István Mikola, is chairman of the Health Committee of the Hungarian Parliament, and was Minister of Health in the first Fidesz government from 2000 to 2002. This conversation took place during a break in a conference entitled “The rebirth of birth”, organized by the Semmelweis Movement at the Hungarian Academy of Sciences in November 2010. An outspoken critic of the system of informal payments to doctors by patients, he was also the first Health Minister in Hungary to support homebirth publicly.
NT: Why is the Hungarian health care system sick, and what is it suffering from?
IM: The system is sick and the main reason for its illness is the lack of resources, the lack of money. In Hungary today we can spend 4,3% of the GDP on health care, which adds up to about 350–400 dollars per capita (for the entire population) each year. Other European countries spend much more. In Austria the figure is almost 3000 dollars per capita, while in Germany it is even higher. In the United States they have already surpassed the magic figure of 6000 dollars per capita, so how can we expect to perform any miracles with our 350–400 dollars?
At the same time, medical science is highly developed in Hungary, doctors are well acquainted with the new technologies, they want to use new, innovative medicines and therapeutical practices, but the resources needed to do so are simply not available. This is the biggest source of frustration for the medical profession, and this mood spreads to the patients as well. To mention one example, I have just had a conversation with a young woman who would like to have a baby through the testtube programme, but this programme supports only a small number of attempts, it cannot afford many, it cannot finance such individual and justified expectations.
So the biggest problem of Hungarian health care is the lack of resources.
NT: The state may lack the money, but the public seem to find it from somewhere. The system of “gratitude money”, where the patient pays an agreed sum in an envelope, and the doctor illegally accepts it, is enormous in Hungary. In maternity care alone it was recently estimated that couples pay 20 million USD each year. How can this practice be changed? And when will medical staff be properly, legally paid?
IM: This may be the case in obstetrics, but the laboratory doctor, the specialist in internal medicine or the pediatrician receive very small amounts, if they receive anything at all. But it is true, gratitude money is a huge problem in the Hungarian health care, it acts against the best interests of the patients and healthcare professionals, and it must be changed. If we study other European examples, I am only familiar with one way to abolish the system of gratitude money. That is to establish in law the status of a medical professional as a freelance specialist. That means that a specialist is capable of independent work, and signs a contract with the health insurance system, and signs a contract with a hospital, and accounts for his activity on the basis of a previously agreed specialist rate.
In 2001 we prepared such a law, and I as Health Minister at that time signed the draft legislation, in which we spelt out the basis of such a legal status, but the political changes in 2002 (the victory of the Socialist-Liberal alliance in Parliamentary elections) swept it away. We are now going to re-examine it, because we cannot accept any longer that gratitude money be part of the system. So to repeat, the doctors should have freelance status, contractual status, under which they account their activity vis-a-vis the health insurance system on the basis of an agreed, specialist rate. This would also amount to the end of the current, semi-feudal, paternalistic system, because this will mean that those doctors will earn most who heal their patients in the shortest time, rather than the professor of medicine sitting at his desk.
And that is why there is so much resistance to change from the guardians of the existing system. But we cannot avoid this, the change has to come.
NT: Do the doctors themselves support or oppose your proposals?
IM: Young doctors support such a change, older doctors are against it. Those of my generation, in their sixties, oppose it. When I first announced this draft concept on establishing freelance specialists in law, I had serious arguments with leading doctors. They were not happy about it because in the Hungarian system the senior doctor sets the limits of the activities of the younger ones in a clinic or a hospital department. Today that system is outdated, elsewhere in Europe it is not like this, so it has to change, and with the introduction of this new legal status we can expect it to change, and gratitude money to disappear.
NT: This interview is being conducted on the sidelines of a conference on improving maternity care in Hungary. One of the main proposals put forward here is for the establishment of midwifery as a separate profession, independent of the obstetricians and gynecologists. Do you support that endeavour?
IM: I support the demand of midwives to have their own code of practice, so that they can work independently, outside hospitals. Thus I also support home birth, but only under certain conditions. Home delivery can be only allowed for proven low risk births. Higher risk births should take place in hospital, because we cannot endanger the lives of mothers and babies.
So midwives need to reach a new agreement with obstetricians. Obstetricians have to provide a safe professional background for home birth. And if a sudden complication occurs during a low risk birth, then they must be available as well. Midwives and other birth assistants must know that they can attend only those births which have been identified as low risk. This is a very delicate question. Regulations are being worked out at the moment, and I am confident that this process will be successful, and that a consensus will be reached between the professions.
I would like to emphasize that in Hungary the situation is even more complicated, because we also have a system of health visitors. They are very important because they attend mothers and their families before, during and after the birth. They help the families from the time when they decide to have a baby, and during infancy. This is a Hungarian speciality, which is not well-known abroad. And as we establish new professions, it is important that the health visitors too find their place.
NT: At this conference the idea of a “reference ward” has been proposed, a maternity ward in a hospital setting, run by midwives rather than doctors for the first time. Do you support that proposal, and do you think the obstetricians will allow it?
IM: I have also contributed to the proposal on the establishment of a reference ward, and I emphasized that this should be established inside a hospital. Those who first came up with the idea – and the working paper was written by an obstetrician – know well that such a ward, and birth in general supervised by midwives, is only safe if there is a professional obstetrician in the background, not only able but also willing to intervene if there are any kind of problems.
Maybe in this form it will be acceptable to obstetricians, and midwives and health visitors will support it as well. I believe obstetricians will be open to this. Returning to the subject of gratitude money in obstetrics. Such payments are of course made, but the income which Hungarian obstetricians, who have to work night and day, receive in this way does not approach the level of the salary of their counterparts in Austria or Germany.
It would be wrong to give the impression that obstetricians here live like kings from gratitude money. They do undoubtedly live better than other doctors but they are still in a difficult situation. One should also draw a distinction between gratitude money and money which is demanded in advance of the services provided, because in my view this is the main problem in obstetrics, not the gratitude money. In other words, when certain tarifs are set, and it is whispered in the ear of the birthing woman or her family how much money they should give to the obstetrician or the midwives or I don’t know who. This is an unacceptable practice and a criminal act. Gratitude money is not a crime, this is, and it must be rooted out.
A few months ago I invited the leaders of the professional boards of obstetrics and gynecology, and the others, to talk about this problem. Since then I do see a basic change in this field. The leaders made it clear to their colleagues, that it is unacceptable for a maternity ward which is financed by the state, and is part of the Hungarian health insurance system, to set illegal tarifs of its own.
NT: Hungary’s internationally best known midwife, and champion of homebirths, Ágnes Geréb was until recently in prison and is still on trial. What can you say about her case?
IM: Ágnes Geréb has indeed fought for homebirth, and in due course it will be established whether or not she did so in a legally acceptable way. I feel genuinely sorry for her, but the agreement between obstetricians and midwives and other organisations must be reached independently of her. That cannot depend on Ágnes Geréb.
NT: If homebirth had been properly regulated she would not now be standing before a court, but any questions about her professional conduct would be handled by her own profession. Surely this is a double-standard? Other doctors hide behind the hospitals where they work. As an independent midwife, she cannot.
IM: As a law-maker, I would not like to speculate on what would have happened if the laws had been different. There are innumerable situations in everyday life which would require new regulations, because the old regulations have outlived their usefulness. What we have to do now is establish new regulations for homebirth. There is a social demand for this. We should also recognise that pregnancy is not an illness, but a healthy condition. A woman is at her healthiest, when she brings a baby into the world. The care provided belongs nevertheless to the health system, and the health insurance system.
But it is certainly true that there is a real need for new winds to blow through the old corridors, and for the birth of new attitudes in Hungary to birth. But this must happen with great caution, because our responsibility is enormous.
NT: One of the conditions of Hungarian membership in the European Union (in 2004) was the incorporation of patients rights, including the right to information, in law. Are those rights respected today?
IM: I don’t think we lag far behind other countries in respecting the rights of the patients. The legislation is in place and it is respected in most institutions. I personally used to manage two large hospitals, and I have played an active role in several health institutions, and from my own experience I can say the rights of patients in Hungary today are by and large respected. We have nothing to be ashamed of. Institutions have been established which oversee patients rights, like for example the Hungarian National Public Health and Medical Officer Service (ÁNTSZ). And many institutions and foundations exist that deal with the propagation of the rights of patients. There has been a dynamic development in this field in recent years.
So patients do have rights in Hungary today, although of course there are exceptions, and problematic cases.
NT: Is there a health system in another European country that you admire most, and would like to emulate in Hungary?
IM: We can learn something from each of them, but you must also know that health care remains within each nation’s competence in the European Union. Lofty European Union notions like the free movement of labour, the free movement of services do not work in health care, unfortunately. If a Hungarian patient goes abroad, he has to pay for all services, apart from the emergency cases. He cannot just go anywhere and take advantage of any service, even though he is a European citizen. So the borders between countries are still there in health care and European priorities have not been achieved in this field.
Nevertheless there are endeavours to establish common practices between separate health care systems. In certain cases it is possible to freely use certain services. There is an attempt to unify the system, but there is no real unity, compared to the harmonisation which has been achieved in financial or economic affairs in general, but this does not exist in health care.
There are a lot of health care systems from which we can learn. But the real challenge now is how to further develop the health insurance system invented by Bismarck, based on wide social solidarity. This was first established on the basis of a great national consensus one hundred and twenty years ago. Employers and employees pay fees proportionate to their income into a common fund and everybody who needs help is financed from this fund.
This is all very well, but the problem is that this fund is slowly emptying, because wages are low, there are less and less active people of working age who have a job and pay this fee, unemployment is high, and those who do not work, cannot pay. And because we want to revitalise the economy and increase competitiveness, we have to decrease the fees paid by both employers and employees. So there is less and less money in the fund.
And as we negotiated in Parliament the draft budget for 2011, we saw that more than half the money next year will not come from fees paid by employers and employees into the social security fund of the health insurance, but from taxes contributed by the state. And a condition of the state’s contribution is that the state wants to know what is going on, and so takes on a bigger role and responsibility for itself. And the result is that the “Bismarckian” health care system we started with historically, based on society-wide solidarity slides into a state health care system, which resembles the British National Health Service.
To rethink and reshape this is a very serious political challenge, which we cannot avoid. We have to think through it and come up with a new solution for the financing of health care.
NT: The Prime Minister, Viktor Orbán spoke about creating a million jobs in the next ten years, though he was sharply criticised for this, as he was only elected for four. What would you do with health care, if you knew you had ten years to do it?
IM: We have to believe that we will have ten years, and that is the period for which we prepared our program. Health care cannot be reformed in a shorter time-span. During that time I believe economic growth will begin in Hungary. This will mean that our funds, our large money distributing systems will be replenished, and that we can achieve a deep structural and financial refom of health care. What I mean by that is that we put the system back on its feet, and we strengthen the system of family doctors, or General Practioners. It is good for both the patient and the system if he is healed close to his home, without having to run between clinics and hospitals. This pyramid has to be established.
If we can strengthen the system of General Practitioners, we can shift much of the burden away from very expensive hospital care. We would like to make a structural reform, starting from next year, according to which a progressive system will be established, in which the main hospitals, county hospitals, clinics, town hospitals, local hospitals and surgeries will all find their clear places. We are elaborating a system of how to refer patients who cannot be healed by their GP locally, to a higher medical authority. That is one of the changes we will make.
Another change is in the way we finance health care, because the system of financing based on performance has become so distorted in Hungary. This is extremely complicated. We agree that this should remain the normative financial system (diagnosis related group’s system), but certain features which have developed, like the fact for example that certain well-equipped institutions do not work after three p.m. each day because the money has run out, must be abolished.
By creating such a progressive health care system and by strengthening care at the local level, we will create the possibility for a genuinely performance-based system. We must analyse the costs and correct the mistakes. Hungary was the first to introduce this kind of financing, which was then launched in France and became widespread in the United States. We adapted this system and shaped it to the Hungarian model. It is a good model, and with the alterations we envisage it can work well.