Hungary HU Country Health Profile 2019 the Country Health Profile Series Contents

State of Health in the EU Hungary HU Country Health Profile 2019 The Country Health Profile series Contents

The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN HUNGARY 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 9 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 13 and influencers with a means for mutual learning and 5.1. Effectiveness 13 voluntary exchange. 5.2. Accessibility 16 The profiles are the joint work of the OECD and the 5.3. Resilience 18 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 22 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.

Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Hungary.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Hungary, 2017

Demographic factors Hungary EU Population size (mid-year estimates) 9 788 000 511 876 000 Share of population over age 65 (%) 18.7 19.4 Fertility rate¹ 1.5 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 20 300 30 000 Relative poverty rate³ (%) 13.4 16.9 Unemployment rate (%) 4.2 7.6

1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

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2 State of Health in the EU · Hungary · Country Health Profile 2019 83 79 75 81 77 Life expectancy at birth,years EUR 2000 EUR 3000 Prevent ble avoidable deaths. could toreducing contribute on preventioncareand primary greatly improved. More focus of thehealthsystemcould be suggest thattheeffectiveness preventable andtreatable causes High levels ofmortalityfrom Effectiveness Per capita spending(EURPPP) investments are neededtoreduce the performance gaps with therest oftheEU. excessively hospital-centric, with insufficientfocuson primarycare and prevention. Additional reforms and Hungarians rely onout-of-pocket payments toaccesscare, which underminesequity. The healthsystemremains and cancermortality. Publicspending onhealthcare isconsiderably below theEUaverage, andalarge number of alcohol consumption andobesityare among thehighestin EU, contributing tohighrates ofcardiovascular both unhealthy lifestylesandthelimitedeffectiveness ofhealthcare provision. Levels ofsmoking, excessive Despite improvements since2000, healthoutcomesinHungary lag still behindmostotherEUcountries, reflecting 1 per 100000population, 2016 Age-standardised mortality rate EUR 1000 HU HU HU 719 773 mort l t mort l t Tre t ble Highlights Obest Bne drn n Smo n 2000 Overweht nd 2005 EU EU EU Smo n Obest obest 17 21 22 93 % of 15-year-olds % of adults 157 2011 176

19% 20 % HU 2017 26 % 760 809 2017 325 EU care insufficiently equippedtoahave astronger role. health systemremains excessively reliant onhospitalcare, with primary of out-of-pocket payments thatare doubletheEUaverage. Overall, the two-thirds ofhealthexpenditure is publicly financed, resulting inlevels absolute termsandasashare ofGDP. Inaddition, only slightly more than Hungary spendsmuch lessonhealththantheEUaverage, bothin Health system nearly oneinfive 15-year-olds overweight orobesein2013-14. Overweight andobesityare alsoa growing problem inchildren, with obese in2017, arate thathasincreased steadily over thelastdecade. Adult obesityisalsoamong thehighestinEU:onefive adults were one infouradultssmoked daily in2014–thethird highestrate intheEU. deathsinHungary.Lifestyle riskfactorsaccountforhalfofall More than Risk factors the while gap ismore than6 years for women. level ofeducationlive onaverage 12 years lessthanthemosteducated, are large differences inlifeexpectancy by education:men with thelowest 2000, nearly butstill five years below theEU average (80.9 years). There expectancy atbirth was 76.0 years in2017, anincrease offour years since disparities across gender andsocioeconomic groups are substantial. Life Life expectancy inHungary islower thaninmostofitsEUneighbours, and Health status Coverage for selected goodsandservices, 2016 The healthbenefit package Accessibility shortages ofhealth professionals. access tocare isimpeded by for pharmaceuticals. Inaddition, out-of-pocketcosts, particularly EU countries, resulting inhigh limited compared with other insurance fundisrelatively provided by thenational health Hosptl %01 cre 91% Countr EU %01 State of Healthin the EU ·Hungary ·Country HealthProfile 2019 Outptent Countr EU medcl EU Countr cre 58% ceutcls Phrm- 51% HU Dentl cre EU 21% care. sector andstrengthening primary and downsizing thehospital could beachieved by reforming time, substantialefficiency gains health outcomes. At thesame access tocare and, by extension, system would helptoimprove Hungarian health underfunding ofthe the persistent Addressing Resilience EU Countr 3

HUNGARY 2 Health in Hungary HUNGARY Despite gains, life expectancy at birth in lowest among the countries of the Visegrád Group Hungary remains among the lowest in the EU (Czechia, Hungary, Poland and Slovakia).

Life expectancy at birth in Hungary grew by more On average, Hungarian women live almost seven years than four years between 2000 and 2017 (from longer than men (79.3 years compared to 72.5 years). 71.9 years to 76.0 years), an increase slightly greater This gender gap is greater than across the EU as a than the average across the EU (3.6 years). Despite whole (5.2 years) and is largely due to greater exposure this, in 2017 life expectancy at birth remained almost to risk factors among men – particularly smoking and five years below the EU average (Figure 1), and the excessive alcohol consumption (see Section 3).

Figure 1. Life expectancy at birth in Hungary remains almost five years shorter than the EU average

Yers 2017 2000 90 – Gender gap: Hungary: 6.8 years 85 – 834 EU: 5.2 years 831 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809

80 – 791 784 78 7 78 773 76 758 753 749 748 75 –

70 –

65 – EU Sp n Itl Frnce MltCprusIrelnd Greece Polnd Ltv NorwIcelndSweden Austr F nlndBel um Czech Eston Crot Bul r Portu l Sloven GermnDenmr Slov Hun rL thun Romn Luxembour Netherlnds Un ted n dom Source: Eurostat Database.

Inequalities in life expectancy Figure 2. The education gap in life expectancy at age by education are stark 30 is 12.6 years for men and 6.4 years for women

Large inequalities in life expectancy in Hungary exist not only by gender but also by socioeconomic status.

As shown in Figure 2, 30-year-old men with tertiary 528 education live on average more than 12 years longer ers 485 464 ers than those with low levels of education; the difference ers is over six years for women. 359 ers This education gap in life expectancy is well above Lower Higher Lower Higher the EU average, and is partly explained by greater educated educated educated educated exposure to various risk factors among people with women women men men

lower levels of education. These include, for instance, Education gap in life expectancy at age 30: higher smoking rates and poorer nutritional habits Hungary: 6.4 years Hungary: 12.6 years (see Section 3). As higher levels of education tend to EU21: 4.1 years EU21: 7.6 years

be associated with higher socioeconomic status, the Note: Data refer to life expectancy at age 30. High education is defined education gaps in life expectancy are also related to as people who have completed tertiary education (ISCED 5-8), whereas differences in income and living standards, which low education is defined as people who have not completed secondary education (ISCED 0-2). may affect both exposure to different risk factors and Source: Eurostat Database (data refer to 2016). access to care.

4 State of Health in the EU · Hungary · Country Health Profile 2019 -100 (41 %and78respectively). aged 16-64, rates much lower thantheEUaverages in good healthin2017, compared with 70%ofadults Hungarians aged 65 years andolder reported being good health generally declines with age. Only 18%of Similarly, the proportion of people reporting being in as whole.EU self-reported to that reported healthissimilar inthe with only half(53%)inthelowest. This income gap in considered themselves tobein good health, compared quarters (72%)ofthoseinthehighestincomequintile than thoseonlow incomes. In2017, almostthree- incomes are more likely toreport being in good health whole. As inotherEUcountries, people with higher health inHungary, 10%lessthanintheEUasa In 2017, three infive adults reported being in good health, but substantial disparitiesexist Most of the population reports being in good Source: Eurostat Database. Note: Thesize of thebubbles isproportional to themortality rates in2016. Figure 3. Ischaemic disease, heart stroke andcancer account for themajorityof deaths inHungary remained by fartheleading causeofdeathin2016, (Figure 3). Nonetheless, circulatory systemdiseases from cardiovascular diseases–mostnotably strokes been driven mainly by reductions inmortalityrates The increases inlifeexpectancy since2000have leading causeofdeath inHungary Cardiovascular diseasesare the northern Hungary (ÁEEK, 2016;Uzzoli, 2016). central Hungary –andtherelatively poor region of expectancy atbirthbetween the wealthiest region – the mid-1990s, leading toathree-year gap inlife differences inhealth outcomeshave widened since in growing regional disparities. Geographical Inequalities inlifeexpectancy are alsoreflected 100 % c -50 50 0 hn Br Sucde Pncretc cncer est cncer e 2000-16(orner Dbetes Lver dsese Color est ectl cncer

Chronc obstructvepulmonr dsese Lun cncer er) 100 Str 150 oe State of Healthin the EU ·Hungary ·Country HealthProfile 2019

200 health programmes (seeSection5.1). the low levels ofinvestment inscreening and public causes ofcancer-related death, in part reflecting colorectal, liver andbreast cancersthemostfrequent cancer mortalityrate intheEU2016, with lung, A striking feature isthatHungary hadthehighest remains substantially higherthantheEUaverage. stroke more fell rapidly over thesame period, butstill where mortality declined by only 12%. Mortalityfrom the reduction was much more limitedinHungary, more than40% across theEUbetween 2000and2016, mortalityfromWhile ischaemic by heartdiseasefell much higherinHungary thaninmostEUcountries. and rates ofcardiovascular deathsin particular were getting outofbed, thatmay require long-term care. activities ofdaily living, such asbathing, dressing or old age, butoneinsix report somelimitationsinbasic people are abletocontinue tolive independently in percentage points higherthanthe EUaverage. Most having atleastonechronic disease, a proportion 12 Two-thirds ofHungarians aged 65andover report chronic intheirlater diseaseordisability years. since Hungarian women are more likely tolive with healthy life years between issimilar menand women almost four years infavour of women, thenumber of thereWhile isa gender gap inlifeexpectancy at65of particularly thecaseamong older Hungarian women. chronic (Figure diseaseanddisability 4). This is However, many years oflifeafter65are spent with 16.7 years onaverage –1.6 years more thanin2000. Hungarians aged 65could expecttolive anadditional has beenduein part to gains atolder ages. In2017, The general increase inlifeexpectancy inHungary with chronic diseaseanddisability After age 65many Hungarians live Ae-stndrdsed mortlt rteper100000populton,2016 250 300 Isc hemc hertdsese

400 5

HUNGARY Figure 4. Two-thirds of older Hungarians have at least one chronic disease, but relatively few report limitations in activities of daily living

Lfe expectnc t e 65 HUNGARY Hunr EU

67 167 199 10 99 ers 10 ers

Yers wthout Yers wth dsblt dsblt

% of people ed 65+ reportn chronc dseses % of people ed 65+ reportn lmttons n ctvtes of dl lvn Hunr EU25 Hunr EU25

20% 16% 18% 34% 30% 46%

34% 36% 84% 82%

No chronc One chronc At lest two No lmtton At lest one dsese dsese chronc dseses n ADL lmtton n ADL

Note: 1. Chronic diseases include heart attack, stroke, diabetes, Parkinson disease, Alzheimer’s disease and rheumatoid arthritis or osteoarthritis. 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. Source: Eurostat Database for life expectancy and healthy life years (data refer to 2017); SHARE survey for other indicators (data refer to 2017).

Antimicrobial resistance is a Both international quality indicators of antibiotic use growing issue in Hungary and national studies indicate a widespread misuse of antibiotics in Hungary, even though the country is Antimicrobial resistance is becoming a major among the lower antibiotic users in the EU in terms of public health concern in Hungary. In 2014 and 2015, quantity. Data suggest that patients are often treated Hungarian hospitals reported about 4 000 health unnecessarily with broad-spectrum antibiotics, which care-associated infections due to antibiotic-resistant may result in more side effects, higher expenses and bacteria annually to the National Nosocomial more rapid resistance development (Hajdu et al., Surveillance System. In addition, between 2005 2018). and 2015, incidence of these infections increased substantially: from 5.4 to 24.8 per 100 000 patient-days. Overall, the proportion of antibiotic resistance of bacterial isolates in Hungary was higher than the European mean values in 2014 for most combinations of antimicrobial groups and bacteria, and the difference was statistically significant in almost all cases (Hajdu et al., 2018).

6 State of Health in the EU · Hungary · Country Health Profile 2019 (26 %). 1: BasedontheSpecialEurobarometer survey, theproportion ofpeoplecurrently smokinginHungary was 27% in2017, aproportion closertotheEU average highest rates intheEU having smoked inthe past month–again, among the one-third of15-and16-year-olds inHungary reported among adolescentsare also very high. In2015, nearly 2014, compared toone-fifthof women. Smoking rates Hungarian menreporting thatthey smoked daily in significant genderdifference, withalmostone-third of two decades. Furthermore, smoking rates show a than inmostotherEUcountriesover thelast consumption hasdeclined more slowly inHungary EU afterBulgariaandGreece (Figure 6). Tobacco smoking daily in2014–thethird highestrate inthe More thanoneinfourHungarian adultsreported heaviest smokers in the EU decade, Hungarians areamong the Despite reductionsin the past Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). sweetened beverages consumption. death can beattributed to more thanoneriskfactor. Dietary risksinclude14components suchaslow fruitandvegetable consumption andhighsugar- Note: Theoverall numberof deaths related to these riskfactors (62 000) islower thanthesumof each onetaken individually(76 000), because thesame Figure 5. Poor diet andtobacco smokingare rates drivingmortality inHungary far above the39%EUaverage. low physical activity (IHME, 2018). This proportion is poor diet, tobaccosmoking, alcoholconsumption and tobehaviouralbe attributed riskfactors, including deathsinHungaryIt isestimatedthathalfofall can deathsin halfofall inHungary Unhealthy behaviours areimplicated 3 EU 18% Hunr 28% Detr rss Riskfactors 1 .

State of Healthin the EU ·Hungary ·Country HealthProfile 2019 EU 17% Hunr 21% Tobcco 4 %(4500)tolow physical activity (Figure 5). consumption (one ofthehighestlevels intheEU)and with around toalcohol 10 % (12000)attributable deaths(overin anestimated21%ofall 25500), direct andsecond-hand smoking, was implicated than theEUaverage. Tobacco consumption, including consumption), which isten percentage points more and vegetable intake, andhighsugarsalt todietaryrisks(includingattributed low fruit deathsin2017maySome 28%(34000)ofall be tobacco packaging.introductionof plain consideration tocurbtobaccoconsumption isthe on tobacco products. The next policy optionunder of tobaccoretail sale points andincreased excisetax the same year. This drastically reduced thenumber hospitals. The Tobacco Shop Act was alsoadoptedin such asbarsandincertainopen public areas such as leading torestrictions onsmoking inenclosed places Act ontheProtection ofNon-smokers was modified, this public healthissue(Joó etal., 2018). In2012the The Hungarian authoritieshave startedtoaddress EU 3% Hunr 4% Low phsclctvt EU 6% Hunr 10% Alcohol

HUNGARY Figure 6. Hungarians have higher rates of risky health behaviours than most EU countries

Smon (chldren)

HUNGARY Veetble consumpton (dults) 6 Smon (dults)

Frut consumpton (dults) Bne drnn (chldren)

Phscl ctvt (dults) Alcohol consumpton (dults)

Phscl ctvt (chldren) Overweht nd obest (chldren)

Obest (dults)

Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Source: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013-14 for children indicators; and EU-SILC 2017, EHIS 2014 and OECD Health Statistics 2019 for adults indicators. Select dots + Effect > Trnsform scle 130% High alcohol consumption, and adolescent 22 % in 2016, but appear to have stabilised since binge drinking, are of significant concern 2010 (Kovacs et al., 2018). Some recent government initiatives – such as the public health product Alcohol consumption among Hungarian adults has tax – have aimed to tackle childhood obesity (see decreased over the past decade but in 2017 remained Section 5.1). more than 10 % above the EU average: 11.1 litres per capita compared with 9.9 in the EU. Heavy episodic Socioeconomic inequality alcohol consumption (binge drinking2) among contributes to health risks adolescents is also a concern. In 2015, 43 % of boys and 36 % of girls aged 15 to 16 reported at least Many behavioural risk factors are more common one episode of binge drinking during the preceding among people with lower education or income month – among the highest levels in the EU. This levels. In 2014, 30 % of Hungarian adults who is of particular concern given the increased risk had not completed secondary education smoked of accidents and injuries related to heavy alcohol daily, compared with only 13 % among those with consumption. tertiary education – a gap more than double the EU average. Similarly, 21 % of Hungarians without Overweight and obesity are a growing secondary education were obese in 2017, compared public health issue in Hungary to 17 % of those with higher education levels. This higher prevalence of risk factors among socially Poor nutritional habits partly explain the increasing disadvantaged groups contributes significantly prevalence of obesity in Hungary. In 2017, 60 % of to socioeconomic inequalities in health and life adults reported not consuming any fruit on a daily expectancy. basis, and 70 % said they did not eat vegetables daily – a higher proportion than in most EU countries (Figure 6). One in five Hungarian adults (20 %) was obese in 2017 compared to 15 % on average across the EU.

Overweight and obesity rates are also becoming a major problem among Hungarian children. Almost one in five 15-year-olds were overweight or obese in 2013-14, and overweight and obesity rates are even higher among younger children age 7 at around

2: Binge drinking is defined as consuming six or more alcoholic drinks on a single occasion for adults, and five or more alcoholic drinks for adolescents.

8 State of Health in the EU · Hungary · Country Health Profile 2019 4 000 3: OOPpayments includedirectpayments, cost-sharingforservicesoutsidethebenefitpackage andinformalpayments. Source: OECD Health Statistics 2019 (data refer to 2017). Figure 7. Hungary spendsless onhealthcare thanmost other EU countries serves astheumbrella organisation forregional and management, and medicallicensing. The ÁEEK also include care coordination, hospital planning and Service Centre (ÁEEK), whose responsibilities health systemthrough theNationalHealthcare The MinistryofHumanCapacities administersthe inpatient care. well asdelivering mostoutpatientspecialistand financing andissuing andenforcing regulations, as responsible forsetting strategic direction, controlling centralised. The national government isnow the Hungarian health systemhasbecomehighly Following aseriesofreforms initiatedin2011, control over the healthsystem The central government exerts strong supervision oftheMinistryHumanCapacities. is a government organisation currently underthe Health Insurance Fund Management (NEAK), which The fundisadministered by theNationalInstituteof employees, andfrom direct government transfers. from payroll from contributions employers and coverage fornearly residents. all Funding comes a single healthinsurance fund providing health The Hungarian healthsystemisorganised around coverage for the Hungarian population A single healthinsurance fundprovides 4 EUR PPPpercpt 2 000 5 000 3 000 1 000 Government &compulsor nsurnce 0 Norw Thehealthsystem

Germn

Austr

Sweden Netherlnds

Denmr

LuxembourFrnce

Belum

Irelnd Voluntr schemes &household out-of-pocet pments

Icelnd Unted ndom Fnlnd State of Healthin the EU ·Hungary ·Country HealthProfile 2019

EU Mlt

Itl and 6.9%in2017, still well below theEUaverage. relatively stable, fluctuating between 7.5%in2010 so healthspending asashare ofGDPhasremained increased ataboutthesamerate asGDPsince2010, the EU(Figure 7). Healthexpenditure per capita has purchasing power), which isamong thelowest in EUR 1468 per capita (adjustedfordifferences in underfunded. Expenditure onhealthcare is The Hungarian healthsystemischronically levels ofout-of-pocket payment below the EUaverage, resulting inhigh Health expenditureissubstantially mental andchild health. diseases, andrheumatological oncological as well as health policy priorities inthefields ofcardiovascular, was adopted;thisdefinesthemain government hospitals). In2018, theNationalHealthProgramme the managing authorityrunning thesestate-owned municipal governments in2012(the ÁEEK serves as resumed control oflocalhospitalsfrom countyand local healthsystemagencies. The central government Spn Section 5.2). for 27%, almosttwicetheEUaverage of16%(see 2017, out-of-pocketwhile (OOP)spending more thantwo-thirds oftotalhealthexpenditure in and compulsory insurance) accountsforonly slightly The public share ofhealthspending (government

Czech

Sloven

Portul

Cprus

Greece

Slov

Lthun

Eston

Polnd

Hunr

Bulr

Crot 3 accounts Ltv Shre of GDP Romn % of GDP 00 25 50 5 7 100 125 9

HUNGARY The Hungarian parliament is responsible for The government controls outpatient and inpatient determining the size of the health insurance budget budgets via a so-called ‘performance volume limit’. – setting the contribution rate, agreeing direct At the beginning of each year, this limit is defined

HUNGARY government transfers to the fund, and imposing for each health service provider, based on data from taxes to raise the necessary revenues. Since the social preceding years. However, the health sector struggles contribution tax (paid by employers) funds not only to operate within these budget constraints, often the health system but also pensions, the amount leading to growing hospital debt and other difficulties allocated to health has been subject to fluctuations in supplier payments (see Section 5.3). based on government priorities (Szigeti et al., 2019). As a result, health spending in Hungary has a level of Hungary provides close to full population health instability, even within a single financial year, with the coverage, but the benefit package is limited government sometimes changing allocations between The Hungarian constitution states that all Hungarian the pension security fund and health insurance fund citizens have the right to access care unconditionally as the year progresses (Hungarian State Treasury, for emergency life-saving services, services that 2018). prevent serious or permanent health damage and Health care providers face reduction of pain and suffering. Access to all other challenging budget constraints health services is subject to participation in the statutory health insurance scheme. Since 2007, In primary care, general practitioners (GPs) are paid publicly funded providers are obliged to verify the on a capitation basis (accounting for about 70 % entitlement status of each patient using an online of practice income), with an amount assigned for system. In 2017, about 6 % of the population had each person enrolled whether or not they seek care, unclarified social health insurance status, mostly albeit with some adjustments for age and physician Hungarian citizens working abroad in other EU qualifications. This is complemented by some other Member States and covered by their country of sources of revenue: a pay-for-performance component residence. Some Hungarians living in the country are and some location-based fixed allocations, both not insured because they do not have a fixed address. accounting for the remaining 30 %. Outpatient In practice, however, no Hungarian resident is denied specialists are paid on a fee-for-service basis: each access to services at the point of care. Some groups of procedure is assigned a number of points and non-EU foreigners can voluntarily join the system for providers claim payment of their points directly from a fixed premium. They are entitled to only a limited the health insurance fund. The health insurance benefit package, which excludes dental care, cross- fund pays for hospital inpatient services according border treatment and transplantation. to diagnosis-related groups (DRGs) for acute care and hospital days for chronic care, except for a few specific interventions.

Figure 8. Pharmaceuticals and medical devices account for nearly one-third of health expenditure

EUR PPP per cp t Hun r EU

1 000

800 835 858

600 31% 31% of totl of totl 30% spend n spend n of totl 522 spend n 400 457 471 449 424

200 4% 3% of totl spend n of totl spend n 89 0 6611 3399 Inpt ent0 cre Phrmceut cls0 Outpt ent0 cre Lon -term0 cre Prevent on0 nd med cl dev ces

Note: Administration costs are not included. 1. Includes curative-rehabilitative care in hospital and other settings; 2. Includes only the outpatient market; 3. Includes home care; 4. Includes only the health component. Source: OECD Health Statistics 2019; Eurostat Database (data refer to 2017).

10 State of Health in the EU · Hungary · Country Health Profile 2019 Prctcn nurses per1000populton Source: Eurostat Database (data refer to 2017 orthenearest year). around 30 %inPortugal). InAustria andGreece, thenumberof nurses isunderestimated asitincludes only those workinginhospitals. Note: InPortugal andGreece, data refer to alldoctors licensed to practice, resulting inalarge overestimation of thenumberof practising doctors (e.g. of Figure 9. Hungary hasfewer healthprofessionals percapitathanmost other EU countries also lower thanaverages seenacross theEU. shares to allocated prevention and long-term care are belowis still theEUaverage ofEUR522(Figure 8). The person, adjustedfordifferences in purchasing power) capita, expenditure on pharmaceuticals (EUR449 per EU figure (18%). Despitethis, inabsoluteterms per while pharmaceuticals (also31%) well exceedthe care isonly slightly above theEUaverage of29%, more than60% ofhealthspending. At 31%, inpatient Together, inpatient care and pharmaceuticals account the largestcostitemsin the healthsystem Inpatient careandpharmaceuticalsrepresent medicines andmedicaldevices (seeSection5.2). explains thehighlevels ofOOPexpenditure on 2018). The restricted nature ofthe package partly and dentalcare ismuch more limited(OECD/EU, coverage for pharmaceuticals andmedicaldevices (ambulatory) spending is publicly funded, public countries. mosthospitalandoutpatient While fund isrelatively limitedcompared with otherEU The benefit package covered by thehealthinsurance 20 10 18 14 16 12 0 8 4 6 2 2 Nurses Low Doctors Low Nurses H h Doctors Low 25 PL RO LU U SI 3 LV HU IE BE FR FI HR S EE 35 CZ NL EU EU vere 36 State of Healthin the EU ·Hungary ·Country HealthProfile 2019 CY ES IS 4 MT IT D SE Section 5.2). disadvantaged andliving in poorer rural areas (see to care –notably for populations who are already uneven across regions, which furtherlimitsaccess EU countries. The ofdoctorsisalso distribution professionals remain low compared with mostother even thoughthecurrent average salariesofhealth health professionals hasslowed down inrecent years, paramedics inMay 2018. As aresult, outflow of an unprecedented 19.4%salaryincrease for the salariesofhealth professionals, including In response, theHungarian government hasraised recent years. Emigration ofnurses hasalsobeensubstantialin elsewhere between 2010and2016(OECD, 2019). left thecountryto work inotherEUcountriesor accession totheEUin2004. Almost 5500doctors specialists), which accelerated afterthecountry’s and theemigration of many doctors(particularly have beenexacerbatedby anageing health workforce nurses (6.5 vs. 8.5;Figure 9). Workforce shortages doctors (3.3 vs. 3.6 per 1000 population) andfewer Compared totheEUaverage, Hungary hasfewer Hungary are below EUaverages The numbers ofdoctorsandnursesin BG DE 45 LT NO PT 5 Prctcn doctors per1000populton AT 55

EU vere 85 Doctors H h Doctors H h 6 Nurses H h Nurses Low EL 65 11

HUNGARY Health care delivery remains reduce the total number of facilities in the capital city very hospital-centric while at the same time ensuring that each is better equipped and staffed.

HUNGARY Despite a reduction in the number of hospital beds since 2000 (see Section 5.3), in 2017 Hungary had the The Hungarian health system has fourth highest number of hospital beds per capita been the largest beneficiary of EU in the EU. High hospital discharge rates and average funds dedicated to health length of stay also point to a strong reliance on hospital care. Hungary has received considerable funding to modernise its health system through the EU The transfer of control of hospitals previously run by Structural and Investment Funds (ESIF). In the local authorities to direct national management has 2014-20 period, Hungary will receive EUR 483 million, made the national government the main provider of divided between financing for health infrastructure both inpatient and outpatient (ambulatory) services (EUR 253 million), access to health and social services (since 70 % of outpatient services are still provided (EUR 215 million) and development of eHealth (EUR by hospitals), although a few local governments still 15 million). Hungary also received ESIF funds during own multi-speciality outpatient facilities (polyclinics). the preceding 2007-13 period (EUR 1 336 million), EU Structural Funds have supported infrastructure when the country was the largest beneficiary of ESIF improvements in regional hospitals. In 2017, the funds at that time. Overall, ESIF funds represent as Healthy Budapest Programme was also established to much as 2.4 % of total health expenditure in Hungary modernise hospitals in the capital city. This aims to (European Commission, 2016).

5 Performance of the health system

of unhealthy food products. In 2014, an evaluation 5.1. Effectiveness concluded that the tax had achieved its public health Many deaths in Hungary could be avoided goal of reducing consumption of these products, and through better prevention and health care that this reduction had generally been maintained in the first few years following its introduction. Further, In 2016, Hungary had the third highest preventable more than two-thirds of people who did not choose mortality rate and fifth highest mortality rate from the higher-tax products modified their eating habits treatable causes in the EU, indicating substantial by choosing healthier alternatives. The programme room for improvement (Figure 10). Nearly 30 000 also achieved its financial objectives, meeting the deaths could have been avoided in Hungary in the expected revenue goal for each year, and the extra same year through more effective public health and funds were used to increase health sector wages prevention interventions. A further 16 000 deaths (WHO Regional Office for Europe, 2015). could have been prevented through more effective In the same vein, legislation on control of trans-fatty and timely health care. acids (TFAs) in foodstuffs was adopted in 2013. It Recent policy measures have tried defined a maximum tolerable level of TFAs, revised to promote healthier lifestyles marketing requirements and initiated monitoring of TFA intake in the population. Hungary is one of Historically, Hungary has lagged behind many other the few European countries to adopt such stringent European countries in investing in health promotion legislation on TFAs. In 2015, stricter nutritional and disease prevention. In 2017, Hungary spent 2.6 % rules for public catering (including schools) were of total health expenditure on prevention, slightly also introduced. One objective of this legislation is lower than the EU average (3.1 %). As described in to ensure proper intake of energy and nutrients by Section 3, many risk factors in Hungary are more children to support their healthy development. prevalent than in most EU countries, with high rates of smoking and higher levels of alcohol consumption, Although recent increases have been implemented, obesity and poor nutrition. the excise tax rates on tobacco and alcohol products remain relatively low, despite broad evidence that the In recent years, the Hungarian government has use of taxes to raise tobacco and alcohol prices, along implemented ambitious programmes to improve with regulation of promotion, is effective in reducing population nutrition. A public health product tax was smoking and harmful drinking. introduced in 2011, aiming to reduce consumption

12 State of Health in the EU · Hungary · Country Health Profile 2019 district governmentoffices. organised through public health unitsincountyand at thenationallevel, buttheirimplementation is programme. Immunisation programmes are defined HPV for agedgirls 12, through the public vaccination also receive other vaccines, including influenzaand vaccination against varicella. At-risk populations may since the government decided in2019tointroduce childhood immunisation now includes 12 vaccines regulated by ministerialdecree, and mandatory routine ensurecoverage. good Vaccination programmesare been highinHungary –theresult ofrobust policies to For many years, rates ofchildhood immunisation have children have been very successful Routine vaccination programmes for Source: Eurostat Database (data refer to 2016). indicators refer to premature mortality (under age75). Thedata are based ontherevised OECD/Eurostat lists. treatable (or amenable)causes isdefined asdeath that can bemainlyavoided through health care interventions, includingscreening andtreatment. Both Note: Preventable mortality isdefined asdeath that can bemainlyavoided through publichealth andprimaryprevention interventions. Mortality from Figure 10. Hungary hasamongthehighest from mortality preventable andtreatable causes intheEU Alcohol-relted dseses Ischemc dseses hert Lun cncer Unted ndom Luxembour Netherlnds Lthun Germn Denmr Ae-stndrdsed rtes mortlt per100000populton Romn Hunr Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Preventble cusesofmortlt Itl EU 0 50 Others Accdents (trnsport ndothers) Chronc lower resprtor dseses 100 100 110 115 118 121 129 150 133 134 138 139 140 140 141 154 155 158 161 161 161 166 200 184 195 218 250 232 232 244 262 300 State of Healthin the EU ·Hungary ·Country HealthProfile 2019 310 325 350 332 336 the WHO target of75%. below theEUaverage of44 %, andeven furtherfrom cohort vaccinated in2017. This rate isconsiderably remains very low, however, with only 27%ofthis Influenza vaccination coverage for people over 65 cases are extremely rare andmainly imported. Richardson &McKee, 2018). Consequently, measles for vaccination coverage inthecountry(Rechel, developed aneffective electronic monitoring system WHO (Figure 11). Hungarian authoritieshave also vaccination rates exceedthe95%targets defined by such asinfluenza)are provided free of charge and some voluntary vaccines,(and Mandatory vaccines Unted ndom Stroe Colorectl cncer Ischemc dseses hert Luxembour Netherlnds Lthun Germn Denmr Romn Hunr Ae-stndrdsed rtes mortlt per100000populton Portul Sloven Slov Bulr Belum Norw Sweden Czech Eston Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Greece Frnce Ltv Mlt Spn Itl EU Tretble cusesofmortlt 0

50 62 62 63 67 67 68 69 71 71 71 76 77 78 80 80 Others Hpertensve dseses Brest cncer 100 87 87 89 90 93 95 128 130 150 140 143 168 176 200 194 203 206 208 250 13

HUNGARY As in many other countries, anti-vaccination Hungarian authorities are currently developing a sentiment has gained momentum in Hungary in new cancer plan with the objective of transforming recent years. In response, a constitutional review cancer care and improving patients’ survival and

HUNGARY declared that refusing consent for compulsory quality of life. The effort to promote early detection vaccinations without a legitimate reason could result has already led to the announcement of a new in limiting parents’ rights in raising their children. colorectal screening programme (Box 1). In addition, a As a last resort, if parents do not co-operate with the tax-benefit package has been introduced for patients authorities and refuse to vaccinate their child, the suffering from breast, ovarian, cervical, testicular or government can take the child by law to vaccinate prostate cancer. them. Strengthening primary care could help Figure 11. Immunisation rates for childhood improve chronic disease management vaccinations are excellent in Hungary As described in Section 4, the Hungarian health Hun r EU system remains very hospital-centric and the primary care sector does not have a significant role. While Dphther, tetnus, pertusss Amon chldren ed 2 the numbers of hospital admissions for chronic obstructive pulmonary disease, congestive heart 99 % 94 % failure and diabetes have declined in Hungary since 2005, they remain the second highest among EU

countries reporting these data (Figure 12) and many Mesles could be avoided through more effective primary care. Amon chldren ed 2 Individual practice remains the predominant model 99 % 94 % for Hungarian GPs, which increases the challenges in attracting young doctors to the field and intensifies the complexity of care in the primary care setting. In recent years, a pilot programme to establish group practices in disadvantaged rural areas has led to Influenz Amon people ed 65 nd over better access to health services and improved health in the target populations (Dózsa K et al., 2017). Such 27 % 44 % initiatives show the potential gains from reforming and strengthening the primary care sector (see Section 5.3).

Box 1. A national colorectal cancer screening Note: Data refer to the third dose for diphtheria, tetanus, pertussis, and the first dose for measles. programmeBox 1. A national is being colorectalestablished cancer in Hungary screening Source: WHO/UNICEF Global Health Observatory Data Repository for programme is being established in Hungary children (data refer to 2018); OECD Health Statistics 2019 and Eurostat The introduction of a National Colon Screening Database for people aged 65 and over (data refer to 2017 or nearest year). The introduction of a National Colon Screening ProgrammeProgramme was was announced announced in in 2016, 2016, supported supported byby Cancer care is lagging behind EUEU funding funding and and coordinated coordinated by by the the National National Public Public HealthHealth Centre. Centre. It Itaims aims to to reduce reduce colorectal colorectal cancercancer other EU countries mortalitymortality by by 10 10 % %over over a three-yeara three-year period. period. As described in Section 2, Hungary has the highest TheThe commencement commencement of of the the programme programme was was cancer mortality rates in the EU. High smoking postponedpostponed several several times times when when substantial substantial issues issues rates partly explain mortality rates from lung and emergedemerged during during the the development development phase, phase, such such as as other smoking-related cancers, but the country also inadequateinadequate preparation preparation of of health health professionals, professionals, has other important deficits in cancer prevention, shortageshortage of oftesting testing material material and and lack lack of of capacity capacity detection and treatment. Although for some cancers, to toabsorb absorb increased increased numbers numbers of of diagnostic diagnostic such as breast and cervical cancer, early detection colonoscopies.colonoscopies. The The programme programme finally finally beganbegan in 2019 can improve both quality and length of life, screening and,2019 to date,and, to more date, than more 72 than 000 72people 000 peoplehave received have rates for these two conditions are among the lowest in screeningreceived packages screening from packages their fromGPs. theirOf the GPs. 223 Of 500 the EU. In 2017, only 41 % of Hungarian women aged peoplethe 223 aged 500 50-70 people invited, aged more50-70 thaninvited, 61 000more have than sent 50-69 were screened for breast cancer in the preceding back61 000their have samples. sent backAccording their samples. to the National According Public two years, compared with 61 % in the EU as a whole. Healthto the Centre, National more Public than Health 600 000 Centre, invitations more than will be Cervical cancer screening rates are even lower, with sent600 by 000 the invitationsend of 2019. will be sent by the end of only one-third of woman aged 20-69 screened in 2017 2019. – nearly half the EU average.

14 State of Health in the EU · Hungary · Country Health Profile 2019 OOP Ae-stndrdsed rte of vodble dmssons per100000populton ed 15+ 1 utilities). 4: Catastrophic needs(i.e. expenditure isdefinedashouseholdOOPspendingexceeding40%of totalhouseholdspending netofsubsistence food, housingand Source: OECD Health Statistics 2019 (data refer to 2017). Figure 13. Out-of-pocket payments inHungary are almost doubletheEU average in Hungary (seebelow). Section 4). HighOOP payments are alsoamajorissue less well-covered services, such asdentalcare (see survey showed higherlevels ofunmetneedsfor groups were relatively modest. However, thesame from care. Moreover, thedifferences between income in 2017becauseof waiting lists, costsordistance population reported thatthey could notaccesscare and treatment isrelatively small. Only 1.0%ofthe reporting unmetneedsformedicalexamination The proportion oftheHungarian population cause financialhardship but highout-of-pocket payments Unmet medicalneedsarelow, 5.2. Source: OECD Health Statistics 2019 (data refer to 2017 ornearest year). Figure 12.Alarge numberof hospital admissions could beprevented through stronger primarycare Hunr

000 800 600 400 200 0 Overll shreof helth spendn Portul Accessibility

Itl

Spn 269% OOP

Icelnd Netherlnds

Dstrbuton ofOOPspendn Unted ndomSloven b tpeofctvtes

Others 14% Lon-term cre 06% Dentl cre 24% Phrmceutcls 131% medcl cr Outptent Inptent 29% Eston

Sweden

e Norw 65% State of Healthin the EU ·Hungary ·Country HealthProfile 2019

Irelnd

Denmr Not OOP spending inHungary –oneofthehighest proportions accounted formore thanone-quarter(27%)ofhealth create financialhardship formany. OOP payments medical care forfinancial reasons, OOP payments Although few Hungarians report unmetneedsfor among people inthelowest incomequintile. of thesehighOOP payments was mainly concentrated are available (Figure 14). The greatest financialimpact highest levels across theEUcountriesfor which data catastrophic spending Almost 12%ofhouseholds inHungary faced in theEUandnearly twicetheEUaverage (Figure 13). Frnce OOP EU Overll shreof helth spendn Asthm ndCOPD Fnlnd

Belum

EU21 158% OOP Austr

4 Czech onhealthin2015, oneofthe Conestve flure hert Dstrbuton ofOOPspendn Mlt

Germn b tpeofctvtes

Slov Others 09% Lon-term cre 24% Dentl cre 25% Phrmceutcls 55% medcl cr Outptent Inptent 14%

Polnd

Hunr e 31%

Lthun Dbetes 15 Inptent Outptent medcl cre phrmceutcls Dentl cre Lon-term cre Others

HUNGARY Figure 14. More than one in ten Hungarian households incurred catastrophic health care costs in 2015

Poorest Quntle 2nd Quntle 3rd Quntle 4th Quntle Rchest Quntle HUNGARY Shre of households wth ctstrophc spendn on helth (%) 16

EU20

Itl (2016) Spn (2015) Ltv (2013) Greece (2016)Polnd (2014) C prus (2015) Austr (2015) Frnce (2011) Irelnd (2016) Eston (2015) Crot (2014) Slov (2012)Czech (2015) Sweden (2012) Lthun (2016) Hunr (2015) Portul (2015) Germn (2013) Sloven (2015)

Unted ndom (2014)

Source: WHO Regional Office for Europe (2019).

In addition, almost half of all OOP spending in citizens of member countries. This project was Hungary goes to pharmaceuticals and medical devices established among the Visegrád Group (Czechia, – one of thePoorest highest Quntle rates2nd in theQuntle EU. Substantial3rd Quntle user 4thHungary, Quntle Poland,Rchest Slovakia), Quntle but is also open to other charges are imposed and protection mechanisms countries (Lithuania is one of its founding members for vulnerable populations are weak. Patients in and Latvia an invited guest). Several regional meetings Hungary must make co-payments on most prescribed and technical consultations have been organised. medicines. In general, a higher reimbursement rate The project is being shaped as a complementary is granted if the disease is considered more severe platform allowing better, proactive preparation of or longer lasting, or if the medicine is deemed more national reimbursement and pricing decisions. A effective. While the outpatient reimbursement pilot joint negotiation is under way to define possible scheme provides some exemption mechanisms for mechanisms for future regional negotiation strategies. specific, vulnerable populations, in practice these are rather limited. Co-payments are waived only Health workforce shortages are up to a monthly ceiling of 12 000 Hungarian forints a major issue in Hungary (approximately EUR 40), and patients whose monthly As noted in Section 4, Hungary not only has a lower co-payments exceed this have to pay the difference physician to population ratio than the EU average (WHO Regional Office for Europe, 2018). but the health workforce is also unevenly distributed The authorities are trying to improve across the country. The central region has almost access to medicines twice as many doctors per capita than the north, and shortages in each region are concentrated in rural The question of access to medicines has gained areas. This is reflected in the number of permanently attention in recent years. The government has taken vacant GP practices, which are concentrated in poorer action to enhance generic competition, including counties (Figure 15). prescription by international non-proprietary name, revision of treatment protocols and centralised New service houses are being built or refurbished for procurement. GPs as part of the Hungarian Village Programme in small settlements, where positions have remained Hungary also started to engage in regional vacant for a long time. The aim of the project is collaboration to improve access to medicines. The to make the positions more attractive for young Fair and Affordable Pricing initiative, established in professionals. Some 11 billion forints (EUR 34 million) March 2017, is an inter-country regional collaboration will be dedicated to renovating and modernising platform to improve access to medicines for the doctors’ premises.

16 State of Health in the EU · Hungary · Country Health Profile 2019 and by 26%forotherhealth professionals. foreign work certificates decreased by 13%fordoctors and 2018, thenumber of professionals asking for started tohave ameasurable impact: between 2017 60 %since2010(Figure 16). These pay raises have country, andnet wages have increased by more than doctors, to provide a greater incentive tostay inthe has substantially increased theremuneration of work abroad between 2010and2016. The government (around active 15%ofall physicians) leftHungary to As mentionedinSection4, nearly 5500doctors Capacities, 2014). already above theretirement age (MinistryofHuman even more acuteamong GPs, one-third of whom are 25 %to43%. Ageing ofthemedical workforce is of doctorsaged over 55 years increased from around replace them. Between 2000and2017, the proportion care unlessasufficiently large number ofnew doctors will worsen regional disparitiesandimpair accessto substantial proportion ofHungary’s practising doctors physician shortages. The progressive retirement ofa Ageing andemigration factorsalsoexacerbate Source: ÁEEK(2016). Note: Data refer to total vacant GPpractices includingpractices for children only, for adultsonlyandfor mixed populations. Figure 15. Poorer regions inHungary report thehigherrates of vacant GPpractices Vs Gor-Moson-Sopron Zl Somo Veszprém omrom-Eszterom Brn Feér Toln Budpest State of Healthin the EU ·Hungary ·Country HealthProfile 2019 Bcs-sun Pest Nord 200 300 250 Monthl net wes (nHUFthousnd perperson) 350 100 150 50 Source: ENKK(2016). increased substantially inrecent years inHungary Figure 16. Physician remuneration has been 0 Jsz-Nun-Szolno 2010 Csonrd Heves Borsod-Abu-Zemplén 2011 Béés 2012 Hdu-Bhr 2013 Szbolcs-Sztmr-Bere

Other helthcre wor ers Ntonl vere we Doctors 100 000populton,2016 unflled GPprctcesper Number ofpermnentl 647 -831 464 -647 280 -464 097 -280 2014 2015 17

HUNGARY Doctors Other helthcre wor ers Ntonl vere we 5.3. Resilience5

Public spending on health was projected to grow more slowly than in the EU as a HUNGARY affected by the economic crisis whole in the coming decades, increasing by only 0.8 GDP percentage points overall by 2070 under current Over the past ten years, public spending on health policies (below the 0.9 percentage point average in Hungary has fluctuated in line with the national growth expected for the EU). Public spending on economic context. It remained below GDP growth long-term care is projected to increase by only 0.4 % from the time of the 2008-09 economic crisis until of GDP by 2070, also much less rapidly than in most 2012, leading to a reduction of the share of publicly EU countries (European Commission, 2019). Increasing financed health expenditure in real terms (Figure 17). public spending on health could help improve access However, since 2013 it has been mostly equal to or to and quality of care and, by extension, health higher than the growth of the general economy, and outcomes – assuming the resources are well allocated. reached pre-economic crisis levels in 2017. Hungary faces low fiscal sustainability risks in the As noted in Section 4, Hungary currently spends short run. Conversely, in the medium and long term, much less on health than most other EU countries, the risks are high, even though the contributions of both on a per capita basis and as a share of GDP. This health care and long-term care to these risks could be is driven by low levels of public spending, reflecting relatively minimal (European Commission, 2019). the limited political priority given to health. Only 10 % of all government spending is allocated to this sector, compared with an average of 16 % in the EU as a whole. Public spending on health in Hungary accounted for only 4.9 % of GDP in 2016, a much lower proportion than the EU average (7.8 %). It is also

Figure 17. Public spending on health decreased following the economic crisis

Annul chne n rel terms GDP Publc spendn on helth 5% 4% 3% 2% 1% 0% -1% -2% -3% -4% -5% -6% -7%

-8% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Source: OECD Health Statistics 2019; Eurostat Database.

5: Resilience refers to health systems’ capacity to adapt effectively to changing environments, sudden shocks or crises.

18 State of Health in the EU · Hungary · Country Health Profile 2019 limiting theirusefulnessasameansofimproving tariffs donotreflect thetruecostsofhealthservices, take depreciation intoaccount. As aresult, current system hasnotbeenupdatedregularly anddoesnot DRGs were introduced inHungary in1993, butthe incentives todeliver servicesinthemostefficient way. The hospitalfunding systemdoesnot provide services. is being implemented tofurtherenhanceday surgery framework oftheStructural ReformSupportService rarely thecaseinHungary. A new project within the are performed asday surgery intheEU, thisis Similarly, almostone-thirdwhile oftonsillectomies same-day basis, well below theEUaverage of84%. only 55%ofcataract surgeries were carriedoutona low relative tomostEUcountries(Figure 19). In2016, has progressed inrecent years, current useisstill resources. dayWhile surgery forsomeinterventions services makingwhile more efficientuseofhospital promising optiontoincrease timely accessto Further development ofday surgery isalsoa expenditure efficiency ofhospital More relianceonday improve surgerycould EU (OECD/EU, 2018). tomography scanners per capita are thelowest inthe magnetic resonance imaging unitsandcomputed of high-technology medicalequipmentsuch as well equippedandfunded. For example, thenumbers focus onensuring thattheremaining hospitalsare By reducing thenumber ofhospitals, Hungary could Source: Eurostat Database. Figure 18. Thenumberof hospital bedsinHungary isfar above theEU average were almost40%more beds per 1000 population in has reduced marginally; asaresult, by 2017there the number ofhospitalbeds per 1000 population hospital-centric inHungary. Inthe past decade, As notedabove, healthcare provision remains highly inmoreefficientresult useofresources Reorganising careprovision hospital could 8 4 6 9 Beds per1000populton 5 3 7 2007 2008 2009 2010 2011 State of Healthin the EU ·Hungary ·Country HealthProfile 2019 2012 Hunr tariffs more regularly would therefore restore some the general efficiency ofthehospitalsector. Updating ten years. care, asthe ALOS foracutecare decreased inthe past result ofincreased useofrehabilitative andlong-term However, thehigher ALOS inHungary ismainly the stay (ALOS)intheEU(9.6days vs. 7.9across theEU). also reports thesecondlongest average length of Hungary thanthe EUaverage (Figure 18). Hungary leading tocurrent levels ofindebtedness. and economicsituationsidentify themainfactors budgetary supervisors reviewwill theexpenditure Together with thehospitalmanagement, the budgetary supervisorstothemostindebtedhospitals. situation, in2019theauthoritiesdecided toappoint (Hungarian State Treasury, 2018). To remedy the inSeptembertotal debtsofEUR142million 2018 between December2017 andSeptember 2018to increased by around EUR10.5million per month Rising hospitaldebtsremain a problem; they absorbed by central government. and increased hospitaldebts, which are eventually referral rates from hospitalstolarger smaller ones limits hasunintendedconsequences, such ashigher hospital funding systemthatincludes output volume adjust thesupply ofhealthservices. The current ofhospitalstomanageability care effectively and making authorityattheinstitutionallevel limitsthe In addition, thelack oflocalautonomy anddecision- price signals. 2013 Beds 2014 ALOS 2015 EU 2016 Beds

2017 ALOS (ds) ALOS 4 6 8 10 12 19

HUNGARY Figure 19. The use of day surgery has increased in recent years but remains much more limited than in most EU countries

HUNGARY % of d sur eres 2006 2016 100 90 80 70 60 50 40 30

20 10 0 Hun r EU Hun r EU Hun r EU

Ctrct In unl hern Tonsllectom

Source: OECD Health Statistics 2018; Eurostat Database (data refer to 2000 and 2016, or nearest year).

Recent pilot projects at the primary care level show promising results

Development of a robust primary health care sector professionals. Second, solo GP practices were is essential to respond more efficiently to the growing functionally integrated into group practices, which burden of chronic diseases. Shifting more care out enabled sharing of working processes and patient of hospitals and increasing the focus on preventive data, enhanced collaboration with other service services can save costs overall but increases the providers and introduced innovative IT solutions burden for the primary care sector. Traditionally (Dózsa K et al., 2017). organised primary care, with solo GPs and minimal support staff, would be hard pressed to meet this increased demand (see Section 5.1). Strengthening the primary care sector was also the subject of the country-specific recommendation issued by the Council of the European Union in the context of the 2019 European Semester6 (Council of the European Union, 2019).

The Swiss-Hungarian Primary Health Care Development Model Programme was intended to initiate the transformation of the primary care system by implementing an innovative pilot project between 2013 and 2017. The project expanded the responsibilities of primary care providers, with the co-operation of GPs, and the involvement of allied health professionals including dieticians, physiotherapists, psychologists and public health professionals. The project transformed local primary health care in two main ways. First, it provided preventive tools and human workforce for local GPs so that other options beyond medicine treatment, such as diet and physical therapy, were made available to patients. This resulted in enhanced health promotion and prevention interventions in primary care through the involvement of qualified allied health

6: In July 2019, the Council of the European Union issued Hungary a country-specific recommendation to ‘improve health outcomes by supporting preventive health measures and strengthening primary healthcare’.

20 State of Health in the EU · Hungary · Country Health Profile 2019 the GP profession.the care andtoenhancetheattractiveness accessibility of specialists to GPs has high potential to increase health other health professions, theshiftofcompetence from (Box 2). Apart from task-shifting between doctorsand delegationofcertaintaskstonursesto facilitate in 2017isanimportant step inthatdirection, aiming tertiary education programme launched inHungary for non-physicians. The advanced practice nurse countries have already expandedthescopeof practice between health professionals. Many European efficiency. Oneexample is greater task-shifting professions may alsohelptoimprove accessand development oftheroles ofdifferent health shortages ofhuman resources inhealth. Further have already taken important actiontoaddress the inSection5.2,As described theHungarian authorities shortageshealth workforce Task-shifting helpaddress could development. which tasks willbetransferred isstill under 2019, theformal legislative framework regulating although thefirst cohort graduated inJanuary currently offer APNtraining programmes; however, prescribing vaccines. Three Hungarian universities as hypertension ordiabetes; andordering and managementsupport for chronic diseases such and analysing laboratory tests andimaging; primary care nurse practitioners includeordering could eventually betransferred from GPs to or perioperative nurse practitioner. Tasks that nurse practitioner, geriatric nurse practitioner emergency care nurse practitioner, acute care anaesthetist, primarycare nurse practitioner, specialise insixdomainsto become anurse these professionals inHungary. AnAPNcan (APNs), givingaformal role definition to competencies of advanced practice nurses In 2016, alegislative decree regulated the Hungary to compensate for thelack of physicians in Box 2.Advanced practice nursing may help State of Healthin the EU ·Hungary ·Country HealthProfile 2019 Amid the struggleofthe public system tomaintain access to careiscurrently underdiscussion The role of the private sectorinfostering appliances and medical devices inthefuture. of medicinesbut beexpandedtotherapeuticwill The systemcurrently only allows for prescription community pharmacies inHungary (OECD/EU, 2018). prescriptions were transmitted electronically to of thissystem was quiterapid: by 2018, 75%of in the pharmacy over systemall thecountry. Uptake a central ITcloud andbecomes immediatelyvisible enters a prescription inthesystem, itisloadedinto component ofthe EESZT. When ahealth professional electronically. The ePrescription functionisacentral patient-related information such asmedicalhistory professionals can record theiractionsandother In thissystem, treating physicians andotherhealth (EESZT) was developed using EUStructural Funds. and efficiency. The NationaleHealthInfrastructure information isanoptiontoimprove healthoutcomes timely andreliable sharing ofclinical andother informationinfrastructureA digitalised thatensures 2017 which now covers 75%ofprescriptions Hungary introduced anePrescriptionsystemin entities are being debated. functions androles performed by public and private issues such asamore transparent separation ofthe government hasnot yet published aclear plan, but sector asaformal provider ofhealthservices. The are focusing onclarifying therole ofthe private access tocare andquality, increasingly discussions 21

HUNGARY 6 Key findings HUNGARY • The life expectancy of the Hungarian • The high levels of co-payments population has improved substantially since disproportionately affect low-income groups 2000 but remains almost five years below and lead to significant rates of catastrophic the EU average and the lowest among the health expenditure. Almost half of all out-of- countries of the Visegrád Group. Substantial pocket spending goes to pharmaceuticals inequalities persist across genders, with and medical devices – one of the highest women living seven years longer than men, proportions in the EU – and protection and even more so by education level: at age mechanisms for vulnerable populations are 30, the most educated men live 12 years weak. longer than the least educated, a much larger gap than the EU average of seven years. • The shortages and uneven distribution of health professionals also undermine access to • Half of all deaths in Hungary can be health services. The government substantially attributed to behavioural risk factors, raised the remuneration of doctors and including poor nutrition, high tobacco other health professionals in recent years in smoking and alcohol consumption, and low an attempt to attract and retain them, but physical activity. More than one in four adults improving other aspects of their working reported smoking daily in 2014, one of the conditions and career prospects may also be highest rates in the EU. Smoking rates are required. more than two-times higher among the least educated people than the most educated. • Overall, health care provision remains highly The obesity rate in adults is also among the hospital-centric and primary care does not yet highest in Europe, with one in five adults being play a prominent role in Hungary. There have obese in 2017, with disparities by education been some efforts in recent years to shift more level. This high prevalence of lifestyle-related care to the outpatient sector, by promoting risk factors contributes to high mortality rates group practices for general practitioners as from cardiovascular diseases and cancer. The well as greater task-sharing between doctors Hungarian government has taken a series of and other health professionals such as nurses. measures to improve nutrition, including the Recent pilot projects in primary care have introduction of a public health product tax shown promising results, but ongoing funding to reduce consumption of unhealthy food and scaling up of these initiatives remain in 2011 and the adoption of a legislation to unclear. control trans-fatty acids in food in 2013.

• The Hungarian health system is organised around a single health insurance fund and is highly centralised. It provides coverage to nearly all the population, but the benefit package is less comprehensive than in most EU countries. The health sector remains chronically underfunded and health does not appear to be a high priority, as reflected by the relatively small share of government spending allocated to health. The public share accounts for only two-thirds of health expenditure, much less than the EU average (79 %), resulting in high levels of out-of-pocket spending (27 %) compared to the EU average (16 %).

22 State of Health in the EU · Hungary · Country Health Profile 2019 Key sources

Gaál P, Szigeti S, Csere M, Gaskins M, Panteli D (2011), OECD/EU (2018), Health at a Glance: Europe 2018: State Hungary: Health System Review, Health Systems in of Health in the EU Cycle. OECD Publishing, Paris, https:// Transition, 13(5):1-266. doi.org/10.1787/health_glance_eur-2018-en.

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ÁEEK (2016), Hungarian Health System Scan 2014-2015, Kovacs VA et al. (2018), Weight Status of 7-Year-Old Budapest. Hungarian Children between 2010 and 2016 Using Different Classifications (COSI Hungary). Obesity Facts, Council of the European Union (2019), Council 11(3):195-205. Recommendation on the 2019 National Reform Programme of Hungary. Brussels, http://data.consilium. Ministry of Human Capacities (2014), Healthy Hungary europa.eu/doc/document/ST-10170-2019-REV-2/en/pdf 2014-2020. Government resolution: 1039/2015. (II. 10.)

Dózsa K et al. (2017), Public Health Focused Model OECD (2019), OECD Economic Surveys: Hungary, 2019, Programme for Organising Primary Care Services Backed Paris, OECD Publishing. by a Virtual Care Service Centre. Swiss-Hungarian Cooperation Programme, Budapest. Rechel B, Richardson E, McKee M, eds. (2018), The organization and delivery of vaccination services in ENKK (2016), Report on human resources in the health the European Union, European Observatory on Health sector, Budapest. Systems and Policies and European Commission, Brussels. European Commission (2016), Mapping of the use of European Structural and Investment Funds in health Szigeti Sz et al. (2019), Tax-funded Social Health in the 2007-2013 and 2014-2020 programming periods. Insurance: an Analysis of Revenue Sources, Hungary, Brussels, http://www.esifforhealth.eu/pdf/Mapping_ Bulletin of the World Health Organization, 97(5):335-48. Report_Final.pdf Uzzoli A (2016), Health Inequalities Regarding Territorial European Commission (2019), Joint report on health care Differences in Hungary by Discussing Life Expectancy, and long-term care systems and fiscal sustainability – Regional Statistics, 6(1):139-63. Country documents 2019 update. Institutional Paper 105. Brussels. WHO Regional Office for Europe (2015), Assessment of Hajdu Á et al. (2018), Policy Brief: Promoting the the Impact of a Public Health Product Tax. WHO Regional Appropriate Use of Antibiotics to Contain Antibiotic Office for Europe, Copenhagen. Resistance in Human Medicine in Hungary. WHO Regional Office for Europe, Copenhagen. WHO Regional Office for Europe (2018), Medicines Reimbursement Policies in Europe. WHO Regional Office Hungarian State Treasury (2018), Funding data, http:// for Europe, Copenhagen. www.allamkincstar.gov.hu/ [In Hungarian]. WHO Regional Office for Europe (2019), Can People Joó T, Szócska M, Vokó Z, et al. (2018) The impact of Afford to Pay for Health Care? New Evidence on Financial anti-smoking policies of the 2010-2014 Hungarian Protection in Europe. WHO Regional Office for Europe, government – a comprehensive evaluation. Tobacco Copenhagen. Induced Diseases, 16(1):440. Country abbreviations

Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK

State of Health in the EU · Hungary · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019

The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.

Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Hungary: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

ISBN 9789264827813 (PDF) Series: State of Health in the EU SSN 25227041 (online)