- Latest Updates:
- 18/04/2019: Update on The colon cancer screening program has finally started by Peter Gaal, Zita Velkey
- 12/04/2019: Update on The argument against compulsory vaccination was refused by the Constitutional Court by Peter Gaal, Zita Velkey
- 16/01/2019: Update on Strengthening public health interventions at the primary care by Peter Gaal, Zita Velkey
- 12/09/2018: Update on Do we eat healthier in Hungary as a result of public health interventions? by Peter Gaal, Zita Velkey
- 24/05/2018: Update on An extension of Group Practices in 2018 by Zita Velkey, Peter Gaal
- 13/11/2017: Update on Increase accessibility to screenings in 2018 by Zita Velkey, Peter Gaal
- 12/07/2016: Update on Colorectal screening program is to be introduced in 2017 by Peter Gaal, Zita Velkey
- 12/11/2013: Update on UN World Water Summit 2013 held in Budapest by Szabolcs Szigeti, Rita Kleska
- 12/11/2013: Update on Reduction in cigarette purchases mainly due to shift to hand-rolled products by Szabolcs Szigeti, Rita Kleska
- 12/11/2013: Update on World No Tobaco Day 2013 Award for Prime Minister Viktor Orbán by Rita Kleska, Zsófia Pusztai, Szabolcs Szigeti
- 20/10/2013: Update on Restricting access to tobacco products by Zsófia Pusztai, Peter Gaal, Szabolcs Szigeti
- 26/03/2013: Update on Implementing the WHO Framework Convention on Tobacco Control (FCTC) in Hungary by Szabolcs Szigeti, Zsófia Pusztai
- 17/01/2013: Update on Hungary to abolish routine screening for tuberculosis by Szabolcs Szigeti
- 01/04/2012: Update on The grace period for applying the new regulation on the smoking ban expired on 1 April 2012 by Szabolcs Szigeti
- 01/03/2012: Update on Concerted efforts to decrease the prevalence of smoking in Hungary by Szabolcs Szigeti
5. Provision of services
ealth care delivery is based on the constitutional obligation of the state to make health services available to all eligible residents. At the heart of the system is the territorial supply obligation, which divides responsibility for service delivery among local governments according to geographical areas and levels of care: municipalities are responsible for providing primary care and county governments are responsible for providing specialist health care services within their respective jurisdictions.
There are cases in which municipalities are allowed to provide outpatient specialist and inpatient care. Indeed, according to the principle of subsidiarity, county governments may not refuse to pass on the responsibility for service provision to the municipalities if the latter are willing to accept it. Furthermore, the territorial supply obligation determines the size of health care providers’ catchment areas, which can vary with different levels of care and types of services. For instance, there are municipal hospitals that provide secondary care not only to the inhabitants of the municipality concerned, but also to the neighbouring population. Similarly, large county hospitals provide tertiary care in certain medical specializations to the population of more than one county.
To understand fully how the delivery system operates in Hungary, however, two further distinctions must be made. First, the territorial supply obligation does not require local governments to deliver health services themselves; they are allowed to outsource service delivery to private providers, who deliver the services in a health care facility and with equipment owned by the local government. Referred to as “functional privatization”, this arrangement is the predominant form of service provision in primary care and has become increasingly common in secondary care since the late 1990s. Second, whether public or private, the owners of health care facilities that provide services under the territorial supply obligation are responsible for keeping the assets in working order – that is, for covering the capital cost of services. This principle is referred to as a maintenance obligation and has special relevance in cases where service delivery has been outsourced. The types of primary, secondary and tertiary services whose provision must be ensured by local governments are defined in Act CLIV of 1997 on Health. The provision (and direct financing) of certain services, however, is the responsibility of the central government. These include public health, emergency ambulance services and blood supply.
5.1 Public health
Public health services are the responsibility of the central government, in particular the State Secretariat for Healthcare, which is part of the Ministry of National Resources (see section 2.3.3). The State Secretariat for Healthcare provides these services through the NPHMOS. The NPHMOS was formed in 1991 on the basis of the State Supervisory Agency for Public Hygiene and Infectious Diseases, which had its origins in the late nineteenth and early 20th centuries, when the state assumed responsibility for public health, social medicine and health administration services, to be provided by civil servants known as medical officers. As part of the Semashko-style health system in place during the communist era, the sanitary stations of the State Supervisory Agency implemented successful compulsory immunization and public hygiene programmes, which led to substantial improvements in the health status of the population but failed to respond adequately to the transition that made chronic non-communicable diseases the number one public health problem (see section 1.4). By establishing the NPHMOS in 1991 (1991/1), the government aimed to address this shortcoming. Although the duties of the NPHMOS were expanded according to modern concepts of public health, the successful public hygiene and infectious disease control structures already in place were preserved. At the same time as the NPHMOS was established, several health administration duties were deconcentrated, including compulsory registration, licensing and the professional supervision of health care providers.
The administration of the NPHMOS is divided into three levels: central, regional and subregional (kistérség; for more details on organizational structure see section 2.3.3). The NPHMOS is responsible for controlling, coordinating, supervising and delivering public health services and for supervising the supply of pharmaceuticals and the delivery of personal health services (2006/22). The central office, also known as the Office of the Chief Medical Officer, is responsible for planning and coordinating health promotion and prevention programmes at the national level. It directs and coordinates public health, epidemiology, health promotion and health administration, including the registration, licensing and professional supervision of health care providers and pharmacies. In turn, the regional offices are responsible for implementing these tasks either directly or through their subregional offices. To perform these duties, the regional offices employ medical officers, pharmacy officers and MCH nurse officers. Each of these groups of professionals is directed by a national and a regional chief officer.
In terms of the organization and financing of health care, the most important health administration duties of the NPHMOS are to take decisions on the modification of specialist capacities and to designate the borders of health care providers’ catchment areas within the framework of the territorial supply obligation. These tasks were assigned to the regional offices of the NPHMOS (and, in cases of inter-regional redistribution, the National Chief Medical Officer) in late 2008, when the previous system of capacity planning and distribution was found to be unconstitutional by the Constitutional Court.
The work of NPHMOS is supported by nine National Institutes of Health, which carry out methodological, scientific, educational, administrative, professional supervisory and expert consultancy tasks in various domains of public health and personal health services (2006/22). The National Institute for Epidemiology is responsible for the supervision of immunobiological preparations and diagnostics, epidemiological and clinical microbiology and for the surveillance of communicable diseases based on a system of compulsory reporting by medical practitioners (1998/6, 2010/5). The National Institute for Health Development is responsible for prevention, health education and health promotion. The Institute coordinates the NPHP and organizes lifestyle counselling, as well as education and information provision programmes. The National Institute for Environmental Health controls and coordinates activities that monitor, evaluate and maintain the quality of air, water and soil, while the Frédéric Joliot-Curie National Research Institute for Radiobiology and Radiohygiene and the National Institute for Food and Nutrition Science supervise and control the areas corresponding to their names. The National Institute of Chemical Safety deals with toxicology and chemical risk evaluation (2010/6). The Institute operates the Health Care Toxicology Information Service, which maintains a database registering dangerous substances, provides information around the clock by telephone or in writing to health professionals, authorities and the general public, and also collects and analyses data and prepares an annual report on cases of poisoning reported by health care providers.
In the area of personal health services, there are three National Institutes with methodological, supervisory and coordination roles. The National Institute for Child Health collects and analyses data on children’s health; conducts research; performs methodological and administrative tasks; provides information and education; and assists in organizing, financing and ensuring the quality of provision in children’s health care. The National Institute of Primary Health Care is responsible for supervising the provision of primary care and monitoring the health status of the population based on reports submitted by primary care providers. The main task of the National Centre for Health Care Audit and Inspection (NCHAI) is to supervise the activities of health care providers by monitoring the quality of their health services, as well as their adherence to legal regulations, clinical guidelines and professional norms, through regular inspections and clinical audits (2010/6). In addition to managing, coordinating and controlling the work of the system for supervising health care professionals (2005/2), the NCHAI is also responsible for the surveillance of non-communicable diseases and for running the National Register of Congenital Disorders. The NCHAI has three specialized centres: the Centre for Rare Diseases, the National Centre for Psychiatry and the National Centre for Addictive Disorders (2010/6).
Until 2007 the areas of occupational health and food safety also fell within the remit of the NPHMOS. As part of its plan to introduce managed competition to Hungary’s single-payer health insurance system, the government in power from 2006 to 2010 began to shrink considerably the scope of its public health and health administration functions. The HISA was established and the agencies of occupational health and food safety were put under the control of other ministries (see subsection A third attempt to introduce managed competition to the health insurance system and subsection The Health Insurance Supervisory Authority in section 6.1.1). Since 1995, employers have been responsible for financing occupational health services (1995/8). Whereas larger employers maintain and run their own services, smaller employers can contract with occupational health care providers on a private basis. The NPHMOS used to exercise control over occupational safety, supervise occupational health care at the employer level and provide specialist occupational care through the National Institute of Occupational Health. With the exception of professional supervision, these functions, together with the National Institute of Occupational Health, were transferred in 2007 to the Labour Inspectorate of the Ministry of Social Affairs and Labour (2006/15).
A similar reorganization was implemented in the field of food safety. The rationale behind the changes in this instance was to concentrate the supervision of the entire food chain – from the production of raw materials to the consumption of meals – in one authority. The former task of the NPHMOS to supervise the preparation and consumption of food was relocated to the Central Agricultural Office under the Ministry of Agriculture and Rural Development17 (2007/8). The National Institute for Food and Nutrition Science remains under the NPHMOS, but food inspection duties have been transferred to the Central Agricultural Office.
Other actors participate in the delivery of public health services, especially in the primary care sector. For instance, the NPHMOS, through the National Institute for Epidemiology, plans, directs and coordinates the compulsory immunization programme and supplies the vaccines through its regional and subregional offices, and family doctors and the school health services carry out the actual vaccinations (1998/6). The District MCH Service provides pre- and postnatal care, as well as prevention and health education for families and schools, and is coordinated and supervised by senior MCH nurses from the NPHMOS (1997/10). These well-organized, accessible and good-quality programmes have likely played a key role in achieving Hungary’s excellent immunization record.
Other public health services have been less successful, especially health promotion and other prevention programmes. The NPHP aims at reducing morbidity and mortality rates for the most important public health problems – that is, cardiovascular disease and cancer – through a comprehensive action plan, including health promotion, prevention and screening, as well as improving health care services in priority areas (2003/1). However, the financial resources allocated to the implementation of this programme have decreased year by year, and its budget in 2007 was two-thirds less than in 2003 (Ministry of Health, 2008).
A breast cancer screening programme was established in 2002, whereby women between 45 and 65 years of age are invited to visit providers with screening facilities once every two years (1997/17, 2003/8). More than half a million women, some 41% of all those eligible, participated in programme during its first year. Participation has, however, remained between 40% and 50% since this time. Screening for cervical cancer was launched in 2003, whereby women between the ages of 25 and 65 are invited to visit providers with screening facilities once every three years (2003/8). Participation in this programme has been much lower, with only 5% of eligible women having taken part (Ministry of Health, 2008). In 2006, two further screening programmes – for occult gastrointestinal bleeding and prostate cancer – were introduced on a pilot basis for people aged 50 to 70 years, but these were terminated in 2009 (2005/11, 2009/3).
At present, the only compulsory screening programmes in Hungary are those for infants and children, including screening for congenital disorders and examinations of the sensory organs and blood pressure on an annual basis (1997/17). Compulsory screening for adults can be ordered only in special cases (1998/6).
In addition to these regular screenings, there are also on-off or short-term initiatives, such as the “Screening for Life Programme” conducted by the Ministry of Health in 2007.18 As part of an all-day health fair, screening teams measured and recorded participants’ blood pressure, blood glucose and BMI, as well as any dental, ophthalmological, paediatric or orthopaedic conditions. They also screened for COPD and melanoma, and provided self-examination training. A variety of pilot programmes have also been implemented, including screening for colorectal cancer among people aged 50 to 70 years and for labial and oral cancer, and for increasing the effectiveness of cervical screening with the involvement of MCH nurses (Ministry of Health, 2009b).
Hungary has the highest mortality rate for deaths related to colorectal cancer in Europe, and fourth highest worldwide. More than 10,000 cases of colorectal cancers are diagnosed annually and at least 5,000 patients die from the disease often due to late recognition. The National Colon Screening Program was launched in 2016 with EU funding support, and aimed to reduce colorectal cancer mortality by 10% in three years by screening 70% of the target population, assuming 7% of screenings had positive results. Due to HR shortages and reorganisation of background institutes, the program was postponed several times, and finally started in 2019.
The implementation requires two subsequent steps: a fecal occult blood test followed by a colonoscopy,with the option to skip the blood test.
To date, more than 72,000 people received screening packages from GPs and over 61,000 sent back their samples out of 223,500 invited persons aged 50-70. According to the National Public Health Centre (the reestablished National Public Health and Medical Officer Service), 600,000 invitations will be sent in 2019. Of the 72,000, 1,500 people had colonoscopy appointments and 750 had medical examinations, with 200 positive cases (polyp or adenoma).
A constitutional review regarding an actual case of parents refusing to vaccinate their child declared that irrespective of constitutional rights, vaccinations increase the resistance of the human body against infectious diseases and prevent the transmission of infectious diseases, therefore are both an individual and a public interest.
The Constitutional Court also declared that refusal of compulsory vaccinations without a legitimate reason could be a valid legal basis to limit the rights of parents for raising their children.
As a last resort, if the behaviour of the parent seriously risks the children, and the parent refuses to cooperate with the authorities, the child could be taken from the family by law in order to get vaccinated.
The Minister of Human Capacities, Miklós Kásler, introduced a new program, “With three generations for health” to strengthen public health interventions. Already in Hungary, GP clusters combine multiple GPs with other health professionals, including physiotherapists and dieticians. With the new program, GP clusters and practices as well as municipalities are able to apply for all together 5.8 billion HUF for public health interventions and prevention. Miklós Kásler has announced that the program aims to increase the number of years spent in health, to measure the risk factors of cardiovascular and cancer diseases, as well as the factors affecting children's health. Each GP cluster is able to apply for 50-90 million HUF (159,000-286,000 EUR) in funding.
In 2011, a special tax, the so-called Public Health Product Tax, was introduced on “unhealthy” foods and beverages to decrease their consumption, make producers lower their salt and sugar content and raise revenues for salary increase in the health sector. From January 2019 onwards, the public health product tax rate will increase for all taxable products, by 20%. Since the introduction of the tax in September 2011, the fixed amount of tax on certain products virtually lost its deterrence effect and its raised revenues decreased.
In addition, public catering in educational institutions, like schools and kindergartens was also regulated in 2015, in particular the frequency of use of different foods was determined in 10-day cycles. In 2017 the National Institute of Pharmacy and Nutrition analyzed the reform impact and published the results in September 2018. The main findings show that the average salinity of school meals decreased significantly (it has changed from 8.6 grams per meal in 2013 to 6.4 grams in 2017) as well as the amount of added sugar stayed under the WHO recommended level in three-quarters of cases. Beside the increased milk, fruit and vegetable consumption, dietary foods were used noticeably more widely, and the proportion of whole grain products increased as well. According to the survey, one of the biggest problems is that the time for lunch is very short, and children often eat food in hurry.
Source: National Insitute of Pharmacy and Nutrition, Medical Online
To strengthen prevention in the primary care, 60 new Group Practices will be operational as of 2018. This was announced by Dr Péter Vájer, director of the Primary Care Departure at the National Health Insurance Fund. Under a European Project to improve primary care and health development (EFOP 1.8.2.), an 8 billion HUF fund became available. Each new Group Practice will receive a 150 million HUF grant. The new practices will operate all over the country to decrease the inequality of primary care, improve prevention and help to counterbalance the HR crises in the healthcare system.
Between 2010-2017, 3,4 billion HUF from Swiss Contribution was delegated to form 4 Group Practices in disadvantaged settlements, where teams of GPs and their assistants, dietetics, physiotherapists and mental health professionals took run the practice jointly. During this period, 80 percent of the population participated in screening programs. Beside the 4 initial Group Practices 24 more Practices joint the program as volunteers. With the starting new EFOP project 60 more Practices are able to use the existing know-how.
Starting in March 2018, 20 so called “screening busses” are going to drive across the country to offer the obligatory screening examinations as close to the people as possible- was announced by Zoltán Balogh, Minister of Human Capacities.
The aim of this programme is to reach out to those small villages, which are not captured by other screening programmes. Out of the 20 busses, 10 will be used for general examinations and 10 for mammography. Their cost is depending on their function: a general screening bus will cost 100 million HUF, while a bus with mammography costs 180-190 million HUF.
In 2017, a centrally organised national colorectal screening program is introduced under the National Public Health and Medical Officer Service. Citizens between 50 and 70 years of age are invited to participate once in every two years. The screening is based on the detection of faecal blood and colonoscopy for those, who tested positive and supported by 6 billion HUF of different EU funds.
Hungary hosted the United Nations World Water Summit, which took place on 8-11 October. The Budapest Water Summit was co-organized by the Hungarian Ministry of Foreign Affairs and the Ministry of Rural Development with the participation of Hungary’s President János Áder, UN Secretary-General Ban Ki-moon and WHO Director General Margaret Chan. The Summit provided a policy forum to facilitate consensus-building among stakeholders concerning water and sanitation policy goals in line with the Rio+20 UN Conference on Sustainable Development. The Conference had confirmed the overarching importance of water in and for sustainable development.
Clarifying earlier media reports on the dramatic decline of purchased cigarettes across Hungary, the National Tax Authority issued a press release in September 2013 stating that the consumption of cigarettes has indeed decreased substantially. However the total consumption of tobacco was down only by 0.5 % compared to the previous year and the large decline in cigarette consumption is not due to the increasing role of the black market or large numbers of users giving up smoking but reflects a shift among tobacco users from prepackaged cigarettes to homemade, hand-rolled products.
On 8 October Director General Margaret Chan formally presented Prime Minister Viktor Orbán with a World No Tobacco Day 2013 award in recognition of the Hungarian government’s non-smoking initiatives. The Director General noted the Orbán government’s “victory over the tactics of the tobacco industry” and cited such positive moves as the 2012 ban on smoking in all closed public spaces, and the introduction of illustrated health warnings on tobacco packaging in 2013.
In line with Act CXXXIV of 2012 on reducing smoking prevalence among young people and the retail of tobacco products adopted by the Hungarian Parliament on 11 September 2012, the National Tobacco Trading Non-profit Company (a 100% government-owned joint-stock company) published the names of those who are allowed to open supervised tobacco stores as of July 2013. The process of distribution of store licenses among applicants was heavily criticized by the opposition parties, who accused the government of allocating operation rights in a non-transparent way. Around 5200 such stores have since began to operate compared to more than 40 000 unsupervised retail outlets selling tobacco products up to that point, a reduction that marks a substantial restriction in access to tobacco products. On the other hand, it is expected that the National Tax Office will have to handle increasing sales of tobacco products on the black market, especially since the sale of tobacco products will be strictly controlled for people below 18 years of age at the supervised retailers.
National Tax Office data covering the period up to end of July 2013 shows that there was a 40% decline inturnover from tobacco products between June and the end of data collection (the government introduced the new regulation restricting the number of shops on July 1st). At the same time, the tobacco industry is expected to introduce price reductions to counteract shrinking consumption. Regarding this decreasing trend in consumption, analysts have highlighted that it has been apparent since mid-2012, when the turnover was still 26% higher than in the same month in 2013. Furthermore, they emphasized that the sale of tobacco products has partially been taken over by the black market. Therefore, the evaluation of the new regulation’s true impact requires further analysis and research on the changing pattern of smoking habits.
In line with the WHO Framework Convention on Tobacco Control (Article 8), on 26 April 2011 the Hungarian Parliament voted for a new legislation for tobacco control that banned smoking in closed public places, such as restaurants, bars and workplaces, as well as in certain outdoor areas. Effective as of 1 January 2012, the amendment of the Act on the protection of non-smokers has not only introduced stricter rules for smoking, but also stipulated that the labeling of tobacco products shall include combined warnings with text and pictures from the library created by the European Commission. The WHO contributed its expertise to the long debate preceding the final vote.
Soon after the new Act was passed, a survey indicated that the majority of the population considered the changes to be favorable. Only 20% of respondents aged 18-64 said that the policy has more disadvantages than advantages while two-thirds of the respondents found that the regulation did not hurt the personal freedom of the smokers.
At the same time, the National Public Health and Medical Officer Service (NPHMOS) reported that, based on 56 000 on-site inspections at public places, adherence to the new regulation seemed to be high. The total of fines collected in 2012 was only 12 million HUF (€40 000 EUR) in the whole country. However, out of the 56 000 inspections 18 000 were conducted during the grace period between 1st January and 31st March, when the NPHMOS did not impose fines for violating the new regulations. After the expiration of the grace period the NPHMOS found only 5-6 violations per 1000 inspections, which represented a 90% reduction compared to the rate of violations during the grace period.
Smoking is perhaps the most significant public health issue in . The number of cigarettes smoked annually per capita exceeds 2000. A survey conducted by the National Institute for Health Development in February-March 2012 serves as baseline for analysing the impact of the new regulation. According to its findings the rate of daily smokers among men has been on the decline since 2000. In contrast, no significant change has been observed among women. Compared to 2009, there was a 2% decrease among men under 65 years, coupled with a 2% increase among men above 65, while the rate of daily smokers among women increased by 1% since 2009.
The rate of daily smokers among men significantly decreases with increasing level of education. While the rate of daily smokers among men with elementary school education (8 years) is 45%, it is 32% among men with secondary school education and 20% among men with an education level higher than that. The highest rate of daily smokers among women is among those with secondary education (22% among women with elementary school education; 26% among women with secondary school education; and 18% among women with an education level higher than secondary school).
The number of cigarettes smoked decreased by nearly 8% since 2009. The ratio of machine-made to hand-rolled cigarettes has changed substantially: the number of hand-rolled cigarettes almost doubled in 2012 and reached one third of the total number of smoked cigarettes.
The majority of non-smokers (61%) agree with the smoking ban in bars and pubs along with, importantly, one fourth of smokers. The study of the National Institute for Health Development estimates that 20 470 people died due to consequences of smoking in 2010 in Hungary, accounting for one sixth (16%) of total mortality. Nearly one fourth (23%) of total mortality among men and one tenth (9%) among women was caused by smoking.
At the same time, state revenue from smoking in 2010 – stemming from VAT, excise tax and other payments (personal income tax, corporation tax, contributions) – was more than HUF 360 billion (€ 1.2 billion). Nearly three quarters of this amount came from excise tax and one quarter from VAT. In contrast, the direct and indirect costs of smoking in the Hungarian population in 2010 amounted to more than HUF 441 billion (€ 1.47 billion).
On 14 January 2013 the WHO Country Office for Hungary and the National Institute for Health Development held a press conference on the findings of the smoking habits of young people aged between 13-15 years, which had been studied for the third time as part of a WHO international research project. The results of the Global Youth Tobacco Survey show that thanks to the legislation protecting non-smokers and to numerous EU-funded projects launched recently, fewer and fewer young people are forced to suffer the harmful effects of tobacco smoke.
On 16 January, the Ministry responsible for health (State Secretariat for Health of the Ministry for Human Resources) announced in a press-conference that it is going to stop the current routine screening practice for TB. Following the suggestion of a WHO/ECDC review team from May 2012, the compulsory screening practice will be discontinued mainly because of efficiency considerations. The Ministry is going to focus on risk-group screening, including people living with HIV, prisoners, socially disadvantaged groups and TB contacts among others. In particular, it will be important to intensify the cooperation with social service providers in order to better reach homeless people.
The regulation, effective January 1st, 2012, aimed to make public places, restaurants, bars and workplaces in the country smoke free in line with WHO FCTC Article 8. The National Public Health and Medical Officer Services (NPHMOS) performed 13 000 pre-monitoring test visits at different public places in the first months of 2012, and found 800 cases, in which the new regulation was not observed. After the grace period, the violation of the regulations can be fined with up to 2.5 million HUF.
The government raised the excise tax on tobacco by 10% in February 2012 and by a further 4% in July of the same year. Meanwhile, a public opinion survey found ssupport for the law that bans smoking in closed public places, including restaurants, which came into effect in January 2012 to be high. The majority of the population feels that the changes are favourable. In the age-group between 18 and 64, only 20 % of respondents thought that the policy has more disadvantages than advantages. Two-thirds of respondents believed that the regulation does not hurt the personal freedom of smokers.