should not accept gratitude money from each other and should not even give gratitude money.
69: A strict distinction should be drawn between gratitude money and pecuniary benefits either offered or extracted as a result of behaviour alluding to it in advance, which classifies as corruption and extortion.
Thus the Ethical Codex of the MOK (Magyar Orvosi Kamara or Hungarian Medical Chambers), published in 1998 and quoted in a fascinating article by Peter Balazs, an expert on the uniquely Hungarian institution of halapenz or "gratitude money", payments made to doctors by patients in the hope that they will be given proper treatment, a practice which everyone is aware of, but which the government tends to turn a blind eye to (except in the heat of election campaigns), though ironically doctors are expected to pay tax on it. Its other name in Hungarian - paraszolvencia - sounds much grander, a euphemism which imbues it with a false air of respectability.
What patients expect when they make this investment is clear: it has a placebo effect, acting as a psychological prop to stave off anxiety at a time when the patient is at his or her most vulnerable, in the hands of white-gowned magicians (as Dr Peter Kende dubbed them) who often quite literally have the power of life and death over them. Slipping the doctor a contribution (which for many can be ruinous financially) is supposed to ensure that he will take charge of them more effectively once they are admitted to hospital, that they will be given more individual care, they will be made a fuss of, examined in a daily ritual of reassurance, that hierarchical strings will be pulled on the patient's behalf, confirming him in his belief that forking out gratitude money was indeed the lesser of two evils.
As point 66 of the Codex makes clear, not every doctor receives gratitude money. Those who have decision-making powers are far more likely to receive it (Balazs, p 57), giving rise to a "feudalistic" pecking order. Doctors performing diagnoses, radiologists, anaesthetists and pathologists, for example, are less likely to receive such payments. The atmosphere has been further poisoned with the appearance of new technology, as doctors active in the areas where gratitude money has traditionally been paid have attempted to monopolise expertise with the new equipment (such as fibre optic investigative cameras). This ensures that they carry out the examination which leads directly to the operating theatre, staffed by individuals belonging to their network of contacts. This means that the doctors who accept gratitude money increase the workload of already overstretched colleagues who do not receive a penny in excess of their statutory salaries for their services.
Gratitude money is a long established tradition, dating back to the end of the 1940s when the Communist Party openly condemned doctors' illegal income. It was only in the second half of the 1950s that official rhetoric began to employ the device of circumlocution to allude to the problem rather than tackle it head on. The terminology of "moral and financial respect" has remained virtually unchanged to this day. The concept of gratitude money replaced the conventional "gratuity" in the 1960s denoting its recognition as a distinct subspecies of the tip (See Balazs, p 52).
After the collapse of Communism, the absence of a "genuine" free market was blamed for the persistence of the phenomenon, although few challenges have been issued against the general consensus as to its real cause. To quote the words of Emil Weil, speaking in 1947 at the Second Congress of the Free Trade Union of Hungarian Doctors: "amongst employees in the health service the practice of tipping flourishes [...], this is even true, we are forced to admit, amongst doctors working in hospitals. The cause is identical. It is because doctors salaries are so low that they do not guarantee a decent standard of living" (Balazs, p 53).
It is here that the state is implicated. In an astonishing act of hypocrisy, successive governments have decried the appallingly low salaries paid to doctors yet have refused to raise them to a level that would render acceptance of institutionalised bribes unattractive. The state thereby actively colludes in the perpetuation of gratitude money, all the more so since it factors it into such pay rises as it does deem appropriate to award and, as mentioned above, expects doctors to pay tax on it.
It would not break the bank to stamp out the problem nor would a solution founder due to social opposition. According to conservative estimates, the annual amount of gratitude money in circulation in the economy is around HUF 30 billion (USD 125 million). Distributed equally among the country's 30,000 doctors, this would be the same as each one of them receiving HUF 83,000 (USD 345) extra a month net. Opinion polls show that the Hungarian public would accept doctors employed in the civil service earning three times their current salaries without this appearing excessive (Balazs, p 59).
The insidiousness of the system is that it distinguishes between first and second class patients, between those who can afford to pay gratitude money and those who are "only" covered under statutory health insurance. The fiction of equality is maintained at all costs. As Jozsef Botos writes (Magyar Nemzet, 31 March 1999), a parallel exists in the insurance sector. The split of the statutory health insurance provider into two separate bodies four years ago in the name of healthy competition involved huge costs and opened up a gulf between the two sets of clients:
...here we are not dealing with supplementary insurance designed to cover the costs of extra services, but with basic provision, which a worker in Nyirseg on a minimum wage is supposed to receive under the same conditions as a joint venture businessman in Gyor or a bank employee residing in Budapest's Fifth District.
How is one health insurer supposed to get hold of better basic services than another? By being richer, by including the wealthier citizens of a more prosperous region or social class amongst its clientele. This insurance would, however, completely break away from the statutory social insurance scheme based on solidarity and in which one human life is as precious as any other. This would achieve nothing other than increasing the divisions within society since it would mean that those who are better off already would enjoy better provision within the statutory framework and they could afford to pay for extra services under supplementary schemes should the need arise.
We are naturally not opposed to people joining private supplementary insurance schemes where they can afford to do so. In the statutory system, however, competition between the individuals and organisations which provide services and have a relationship with the social insurance providers rather than between the insurance providers themselves has a justification. In order for this to work, a certain, clearly defined number of members of the Hungarian Medical Chambers (75 to 80%) would have to enter into a contractual relationship with the insurance provider such as is the case in Austria and France.
The system of contractual relationships outlined would put an end to gratitude money and would clarify the doctor-patient relationship. A contractually based medical practice would make doctors interested in using less expensive medicines, thereby helping to break the monopoly currently enjoyed by pharmaceutical manufacturers and retailers and who are allowed to hike prices in the almost total absence of outside control, causing huge financial difficulties for insurance providers and where funds are not available for the state budget as a whole.
The frustrations of the current situation from a doctor's point of view are eloquently set out in an article in Magyar Nemzet by Nasri Alotti, chief consultant at the heart surgery clinic in Zala county (20 January 1999). The alternative to acquiescing to the pressures of the system is bleak:
I have been working as a doctor in the Hungarian health service for 14 years, starting off as a surgeon and then, since 1991, working in the field of heart surgery. Day by day I encounter the problems caused by gratitude money, which even today forces the medical profession into the most rigid of hierarchies, into division within a closed shop. I work with people - doctors, nurses, assistants and medical clerks - who quite literally sacrifice "their lives and blood" for the infirm in the course of doing their jobs, and they do this in the conditions that prevail in contemporary Hungary for a humiliatingly, indeed sickeningly, low level of pay and for a respect that has these days long since ceased to exist in society.
For almost 15 years now I have been listening to the empty slogans of professional and political leaders about representation of interests, about doctors collaborating with each other as well as on the constantly recurring subject of the "urgent and imperative" need to do away with gratitude payments. In the course of my work I obviously meet many different kinds of people as patients. There are some, who remunerate the doctor for his work generously and without making a fuss about it. For others, paying gratitude money is tantamount to financial catastrophe. It is very difficult to determine in advance who belongs to which category if your attitude is that of an honest doctor. The vast majority of patients nevertheless tries to slip the practitioner an envelope with money, and it is up to the doctor to select, on the basis of the dictates of his conscience, his knowledge of his fellow men and his experience, when, from whom and what he should be accepting. At the same time, I have come across people, who because of information they have heard through the grapevine or first hand or because of previous personal experience would not embark on, say, a major operation because they think that "paying the doctor" would be beyond their means.
Gratitude payments are a regrettable form of schizophrenia. I do not believe that anywhere in the world there is any type of income that is officially illegal yet subject to taxation. Nothing demonstrates the character of a society more clearly than this two-faced approach.
In contemporary Hungary, health care is subject to an economy of shortage. Every last one of us has their own private recollections of the shortage economy (under Communism), of the corruption and various forms of bribery that accompanied it. If we begin to bandy about trendy buzzwords such as health care services and profit-orientation then we have to realise that we are but one step away from discrimination. Let's only take care of and cure those patients who are solvent, whom we can see in advance are able to foot the bill and, if necessary, it might be an advantage for the patient to actually pay in advance.
At the same time, gratitude money completely destroys every last vestige of pleasure in the act of healing. Let no one contend that you can feel sincere delight at a professional success in healing a patient with an envelope in your pocket. The patient, though, is quite justified in feeling that he has done his bit in settling the bill once he has handed over the arbitrary amount concerned and the doctor-patient relationship has already sunk to the level of a commercial transaction. The practitioners of this vocation - and I use this rather hackneyed term quite deliberately - know very well that healing is not a commodity and it is not something that can be paid for.
In consumer society, money is the only measure of value. This country has enthusiastically copied Western patterns and succeeded in eliminating every other existing value system in the wake of the former system's demise. It is a good thing that some people have come out on top as a result of the collapse of Communism, but it is worrying that far more people have ended up as losers. The latter turn to us in the health care system in greater numbers and I do not think I need to set out the reasons why in this article. Looking at it from a different angle, the health service has ended up stuck in the role of the poor relation in the shade of the thriving service sector, of the media, the banks and the shopping centres.
I kept close tabs on the first steps taken by [Health] Minister Arpad Gogl when he was new in office. I welcomed his thoughts and actions on the possibility of eliminating gratitude money and increasing the wages of health care workers. I am not looking for scapegoats and I am not seeking to point a finger of blame at either the Minister or the Ministry behind him. I do not consider it expedient to go to war, to preach the word or to bandy about high-sounding slogans. I have taken note of the fact that the people living in this country have - alongside a plethora of other odious realities - also noted that those who look after their most precious treasure are accorded a humiliating degree of respect, or rather a humiliating degree of disrespect. I have taken note of the fact that my medical colleagues also - at least as far as their own interests are concerned and they do have a thorough grasp of these - put up with it, indeed they perpetuate this situation by a variety of means whilst hypocritically holding forth about not putting up with it.
I do not think that I live in Sweden, the Netherlands, Germany or even the United States. I can see Hungarian reality. I am fully aware of this when I say that workers in the health care sector do not have any special requests to make, they do not want privileges or positive discrimination. We would like to fit in with the Hungarian value system. We do not want to be treated as if we were part of the private market, but we do want to be accorded at least the same respect as the other servants of the state. We must gradually come to realise that we are no more important to society than this.
If society and the state were to arrive at this conclusion, I would too. From now on I do not wish to maintain this pretence. I therefore distance myself from those colleagues, who with their unethical behaviour and deeds squeeze out every last drop of gratitude from patients. I no longer have any wish to weigh up whose payments I accept and whose I reject. I do not want the patients to settle the bill. I no longer want anyone to think that I am only doing everything I can to cure them because I expect something in return.
I would like to declare that from this day on I shall never again, under any circumstances, accept from a patient money, gifts or any other kind of service. My decision is a personal one and is not intended to bring pressure to bear on any of my colleagues.
I would like to sleep at night with a clear conscience and get on with my life.
I realise that by taking this decision, I have stirred up a hornets nest. I know that I will be attacked, but I am willing to take on these attacks. I have taken this decision after thinking long and hard about it and with a pure heart. If it means that my family suffers as a result, if there is not enough money for my children to go to school, to wear decent clothes, if they hardly ever get to see their father and if they grow up poor and deprived into the bargain, then I will not hesitate in making a living far away from the health sector because it will be in their interests for me to leave it.
I'll stick it out as long as I can.
A medical whistlebower
In his book What Are You, Gods?, Dr Peter Kende a journalist (editor-in-chief of Pesti Musor, the Hungarian capital's equivalent of Time Out) specialising in championing the cause of the downtrodden and oppressed, blew the lid on malpractice and the conspiracy of silence that surrounds it (Nok Lapja, 7 and 21 July 1999). He researched his subject so meticulously that the predictions of litigation from his more pessimistic colleagues did not come true.In spite of death threats by telephone, he sums up the overall reaction as positive, particularly amongst the general public. Indeed, piles of correspondence testify to the fact that he has touched upon a raw nerve. The obstetrics consultant of an important hospital in Budapest congratulated him, adding that he had bought two additional copies of the work, making it required reading for staff in his department. Kende lays the blame for malpractice squarely on the shoulders of the political elite who are painfully aware that any reforms worth the name would need six to ten years to take effect, longer than the life-span of a government. No party is willing to launch reforms for which the opposition might reap the credit.
According to Kende, most victims of malpractice are not money-grubbers, but merely seek recognition of the wrongs done to them by hospitals. That hospitals defend their staff to the hilt and reject the merest hint of opprobrium is a natural reaction in circumstances where underpaid, beleaguered doctors take refuge behind the mystique of their profession. That society is becoming less tolerant of medical error is demonstrated by the increase in litigation.
Until 1997, when out of court settlements were introduced, the only form of redress for malpractice victims lay in taking hospitals to court. The name of pioneering lawyer Dr Gyorgy Adam featured in almost every case. He was almost single-handedly responsible for bringing malpractice suits to the courtrooms, raising public awareness. Nowadays these cases (the vast majority of which are civil as opposed to criminal or ethical where the chances of success are very limited) only reach the courts if the victim feels that the amount of compensation offered is insufficient. The largest sums are usually awarded where the victims have been completely disabled or where babies have been left disabled as a result of oxygen starvation during birth. A veritable industry has sprung up around these disputes, with lawyers' offices and independent medical experts up for consultation.
The most common errors are leaving swabs or instruments behind in the body during an operation, failing to make women in childbirth adopt the prescribed position (cutting off the oxygen supply via the umbilical cord) and unsatisfactory results within plastic surgery (a minefield if ever there was one!). Again, all experts agree that the doctors themselves are seldom at fault, that the culprit is the chronic shortage of funds (the operation might be successful, but the wound might become infected because no money is available for disposable equipment and reused instruments might not have been properly sterilised).
Glossy medical soap operas such as ER enjoy huge popularity in Hungary. Viewers of this fictional world of glamour and excitement can watch events unfolding on the small screen at a safe distance. Perhaps this explains at least part of their appeal: we can console ourselves from the comfort of our own homes that we are not spending the night in an embattled, underfunded hospital.
Gusztav Kosztolanyi, 11 October 1999
The sources used in writing this article were:
Nok Lapja27 and 29 from 7 July and 21 July respectively
Valosag 8 from 1999 (Peter Balazs, pps. 49-65)
HVG 10 July and 7 August 1999
Magyar Nemzet, 20 January, 31 March and 2 October 1999.
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