"Paraszolvencia" infecting the Hungarian healthcare system

“While my grandfather was extremely outraged when a patient tried to give him money after a successful intervention, in my mother’s time, who worked as a family doctor in the countryside, it was more accepted to receive eggs or chickens from those healed. People choosing health care professions nowadays probably already reckon with parasolvency as a source of income,” says Dr Attila Vereczkey, a former state health employee and current co-head of Versys Clinics, illustrating how parasolvency has become so widespread in Hungary.

As the budget cuts of recent decades have been hitting the health service harder and harder, pushing it onto the verge of collapse by now, “thank-you money,” estimated at HUF 50 billion-100 billion annually, has become a basic component of the health care system. “Everyone hates this,” Vereczkey pointed out. Hardly suprising, since it imposes a huge financial burden on vulnerable patients who are ready to do anything in the hope of recovery, while most doctors feel humiliated by accepting such extra money. “It draws a morally negative picture of healthcare staff, whereas the doctor-patient relationship should be based on trust and nothing else.”

Why is it so bad?

The main reasons behind parasolvency are quite clear. It is widely accepted, even by lawmakers, that wages in the sector would need a significant increase. To draw a net salary of HUF 200,000-300,000, for example, a doctor has to hold two or three part-time jobs simultaneously, all of which typically involve night shifts as well.

As a result of the pressure that the Hungarian Residents’ Association put on the government by depositing the resignation letters of thousands of young doctors, the salaries of 86,000 health care employees were increased from 2012 January 1. However, experts and professional organizations warn that wages are still too low, both to drive back the incidence of parasolvency and to stop the emigration of doctors. While Western Europe gladly extends a warm welcome to highly qualified Hungarian health care staff and offers much higher wages along with better working conditions, those staying behind have to struggle for a living. “Doctors just starting their careers have two options: living in deep poverty, or being corrupted,” Vereczkey said, adding that a monthly net salary of HUF 130,000, which a young doctor earns at the moment, is far too little to support a family.

Another problem is the varying quality of service from region to region, or even from hospital to hospital. While two-bed hospital rooms or wireless internet access may be available in one hospital under basic state health insurance, such services are offered only for an extra charge at other institutions, if available at all. Also, while patients only have to wait a week or so for a given surgery at some hospitals, in other places long waiting lists might delay operations for months, and in many cases it is already too late for the patient by that time. “This situation is a hotbed for the evolution of parasolvency as an organizing force,” Zsombor Kovácsy, former head of the Health Insurance Supervisory Authority and a lawyer specializing in health issues, pointed out.

Nice try

However, new regulations soon coming into force aim to fight parasolvency. After July 1, waiting lists for surgery will be available online. As all patients will be able to keep an eye on the number of people waiting for a given operation in the entire country, in the region, or in a given hospital, the new and more transparent system is expected to reduce the possibility that doctors will take non-professional factors such as parasolvency into consideration when putting people on the list.

Certain paragraphs of the new Labor Code coming into effect on July 1 also affect the issue. The new regulation forbids employees from accepting any payment withouth the approval of the employer, which practically means that health workers can take gratuities only with the permission of their bosses.

Jenő Rácz, director of the Veszprém County Ferenc Csolnoky Hospital, has already made an important statement about this development. While emphasizing that health service has to keep following basic ethical principles, meaning that healthcare staff are strictly prohibited from asking for money from patients beforehand, Rácz added that the staff of his hospital will be allowed to take gratuity if given after the intervention.

However, while this new regulation is at least a step against the conspiratorial silence surrounding parasolvency, it ignores the fact that even if the money is not pre-required by the health care staff and is given only after the services, it may still improve the patient’s chances to gain some advantages next time around. In that respect, there is virtually no difference between the function of pre-provoked parasolvency and that of money given after the fact.

When taking a look beyond the country's borders, there is some reason for moderate hope. “So far, no one has been able to fully eliminate parasolvency,” Kovácsy pointed out, adding that “according to international examples, clearly defined boundaries, patient co-payment contributions, and doctors who are motivated by legitimate financial incentives, for example with the involvement of private health insurance, might be effective tools of resolving the problem.”