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190 Health systems in transition Hungary In practice, it is essential to take into account the ability and willingness of members of society to pay taxes and contributions. Avoidance and evasion have been a persistent problem in Hungary, especially in the health care system. Combined, unpaid health and pension insurance contributions peaked at 4.3% of GDP in 1994, but still amounted to almost 1% of GDP in 2008, out of which 40% was HIF-related payment arrears and claims (NHIFA, 2008, 2009b). In the past, the high rate of social insurance contributions in Hungary likely contributed to late payments, non-payment and under-reporting of income. Arguing that high contribution rates also have an adverse impact on (formal) employment and the competitiveness of the Hungarian economy, successive governments have attempted to address the problem by cross-checking patients’ insurance status (see section 3.3.1),lowering contribution rates, widening the contribution base and introducing other forms of revenue that are less prone to evasion (see section 3.3.2). According to government estimates, the first measure identified 150 000 free-riders, increasing revenues from this source by almost 70% between 2007 and 2008 (i.e. an additional HUF 1.75 billion or €6.9 million). The reduction of the employer contribution rate, on the other hand, decreased HIF revenues without successfully boosting employment (see section 3.3.2) (NHIFA 2009b). Changes have also been implemented to shift some of the burden from the public to the private purse, whether through increased OOP payments (see also section 3.1) or by encouraging voluntary complementary health insurance. Initially, the voluntary health insurance scheme introduced in 1993 was non-profit, with community rating and no risk-adjustment prior to participation (1993/10). The risk-sharing component was decreased to 40% of the insurance premium in 1996 and was eventually eliminated in 2003, whereupon the entire scheme was transformed to a system of MSAs, which is a more regressive form of private financing (see also section 3.5.1). The overall impact of related reforms over the past 20 years is difficult to assess, as the success of different measures varies greatly. A study published in 2002 used the Kakwani index, 3 a summary indicator of equity in financing widely used in international literature, and estimated the total financing burden of the Hungarian health care system as mildly regressive (-0.0211), with overall public sources being mildly progressive (0.0260) and private sources regressive (-0.2745) (Szende et al., 2002). Unfortunately, there is no recent evidence on this issue, except for private expenditure, which was found to be slightly less regressive in 2007 (-0.2726) than in 1999 (Csaba, 2007). 3 The Kakwani index combines population income distribution with concentration of the burden of various health financing revenue sources. It does not take into account the potential level of tax and contribution evasion.
Health systems in transition Hungary 191 7.3 User experience and equity of access to health care 7.3.1 User experience Patient empowerment and participation in the treatment process and in the governance of the health care system is comprehensively regulated by Act CLIV of 1997 on Health (see section 2.9). As mentioned in section 7.1, there are several mechanisms in place for the implementation and protection of patient rights as well as for the expression of dissatisfaction with services. How well these ensure the responsiveness of the system has been addressed by several European and international studies. A study comparing the responsiveness of health care systems to users’ non-medical expectations of health services in Slovakia, the Czech Republic, Slovenia, Croatia and Hungary found that 0.7% of all respondents felt that their health care needs were not met when seeking health care, with Hungary ranking last among the five countries. Hungary scored about average in terms of medicine availability, but ranked last regarding discrimination, treatment inadequacy and involvement in health-related decision-making. Only 15% of Hungarian respondents gave a rating of “good” or “very good” as opposed to 44% in Croatia and 29% overall. Furthermore, only 33.7% were satisfied or very satisfied with how the health care system was run (here Slovakia was the only one with a lower rating). Beside the overall evaluation of the health system, respondents rated their experiences in eight domains (seven in outpatient care) of responsiveness on a five-item scale. The average composite level of health system responsiveness in the study was 68% and Hungary’s score of 71% was second only to that of the Czech Republic (Vitrai, 2007). The results are presented in detail in Table 7.2. An interesting overall finding was the discrepancy between the general health care system ratings and those based on actual experience of utilization: patients anticipated worse performance than they eventually received. This suggests a general distrust (loss of social capital), which also plays a definite role in the persistence of informal payments (Gaál et al., 2006) (see also section 3.4.3).
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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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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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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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