Health Systems in Transition - Hungary - World Health Organization ...

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Health systems in transition Hungary
2.5 Planning
Reforms in the 1990s transformed the Hungarian health care system into a
split purchaser–provider contract model. The two crucial steps in moving
away from the integrated, Semashko-style model were (a) the establishment
of the HIF, the Health Insurance Self-Government, and the NHIFA and
(b) the transfer of responsibility for service provision and the ownership of the
majority of health care facilities to local governments, which act as providers.
The decentralization of both purchasing and service delivery initially left the
central government with the regulatory role only. The expectation was that
local governments would plan for local health needs and would be able to do
away with the legacy of excess capacity without direct intervention from the
central government. For a number of reasons, however, this did not happen.
The most important of these was not a lack of administrative, methodological
or information technology (IT) capacities in health planning, but rather the
political consequences of closing down a hospital which, in certain cases, was
the biggest employer in a given town.
Governments reacted to the situation in two waves, both of which were
targeted at the purchaser’s side. First, between 1994 and 1998, the government
regulated the NHIFA’s capacities for contracting with the providers. Initially,
the Minister of Welfare (now known as the State Minister for Health) was
appointed to make downsizing decisions (1995/9), but this was later found to be
unconstitutional because of the ad hoc nature of the decision-making process
(1995/13). Act LXIII of 1996 on the Obligation of Supply of Health Services
and the Regional Supply Norms approached the problem in a more systematic
manner, defining capacities in terms of outpatient specialist consultation hours
and hospital beds per county according to a needs-based formula (1996/4).
Local governments’ responsibility for health care provision – the so-called
territorial supply obligation – was defined based on these capacities (see section
2.2 and the introductory section of Chapter 5). Second, the government in power
from 1998 to 2002 regained full control over the purchasing function when it
abolished the self-governments of the HIF and PIF (see section 2.2). In reality,
the government had never lost control of health care financing, since the budget
and sub-budgets of the HIF had always been approved by the parliament, and
new investments had always been controlled through the system of so-called
earmarked and target subsidies. Cutting out negotiations simply made the
government’s purchasing decisions, such as controlling pharmaceutical
expenditure, easier to implement (1998/26).