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188 Health systems in transition Hungary An important disadvantage of indicators such as catastrophic and impoverishing health expenditure is that they cannot capture the whole impact OOP spending has on the poor. For example, low-income households might not experience catastrophic health expenditure during a particular study period because they delay or forgo health care precisely due to the deterrent effect of high OOP payments. Even though user charges introduced in February 2007 (and eliminated in April 2008) involved the seemingly negligible amount of HUF 300 (or about €1.20) per outpatient visit and per hospital day, their deterrent effect on the poor was indeed unexpectedly large. According to a survey carried out in April 2007, 15% of respondents said that had not visited a physician because of the co-payments. Among people who had completed only their primary education, this figure was as high as 25%, whereas it was 10% among those with a higher degree of educational attainment. Similar differences were observed among different income groups (GfK Hungaria, 2007). These user charges were also expected to tackle the issue of informal payments (see section 3.4). However, according to another survey, 30% of participating physicians reported that the introduction of co-payments diminished informal payments by an average of 14%, whereas 47% did not notice any change and 1% observed an increase. Only 6.6% of patients said that they had not made any informal payments, or paid less since the introduction of user charges (Szinapszis Kft, 2007). A different study estimated a decrease of 25% in informal payments overall (Medián, 2008). Finally, expenditure on informal payments and the newly introduced co-payments combined increased by over 20% in nominal terms in 2007. This suggests that the overall burden on patients increased, compromising financial protection, equity in financing and access to care. 7.2.2 Equity in financing When evaluating equity in financing in the Hungarian health care system, it is essential to distinguish between theory and practice. By design, the sources of health care financing in Hungary are predominantly public and thus theoretically closer to the middle of the regressivity–progressivity spectrum. Although no longer subject to a ceiling, HIF contributions remain mildly regressive because (a) they are levied only on gross wages (and not on capital income) and (b) there is a minimum contribution base. The hypothecated health care tax, however, is more difficult to place on the regressivity–progressivity spectrum. Whereas the lump-sum component, in place until January 2010, was clearly regressive,
Health systems in transition Hungary 189 the proportional component is levied on income types that are typically derived by individuals with higher incomes, such as dividends and in-kind allowances. Accordingly, the new hybrid tax/contribution (2005/6), called the “simplified contribution payment”, alone can be described as progressive, as it can only be used by artists and media workers who are usually on the wealthier side of the population. However, they end up paying much less in total than others if all taxes and contributions are taken into account, suggesting rather regressivity (revenue from this source represents only a negligible share of total HIF revenue anyway – see section 3.3.2 and subsection Revenue collection in section 6.1.2). Unlike these earmarked sources of revenue, central government transfers to the HIF can be classified as progressive, as they are financed through general taxation. Since 2006 there has been a strong shift towards funding the health system through general taxation, a phenomenon very much in line with recent trends in Europe, which move away from exclusive reliance on labour-related social insurance contributions and use a mix of revenue sources for financing the health insurance system (see section 3.2). At the same time, a large share of health system financing in Hungary is private, consisting mainly of OOP payments, which by definition are strongly regressive. Table 7.1 gives an overview of the progressivity of the main sources of health care financing in Hungary. Table 7.1 Main sources of health care financing in Hungary and their progressivity rated from 1 (strongly regressive) to 9 (strongly progressive) Regressive Proportional Progressive 1 2 3 4 5 6 7 8 9 HIF contribution Hypothecated health care tax x flat (lump sum) x proportional x Simplified contribution payment (for individuals/ small entrepreneurs in the arts) x General taxes (central government transfers) x Local taxes x Private health insurance x Voluntary mutual health funds x Informal payments x Formal OOP payments x
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Health Systems in Transition Vol. 1
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Health Systems in Transition Péter
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Contents Preface
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Preface The Health Systems in Trans
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Acknowledgements The Health System
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Health systems in transition Hungar
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xii Health systems in transition Hu
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xiv Health systems in transition Hu
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Abstract Hungary has achieved a suc
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Executive summary Introduction Hung
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1. Introduction 1.1 Geography and s
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18 NATIONAL/CENTRAL LEVEL REGIONAL
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3. Financing 3.1 Health expenditure
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4. Physical and human resources 4.1
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5.0 4.5 4.0 3.5 3.0 2.5 2.0 Health
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5. Provision of services Health car
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10. Appendices 10.1 References Ád
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The Health Systems in Transition pr
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The European Observatory on Health
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