In the last 70 years, that is since Hungary had a government funded centralised healthcare, informal or gratitude payments (from the Hungarian word ’hálapénz’) were an integral part of the Hungarian healthcare system. Informal payments constituted a large sum; they were frequent and it seemed impossible to end them. In 2007 informal payments were equivalent to ‘13.7 per cent of the average net monthly salary and 20.5 per cent of the average pension’[1], a couple of years later in 2014 (following years of steady increase) according to Transparency International gratitude payments accounted for HUF8.3 billion ($27 million). A survey that was published in 2016 found that 24.8 per cent of people who went into the public healthcare service in the last 12 months in Hungary paid informally[2].
The problem with informal payments was not only their scale, but the injustice too, that they created. The seriously ill were more likely to pay, the socially disadvantaged paid a higher proportion of their monthly income and women were also more likely to pay informally. Informal payments are probably the most common in the Hungarian maternity care, where above 50 per cent of the women offer gratitude payments to healthcare professionals. All it is to say – from a social justice perspective, the penetration of informal payments in Hungarian healthcare was harming the more vulnerable.
The problem with informal payments was not only their scale, but the injustice too, that they created
Although there were earlier attempts to put an end to informal payments (e.g., an unsuccessful legislative move in 2007 in the form of visit fees that aimed to “formalise” informal payments) until last year gratitude payments seemed to be an irreparable ill of Hungarian healthcare. In 2021, however, with a swift legislative move, the Hungarian government criminalised gratitude payments. Criminalisation – especially since it lacks tough enforcement –, however, would not be enough on its own to change an embedded cultural habit. This is the reason why the legislation, Act C of 2020 on the Healthcare Service Provision (egészségügyi szolgálati jogviszonyról szóló 2020. évi C. törvény) did more than just criminalised informal payments. The three pillars that support the main aim of the legislation (i.e. end informal payments) are criminalisation, pay raise for healthcare workers and the separation of private and public healthcare by a new employment contract that requires each healthcare professional to pre-approve their private side employment in healthcare.
All of these three pillars (criminalisation, pay raise, institutional separation) are necessary to end informal payments. Criminalisation introduces a social stigma on informal payments, which did not exist before – this changes the former neutral to positive cultural attitude towards informal payments. The pay raise of healthcare workers removes an incentive to take gratitude payments – now, healthcare professionals can no longer justify unethical habits with their low salaries. Finally, by ending the institutional intertwine between public and private healthcare, the new legislation enhanced institutional clarity, that formalises gratitude payments. Taken together, the pillars of the new legislation work together to put an end to informal payments in Hungarian healthcare.
The legislation attempts to change the culture around informal payments
Nothing shows better that the new legislation also tries to change cultural habits around gratitude payments (instead of strictly enforcing the ban on informal payments) than the recent leaflet campaign in Hungarian hospitals. Following the legislation, four thousand posters were distributed in 167 Hungarian hospitals about the ills of informal payments, warning patients as well as healthcare professionals about the ban. This poster campaign demonstrates that the legislation attempts to change the culture around informal payments – instead of viewing them as socially acceptable, their perception should be negative. This cultural shift away from gratitude payments enhances social justice, as informal payments used to hit the least fortunate the most.
While informal payments are far from completely disappearing from Hungarian healthcare, since 2021 the decline in the frequency of informal payments is demonstrable. Just a couple of months after the legislation was introduced, 16 per cent of doctors said that there are no gratitude payments anymore, while an additional 31 per cent said that informal payments decreased considerably. A study by Juhász and Kereszty has found that before the legislation only 57 per cent of healthcare workers received verbal or written thanking messages at least once in a month.[3] Since the legislation, however, more healthcare professionals report hearing thanking messages without accompanying cash payments. In turn, healthcare professionals are also more likely to reject informal payments.[4] The increasing tendency to reject informal payments, and to express gratitude by words instead of with money both signal a cultural shift. This cultural shift is a direct result of the legislation, which creates a more fair and just healthcare system in Hungary for all.
[1] Baji, Pavlova, Gulácsi, Homolyáné, and Groot, Informal Payments for Healthcare Services and Short-Term Effects of the Introduction of Visit Fee on These Payments in Hungary., International Journal of Health Planning Management, (2012), 74.
[2] Williams, Horodnic, and Horodnic, Who is Making Informal Payments for Public Healthcare in East-Central Europe?, Eastern Journal of European Studies, (2016), 51.
[3] Juhász, and Kereszty, ‘A hálapénzzel kapcsolatos szokások a magyar egészségügyi szakdolgozók körében’, Orvosi hetilap, (2021b), 1664.
[4] Juhász, and Kereszty, ‘A magyar egészségügyi szakdolgozóknak adott ajándék és „hálapénz” a 2021. évi jogi fordulat után’, Orvosi hetilap, (2021a): 370.
