Durham E-Theses Free for all?: processes of change in health care provision in Hungary from 1987-2002 Rae, Jacqueline How to cite: Rae, Jacqueline (2005) Free for all?: processes of change in health care provision in Hungary from 1987-2002, Durham theses, Durham University. Available at Durham E-Theses Online: http://etheses.dur.ac.uk/3017/ Use policy The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in Durham E-Theses • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full Durham E-Theses policy for further details. Academic Support Oce, Durham University, University Oce, Old Elvet, Durham DH1 3HP e-mail: [email protected] Tel: +44 0191 334 6107 http://etheses.dur.ac.uk 2 Free For All? Processes of Change in Health Care Provision in Hungary from 1987-2002 Thesis submitted for the degree of PhD University of Durham, Department of Geography 2004 A copyright of this thesis rests with the author. No quotation from it shouHd be pulbAislhledl without his prior writtell] consent and information derived from it should! be acknowledged. Jacqueline Rae - 1 SEP 2005 CO NT lENTS List of Boxes and Figures v List of Abbreviations vi Declaration vii Abstract viii Acknowledgements ix CHAPTER 1: Introduction: Processes of Change in Central and Eastern Europe 1.1 Introduction 1 1.2 Contextual Background 4 1.2.1 Welfare Provision in Central and Eastern Europe 4 1.2.2 Health Care Reform in Central and Eastern Europe 6 1.2.3 Health Care Reform in Hungary 9 1.3 Developing an Understanding of Processes of Change 10 1.3.1 Aims and Research Questions 12 1.4 Thesis Structure 12 CHAPTER 2: Geographical Perspectives on Health Care Provision 2.1 Introduction: Geographical Diversity 15 2.2 ''Traditional Medical Geography'' 16 2.3 "Contemporary Geographies of Health and Health Care 19 2.3.1 Humanistic Health Geographies 20 2.3.2 Structuralist Health Geographies 21 2.3.3 Poststructural Cultural Geographies 23 2.4 Geographical Perspectives on Health Care Provision and Reform 25 2.5 Conclusions: A Framework for Analysis of Processes of Change 32 CHAPTER 3: "Mixed Economies" of Health Care: Understanding Changing Roles of Providers in Health Care in Central and Eastern Europe 3.1 Introduction 35 3.2 Understanding Welfare States 36 3.3 Themes of Welfare State Theory 39 3.4 "Mixed Economies of Welfare" 46 3.5 State Decision-Making 51 3.6 Health Care Governance 53 3.6.1 Foucault on "Governmentality'', Power and the Medical Profession 56 3.6.2 Complexity of Governance 61 3.7 Civil Society 66 3.7.1 Civil Society Against the State 66 3.7.2 Spaces of Civil Societies 68 3.7.3 The Role of Civil Societies in Central and Eastern Europe 75 3.8 Concluding Comments 81 CHAPTER 4: Chronology of Health Care Reform in Hungary 4.1 Introduction 83 4.2 Early Development 83 4.3 Period of Socialist Health Care Provision 85 4.4 Health Care Reform since 1987 92 4.5 Concluding Comments 105 CHAPTER 5: Research Methodoloav: "Drowning in voices": The "messiness" of cross cultural fieldwork and disseminating participants' understandings of change 5.1 Introduction 107 5.2 Selection of Counties 108 5.3 Preliminary Field Visit 115 5.4 Recruiting and Working with Translators 120 5.5 Interviews 122 5.6 Observations 125 5.7 Secondary Documentation Sources 128 5.8 Analyses and Interpretation: "Drowning in Voices" 129 5.9 Hands Up; the Research is Biased: Issues of Reliability and Validity 133 5.9.1 Researcher Positionality 134 5.9.2 Te beszelsz magyarul? 135 5.10 Conclusions: Writing Participants' Understandings 139 CHAPTER 6: National Processes of Change 1987-2002: Understanding Government Strategies for Reform and the Involvement of International Organisations in Health Care Provision 6.1 Introduction 141 6.2 Perceptions of Change in Health Care Provision at the National Level 142 6.2.1 Primary Health Care and Free Choice of Doctor 144 6.2.2 Decentralisation 146 6.2.3 The National Health Insurance Fund 147 6.2.4 Health Prevention and Promotion Strategies 150 6.2.5 Reform of the Social Care Sector: "You work or go to an institution" 152 6.2.6 Privatisation 153 6.2.6.1 "Parasolvencia" (Gratuities) 159 6.2.7 Processes of Change: The Role of the National Government 162 6.3 The Involvement of International Organisations in Health Care Reform 164 6.4 Concluding Comments 171 11 CHAPTER 7: Complexities of Change: the Role of Local Health Care Providers in Understanding, Shaping and Implementing Reforms 7.1 Introduction 173 7.2 Perceptions of Change 173 7.3 Salaries 177 7.3.1 Salary Differentials 178 7.3.2 Staff Shortages 179 7.3.3 Prestige and Status 180 7.4 Parasolvencia 181 7.4.1 Reluctance of the State to Increase Wages 182 7.4.2 Traditional Cultural Beliefs of Patients 184 7.4.3 Traditional Working Practices of Head Doctors 185 7.5 The Dominance of the Hospital and the Specialist 187 7.6 Privatisation 191 7.7 The National Health Insurance Fund: Issues of Finance 198 7.8 Decentralisation: Inequalities in Service Provision 200 7.9 Discussion and Conclusion: Understanding, Shaping, Implementing Reforms 204 CHAPTER 8: Alternative Processes of Change. Having a Voice: The Role of Voluntary Civil Health Organisations in Health Care Provision and Reform 8.1 Introduction 207 8.2 Contextual Background 208 8.3 VCHO Participants 212 8.3.1 VCHO Pre- and Post-1989 215 8.4 Filling a Gap and Influencing the State 217 8.4.1 Introduction 217 8.4.2 Disability (Mental and Physical Handicap) Care 218 8.4.3 After Care: patient Self-Help Groups 221 8.4.4 Health Prevention and Promotion 223 8.5 Challenging Dominant Traditions and Practices 228 8.5.1 Introduction 228 8.5.2 Recognition of Patients' Rights 228 8.5.3 Patient Choice: The Alternatal Foundation's Home Birth Campaign231 8.6 Cooperation and Conflict 236 8.6.1 Introduction 236 8.6.2 The AIU and the State 237 8.6.3 Personal Conflict 238 8.7 Discussion and Conclusion: Alternative Processes of Change 241 CHAPTER 9: Conclusions 9.1 Introduction 244 9.2 Re-Visiting the Research Questions 245 9.2.1 Processes of Change from 1987-2002 245 9.2.2 Impact of Privatisation 246 9.2.3 Understanding, Shaping and Implementing Processes of Change 248 9.2.4 Implications for Providers' Understandings 252 Ill 9.3 Possible Avenues for Further Research 255 References 256 Appendices 275 lV List of Figures, Boxes and Tables Figures 1.1 Central and Eastern Europe 2 5.1 Regional Inequalities in Resource Use and Capacities 110 5.2 The Counties of Hungary 112 5.3 Major Settlements 112 Boxes 3.1 Am in and Hausner's ( 1997) Four Networks 62 3.2 Hirst's (1994) Principles of an Associational and Confederal Welfare State 65 3.3 Criteria for Identifying Authentic Voluntary Bodies 70 3.4 Deakin's (2001) Spaces of Civil Societies 74 4.1 The Early Development of the Hungarian Health Care System 84 4.2 Socialist Development of Hungarian Health Care 86 4.3 Organisational Levels of Health Care During Socialism 88 4.4 Chronology of Reform in Hungarian Health Care since 1987 95 4.5 National Level Health Care Service Responsibilities 97 4.6 Sub-National Level Health Care Services 97 4.7 Private Health Care Provision 98 5.1 Meeting Mary 121 7.1 Lobby Power: Professional and Personal Connections 201 7.2 Local Government Priority and Commitment 202 7.3 Complexities of Decentralisation: Lack of Commitment and Cooperation 203 7.4 Political Culture and Health Care Provision 205 8.1 Voluntary Civil Health Organisations and Participants 213 8.2 Number of Non-Profit Organisations by County 2000 214 8.3 VCHO Existence before 1989? 215 8.4 VCHO Existence after 1989 217 8.5 "Rights and Obligations of Patients" 229 8.6 Number of Specialists by Selected Speciality 234 Tables 4.1 Average Life Expectancy at Birth 91 4.2 Reform of Health Care Finance and Payments 100 4.3 Average Monthly Gross Earnings of Selected Employees 104 8.1 Non-Profit Organisations by Field of Activities 1990 212 8.2 Non-Profit Organisations by Field of Activities 2000 212 v Abbreviations AIDS Acquired Immune Deficiency Syndrome AIU Alliance and Industrial Union AF Alternatal Foundation GEE Central and Eastern Europe CINDI Countryside Integrated Non-Communicable Disease Intervention CT Computerised Tomography DIFM Department of International Fund Management DRG Diagnostic Related Group EC European Commission EMA Eastern Medical Alternatives EU European Union GP General Practitioner HCSO Hungarian Central Statistical Office HDG Homogeneous Disease Group HIF Health Insurance Fund HISG Health Insurance self-Government HIV Human Immunodeficiency Virus IHD Ischemic Heart Disease MCH Mother and Child Health Nurse MRI Magnetic Resource Imaging NACP National Association of Cancer Patients NGO Non-Governmental Organisations NHIF National Health Insurance Fund NHIFA National Health Insurance Fund Administration NHS National Health Service NPHMOS National Public Health and Medical Officer Service NRP National Renewal Program OECD Organisation for Economic Co-operation and Development PHC Primary Health Care SRA Strategic-Relational Approach UK United Kingdom USA United States of America VCHOs Voluntary Civil Health Organisations WB World Bank WHO World Health Organisation VI Declaration No part of this thesis has previously been submitted for a degree at this or any other university.