Gusztav Kosztolanyi

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.

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:

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:

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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:

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.

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: