Interpreting inequalities in the Hungarian health system

SW. .sci. .%/et/. Vol. 31. No. 3. pp. 275.-284. Prmtcd in Great Brikun

INTERPRETING

1990

0277-9536 90 53.00 + 0.00 Pergamon Press plc

INEQUALITIES IN THE HUNGARIAN HEALTH SYSTEM LAJOSCSASZI*

Hungarian

Academy

of Sciences,

Institute

of Sociology,

1361 Budapest

V, Hungary

Abstract-In reviewing the Hungarian situation it is said that the ideals of a higher living standard and economic security have a much broader appeal in public opinion than equality. The impacts of state intervention to reduce inequalities are reduced by several factors such as the tipping system and centralization. Official statistics do not entirely shed light on prevailing inequities in health, in particular those related to phenomena outside the health system. i.e. there is a heavy biomedical bias. Some contradictory developments are identified. Gne of these is that successful factories have created independent industrial health care services for their workers which not infrequently provide a higher quality of care than the state system. Furthermore, sociology has not played that generalizing and integrating function in the uncovering of inequalities in health as it has in Western countries. One of the rare sociological studies in the field shows that the population considers health only fourth among other desired values. Due to the increase in mortality, the issue of health has recently become more focused in the public debate. In general, this paper considers that the health system conforms with other Hungarian social realities in the realm of economics and politics as well as in value-orientation. This has been reflected in the recently reorganized ministry that now also comprises social welfare. Krr

rrords-Hungary,

medical

sociology,

health

systems,

DIFFERENCESIN THE INTERPRETATION OF INEQUALITY

of equality and made it a part of the political posture with which it faced society. In the question under consideration. the nationalization of health care and the establishment of free services under socialist auspices was meant to secure equal opportunities for every social group. In this fashion, from the moment of its birth, the ideal of equality was connected to the principles of free health care and to the practice of centralized control, the latter of which guaranteed that its goal could be realized independent of regional differences and professional biases. In many respects, this situation created a reversal of positions in the theorization of inequality. The promulgation of the idea of equality became the privilege of the state, while the demonstration of inequality came to be regarded as an oppositional political act. We find similar difficulties in the second precondition for the study of equality which requires the institutionalization of a perspective whose starting point is anchored within the needs of society. What is involved here is not simply the absence of sociology, though undoubtedly it appeared later in Hungary than in the West, and the volume of studies available is also smaller here. More important is the fact that in Hungary sociology plays a less dominant role in the articulation and interpretation of social problems than in the West. Its influence is restricted by two facts. The first is that the state tends to invest statistics with the task of uncovering social inequality. The second is that the population has traditionally looked to literature and journalism for the exposure and collective discussion of social problems.

In sociological studies. equality appears as a normative-descriptive category which poses pragmatic democratic ideals for the different sectors of social life. Its hypothesis is that institutions live up to the ideal of equality when everyone, regardless of his or her social condition, has equal access, in our case in the area of health care, to services. The population’s standard of health, moreover, can be considered equal when social differences do not play a serious role in the biological differences of the population; in other words, when everyone has an equal chance to remain healthy. In the same vein, we could regard inequality an indication of the narrowing of these possibilities. This approach begins with the premise that inequality-thus inequalities in health care-is a negative value. At the same time, it also implies that there exists an institutionalized perspective-sociology-which is able objectively to examine the structure of society and to map out in a coherent fashion the inequalities connected with health care. How do these preconditions apply to Hungary? It seems that they are absent since equality does not count for a vital social value which could eliminate all other values. The ideals of a higher living standard and economic security have a much broader appeal in public opinion than equality. It is also common knowledge that after socialism came to power, the state appropriated for itself the ideal *Address correspondence 1250 Bp. Pf. 20, H-1014

to: Lajos Budapest,

Csaszi, Uri Hungary.

inequalities

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LAJOS

Given these circumstances, we cannot approach the problem of inequality in health care as a sociological problem based on sociological investigations. Hungarian society simply did not regard it in this way and did not discuss it in these terms. It is thus necessary to find a different mode of approach to the problem. THE IMPACT OF STATE INTERVENT

ON EQUALITY

It is an historical commonplace that as one moves from West to East, the state played an increasingly active role in the development of a modern industrial society. Accordingly, civil society was forced to accept a thorough-going state intervention not only in industry but in other areas as well. such as culture and health care. This intervention from above had the simultaneous goal of stimulating the market and of protecting social interests, in other words, of realizing equality and effectiveness. This process has been under way within the region for centuries and the socialist takeover simply extended it in a radical fashion through the process of nationalizing the entire society. Even before the Second World War the state had a profound influence over health care; approximately one-third of the doctors were state employees. After nationalization, however, the entire health care system became part of a bureaucratic social organization when doctors were transformed into full state employees and all institutions of health care were nationalized. What are the differences between a bureaucratic and a Western health care system and how do we begin to interpret these differences? Our starting point certainly cannot be the fact that one pays for services in one and not in the other. Within the Western system. the insurance company often pays instead of the patient; and within the bureaucratic model, the state or the patient-in the form of tipping-can end up paying for services which turn out not to be free either. In our eyes, the important differences between the two models lie in the different forms of control which characterize each. In the Western health care system, the needs of the population directly influence medical care; this forms the controlling element in health care provision. Planning is reserved for public health only, which is meant to serve the collective needs of the population, but within this model it has marginal importance. In direct contrast to this, the bureaucratic health care system is organized from top to bottom in a centralized way. Fundamental to its concerns are the needs of the population, but as constructed, therefore mediated, by the representatives of the state. The satisfaction of the spontaneous complaints of the population can only be realized through peripheral, complicated, often illegal means. For immediate individual needs appear only as unrecognizable, subordinated fragments of the state’s interests, determined through centralized planning. This means that if, for example, there is an increase of tuberculosis in the country, the state will apportion institutions and doctors in such a way as to concentrate its energies on the fight against tuberculosis. Those suffering from other illnesses are given lower priority based on official estimation. So far, this is understandable. The

CSASZI

problem begins when bureaucratic control becomes monolithic, eliminating all other forms of care. so that during the period of anti-tuberculosis programme. patients suffering from other diseases are able to take advantage of neither religious nursing homes nor other forms of adequate care, even if, by chance, they are able to pay for it. Bureaucratic control does not simply restrict but entirely eliminates those corrective mechanisms which could aid the functioning of the state. Moreover. since bureaucratic control. as is well known, is able to react to social needs onlv slowly and only in connection with large numbers.-inevitably, sooner or later, the system will be characterized by shortages and inadequate services. Equality will therefore emerge in the guise of a contradiction between the goals of centralized planning and the needs of the population, rather than as a conflict between different social groups. And the more completely administered the health system is. the more strongly will this contradiction appear. In everyday life, ,this is experienced in the form of administrative intervention between the population’s real needs and medical services so that satisfaction of needs is made possible through various administrative restrictions. The crudest example of this is the patient’s inability to freely choose his own physician. He has access only to physicians centrally appointed to particular districts while doctors themselves can only refer their patients to centrally approved and regionally specific hospitals and clinical wards. The patient thus has to fight his way through this bureaucratic network in order to reach the appointed physician and only then is he able to express his particular complaint. If he succeeds in convincing the physician of the reality of his illness-and naturally. sooner or later, in one form or another, every illness can be accepted as legitimate-then he has to face the reality of shortages; that is, questions such as does the health system possess adequate physical and institutional preconditions for the treatment of his complaint. Shortages of drugs are quite common. while medical instruments are often outdated. Ideally. the renewal of medical instruments-and here we are not talking of high technology-should take place every eight years, while in Hungary it happens on average every I9 or 20 years. Finally, if the patient does not suffer from shortages, he still has to contend with treatment under humiliating, impersonal conditions in which he is denied his human dignity and treated as a case history which has no name, only a number. While the state declares itself to be the guarantor of equality, the structural asymmetry created by the institutional system turns out to be one of the chief sources of inequality. In contradiction to its promise. the institutional system is not primarily a source of services to the population but rather an instrument of enormous, concentrated power over it. The population’s helplessness is not simply that of the layperson when faced with the professional, nor of the client faced with the medical institution, but also that of the citizen faced with his own state. And until recently. this state prohibited all alternative non-official channels for dealing with complaints, even while it remained incapable of satisfying needs through its own approved methods.

Interpreting inequalities in the Hungarian health system THE STATISTICAL PROBLEM OF MEASURING INEQUALITY

Let us examine, after all this. how official statistics mirror inequality. General statistics about health commonly discuss the subject under three headings. A third of the data has to do with the organization of the health system, proof that every institution considers self-perpetuation and self-projection a primary consideration. Even these data are organized from the specific perspective of the utilization of health care services. They contain the number of visits to the physician per year, the number of examinations and treatments per year, the number of patients per hospital bed according to clinical wards. The indicators provide important information for the health system administration which it can utilize in its operation. (At the same time, they serve a legitimating function as they demonstrate to the population the extent of its efforts.) For the health system administration-and for the state-it thus appears much more obvious to speak of differences rather than inequalities. Focusing on the internal tension of the network or on the inadequacies of social services would lead too far beyond its territory and would be less directly useful. Thus the administration openly repudiates all social problems lying outside its institutional boundaries in order to concentrate its attention on the problem of professional directives; it can therefore hardly be expected to speak of anything besides its own administrative activities. The second third of statistical publications focuses on the frequency of different diseases and causes of death according to diagnosis. Here, the organizing criterion is exclusively medical. Most frequently, there is added to this a breakdown according to time periods, which indicates whether the given disease or cause of death occurred more or less frequently than previously. This clearly fulfills a prognosticating function for planners, who want to know where to concentrate resources based on a large or growing number of occurrences. As the first group of statistics ignored all perspectives outside the organizational framework, these ignore questions beyond a narrowly-interpreted medical competence: questions such as what social group is more prone to a particular disease or cause of death? (If such a question occurs at all, it can only be in the case of a direct connection; for example, in occupational diseases or well-known workplace injuries.) If these reflect a strictly medical-biological viewpoint, administrative statistics give voice to the perspective of directors according to whom everyone has an equal chance to get medical care, independent of social location. In either case, the use of sociological categories is regarded unnecessary. At worst, the suspicion may even arise that questions such as the health system’s unequal treatment of one group or another may be used to provoke public opinion. All these political fears explain why the inclusion of social factors does not appear particularly appealing even when statistical research is organized according to diagnostical groupings. Finally, the last third of statistical publications, the so-called vital statistics, contains the most important

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indices of the nation’s biological state: births and deaths. In this group we encounter not only biological-sex and age related-factors, but the presentation of regional distribution as well. On closer examination, however, it becomes evident that the situation is no better here than it was in the previous divisions; the regional groupings always correspond to political-administrative units and do not follow the contours of social, economic or cultural demarcations. Thus within the individual administrative units, economic, cultural and social differences are intermingled in an indistinguishable way. The preference given to administrative, as opposed to cultural, economic and other categories once again proves the dominance of the perspective of the state over that of society. The fact that the political state is also a stratified social body, which contains groups differentiated by levels of schooling, income, profession, origins, mobility, religion, ethnicity-differences which significantly influence the state of health of the population as well as the way it utilizes health care facilities-these factors remain outside the world of statistical analysis. Thus, social inequalities can only emerge in the guise of biological inequalities or, as we saw, perhaps as organizational and administrative variations. According to this mode of statistical depiction, therefore, there can exist different illnesses and these can occur in different frequencies, but these appear independent of social structures. It is no mistake or inattentiveness which is at the basis of this depiction, but rather the inner linkage between the perspective of the state and statistical data gathering. The linkage also elucidates why statistics followed the bureaucratic division of labour between the different ministries and stopped at the boundaries of the organizations. This is the reason why there exist health related data which contain no references to social groups, while elsewhere there exist data relating to the components of social structure which, however, provide no information about the health or diseases of these same groups. We can conclude that just as the state is in a hegemonic relationship to society, so is statistical investigation in a dominant role towards sociology. This fact makes it impossible to depict the inequalities of society since these very studies are lacking which could take into account the social parameter, besides the organizational and biological ones.

ONE POSSIBLE ANALYTIC FRAAMEWORK

As we have already seen, an authentic method for measuring equality is impossible within a centralized, bureaucratically organized health system. Within the given situation, the maximum that would be possible is measuring inequalities that occur in centralized distribution but the social scientist generally has no way of doing this. Even if he did, such an admittedly important study would have the disadvantage that it would not discuss inequalities appearing within the genuine needs of society, and thus it would be impossible to compare what connections exist between inequalities stemming from distribution and inequalities to be found within society in health related questions.

LAJOSCSASZI

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We have reached the conclusion that it is impossible to articulate a problem defined by a democratic, egalitarian value orientation within monolithic societies. Illustration of this is the way a pluralistic viewpoint is reduced to a statistic serving the official state vision. It is surprising then that international comparisons appear almost impossible after this? We would like to call attention to the fact that this would probably be true even if by chance we had access to research data based on independent studies, containing social factors, and thus if we eliminated the obvious obstacles in the way of comparison. My concern is that historical and structural differences within nations may invest identical indices and values with different meanings. But there are further obstacles for comparison even in the most optimal circumstances: the disposition of the theme. To what extent is the given problem present within the intellectual life of the nation, by whom, and how is it analysed, and what relationship exists among the different forms of analysis; for example, which is dominant and which is subordinate? And how do all these relate to the nation’s historical traditions and social structure? How then is it possible to approach the system of inequalities found within Hungarian society in the area of health? Because of the absence of self-evident, coherent data, I would suggest, in place of a normative-descriptive approach, an historical-narrative perspective. This means that we should discuss the problem of inequalities by including explicitly historical, structural and interpretive viewpoints. Concretely, it means that I divide the recent past into distinct periods within which I discuss the structural differences, the inequalities stemming from these differences, and the changing ways society articulated its own health problems. My task is to provide additional information about those connections which statistics does not discuss or only discusses in a one-sided way. Naturally, no matter how problematic we regard the perspective of statistical investigations, and for this reason, no matter how limited we find its conclusions, it would be incorrect to entirely ignore them. A detailed collection of statistical data is to be found in Czaszi, 1986 [I].

THE HUNGARIAN HEALTH SYSTEM BETWEEN 1950 AND 1987 I should explain why I consider 1950 and 1987 historical demarcation lines. This represents the period of the independent Ministry of Health whose characteristic feature was that health care was officially declared a professional-medical task which was both professionally and intellectually segregated from social questions. This segregation was based on the ideological-political premise that in a socialist society all social problems-housing, profession, education, etc.-have automatically been solved and therefore need not be dealt with separately. This segregation is reflected in the title itself: before 1950, the health system was under the jurisdiction of the Ministry of Public Welfare (Nepjoleti Miniszterium), between 1950 and 1987, under the Ministry of Health (Egeszskgugyi Miniszterium), since 1987, under the

Ministry of Social Welfare and Health (Szocialis es Egeszsegugyi Miniszterium). The administrative segregation did not in the least mean that the health system enjoyed an autonomous status, since society’s political and economic order and leadership unmistakably determined its situation. Within the given period, there exists a further subdivision, precisely on the basis of which sub-system had predominant influence over the health system: between 1950 and 1967 it was politics, between 1968 and 1987 it was economics. These are the contexts within which we would like to introduce the emergence of inequalities within these periods. During the period between 1950 and 1968 political considerations were dominant and the health system conformed to political expectations. This meant that, in accordance with the political values of the period. the health system imposed positive discrimination on behalf of workers and concentrated new medical resources to industry. In the medical schools, students of working class background enjoyed priority in admissions examinations. In health care institutions, primary care was emphasized at the expense of hospital care. Ultimately, what was characteristic of the age was the rapid elimination of infectious diseases and the spectacular increase in average lifeexpectancy. This result was explained as a direct consequence of the institution of free and universal health care and the general improvement of economic-social conditions. On top of this, the health system administration spread exaggerated rumours to the effect that if the fight against disease continues to proceed successfully, then even sickness will disappear under communism. The official viewpoint was utopian and monolithic at the same time, which gave no opportunity for the expression of different conceptions and diverging experiences. And yet, certain social classes-the peasantry and the old middle class in particular, which the new regime considered political enemies and dealt with accordingly, moreover, certain groupings, first and foremost those living in villages-quite evidently suffered from disadvantages. Within the field of medicine itself, entire specialities were forced into the backgroundsuch as psychiatry, for instance, which was traditionally advanced in Hungary. In the otlicially created picture of equality, the problem of inequality in the health system obviously did not find a place either. And if it proved impossible to avoid the question, it was regarded either as an historical inheritance, which the passage of time will automatically solve; or as the fault of individuals which stemmed from personal failure, and therefore corrigible through individual responsibility. Between 1968 and 1987, during our second period, economics replaced the previous political domination of the health system. Although the economic reforms of 1968 did not directly affect the health system, and although the 1970s brought important revisions within these reforms, it is nevertheless useful to take 1968 as an historical dividing line. The health sysr n came under entirely different influences, its social context changed, and therefore it also began to face new types of problems. We dealt with the first period only briefly, with the intention of simply sketching out its prominent

Interpreting inequalities in the Hungarian health system features as a prelude to what came after. The second period, however. which constitutes the past 20 years, will be the object of more intense examination, forming the real subject of our present essay. We have to call attention to the fact that the problem of inequality during this second period has different features in Hungary from other East European socialist countries, since here, side by side with administrative leadership and structures, market elements were also integrated into the system. (Similar trends are perhaps visible in Poland and Yugoslavia, but this needs to be demonstrated in future studies.) What also differentiates Hungary from the characteristic practice of other socialist is active popular participation in countries discussions of the new inequalities; the public forum was no longer the monopoly of the state but became accessible to the population as well. Comparable phenomena are observable in Polish and Yugoslav societies as well. but once again, it is difficult to know for certain whether the superficial similarities contain deeper structural identities as well. It is also unclear whether these similarities stem from the common historical-economic structure of the region, from the similar political systems, or from political methods which can be considered more liberal than those of the past. THE RECENT PAST OF THE HUNGARIAN HEALTH SYSTEM

The greater emphasis on the role of the economy had the effect of bringing into prominence within the health system the principle and importance of performance in place of exclusive, ideological declarations of equality. This does not mean that the leadership of the health system had completely given up the principle of equality, only that it ceased emphasizing it in an extreme form lacking all grounding in reality. For example. in the medical schools, the earlier preference for students of working class origins gave way to an emphasis on achievement in entrance examinations. Although a weighted point system remained in place; that is, working class students continued to get in with a lower point average, the proportion decreased by the mid 1980s from an earlier 60% to 25%. This step, as other achievementoriented measures, decreased those inequalities which the previous system of political discrimination-most often consciously and wilfully-brought into existence but which had irrational consequences. What rationality was there in a measure which in the 1950s prevented enormously talented middle class students from ever becoming doctors through a political numerus cluusus while it forced others on to this field who lacked adequate preparation and often even the desire to become doctors? (Our experience is that Western sociologists, who face problems which are exactly the reverse of this, face this phenomenon with incomprehension.) Similar changes took place at the level of the centralized division of resources. Planners decided those issues primarily on the basis of economic considerations, rather than on political desires. This change proved to have tragic consequences for the health system. The authority on which the ministries

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acted was based on a naturalistic political economy which took only direct economic utility into consideration in the division of resources. Since health care services were free because of political and sociopolitical considerations-that is, the health system provided absolutely no income, only expenses-it came to be classified as a so-called non-productive branch which was necessarily subordinated to the so-called productive branches such as industry, commerce, etc. The long-term share of the health system within the GNP ranged between 3 and 4%. figures which clearly indicate its marginality. Even among the non-profit branches, it ranked last, with education outstripping it with its share of approx. 5%. The internal contradictions of the system gave rise to the following trap: free medical care and administrative centralization, which represented the principle of equality, undermined the principle of effectiveness and the possibility of satisfying popular needs. This situation is all the more problematic since in the realm of the economy, the reforming impulse could demonstrate many successes, but it could not successfully deal with the so-called non-profit sectors. In the health system, the perpetuation of the principle of equality led to the lowering of the standard of service, while the introduction of the principle of productivity, which could have maintained or raised the standard, would have led to inequality. This contradiction remains unsolved to this day; the leaders of the health system, if only out of self-interest, took a stand in favour of central planning and against the introduction of market regulation; and they did this precisely in the name of equality. Let us examine what were the consequences of this ideological position in the realm of reality. After the successful elimination of acute illness, there emerged in the 1960s chronic diseases which resulted in an increase in medical costs. Previously neglected hospital construction also required an enormous expenditure of money, at the very time that the public allowance due the health system stagnated at a low level. As a consequence of sustained underfunding, shortages came into existence which nothing could alleviate since the nature of the administrative budget was such that no source of income existed beyond the centralized allocation. As market mechanisms for compensatory and interests-those, as we saw, were rejected for ideological reasons. The health system administration attempted to relieve the emerging shortages by trying to decrease the frequency with which the population took advantage of medical institutions. It reproached the population for unwarrantedly frequent visits to doctors and attempted to administratively curtail such visits. It claimed that the source of the crisis lay in the fact that, with free medical care, the population tended to consult doctors with every insignificant complaint, and demanded treatment immediately at the highest professional level. For this reason, it created stricter rules for consulting doctors. While previously patients were able to freely visit outpatient clinics in their residential districts, now they could do this only after they had consulted with their district physician and were issued an official permit. But it restricted the authority of the district physician as well; for example, he was no longer permitted to

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order X-rays and laboratory tests, things he had been free to do before. Health care came to be regarded not as a service. but as a gift of the state. It was free of charge-certainly-but it was the administration that decided. on professional and official grounds which were unknown and incomprehensible to the population, who was worthy of care, when he would receive it, and what kind of care he would receive. At the same time. it was impossible to criticize this service, partly because there existed a shortage situation which necessarily brought with it secondbest solutions, and partly because it was inappropriate to disparage something that was free and therefore a ‘gift’. No matter how authoritarian the perspective of the health system administration was, its effectiveness was diminished by the fact that there existed different points of view even within the regime. We can isolate at least two other interest groups: that of the decision makers, who gave low priority to the health system; and the ‘lobbies’, or representatives of those productive branches which were in a more favourable position than the health system. A strange and contradictory situation came into existence in which the central government, tight-fisted in the allocation of resources, proved to be much more tolerant towards the complaints of the population and more liberal in dealing with those complaints than the health system administration. Similar kinds of unique and complementary relationships came into being between the productive branches and the health system. Successful factories created independent industrial health care services for their workers which, not infrequently, provided a higher quality of care than the state. It represents a significant departure that the health system’s monolithic structure and perspective was undermined not only within the regime but in other areas as well. There continued to exist a dominant official position, articulated in public pronouncements and statements in the press, which systematically blurred the internal divisions within the regime. But it also became possible for the population to give public expression to its experiences and complaints. We have repeatedly referred to the importance that the role of the economy played in the outlook of the period: we derived its very name from this fact. This explains why, during this epoch cultural and political problems tended to appear in the guise of economics. Thus, we should not be surprised that the population also articulated its health-related problems in the form of an economic question, albeit posed in a different form from that of the government. It approached these problems not from the side of distribution, viewed from above, but from the side of consumption, viewed from below. The population could not accept the shortages and those administrative restrictions which were created by the health system administration. Without openly contesting the ideological use to which the regime had put the principle of equality, it exploited the absence of market considerations and the low pay of physicians in order to enforce its own interests: it resorted to the practice of tipping. This practice gave rise within the press to an endless debate about tipping and through this thematization, established the fact that

discussions of the health system invariably took an economic form. Since the system of tipping embodies in a concentrated form the most important questions of the past 20 years, it presents a particularly appropriate means through which to examine the problem of inequalities manifested in the realm of health provisions. THE SYSTEM OF TIPPING

It is enormously tempting to explain tipping as the population’s economic contribution to the health system, whereby it substituted the missing capital which the health system administration was unable to produce. There is evidently a great deal of truth to this, and in many ways it follows logically from our earlier discussion. We would like to argue, however, that the situation is considerably more complicated than this. Naturally. in one respect, the health system administration had a positive stake in tipping, since in this way it was able to satisfy the needs of the population without expending extra money or effort. On the other, it had a negative stake in tipping since there was a real danger of losing control of both patients and doctors as market regulations appeared side by side, often in opposition to, bureaucratic direction. Consequently, the leadership of the health system implicitly accepted the advantages of tipping, but at the same time it publicly staged repeated, loud-voiced attacks against it whenever tipping came into conflict with its own position. Although the leadership of the health system denied its importance on the public forum, tipping became synonymous with the inner problems of the health system. It has been estimated that during the 1980s doctors and nurses received approx. 4 billion forints in tips, at a time when the official earning of health system workers was 10 billion forints, and the ministry’s yearly budget about 30 billion forints. The problem lay not so much in the size of this amount as in the fact that it represented a new form of control which differed from the official ones. It is precisely these problems of legitimation which show the real nature of tipping and its deeper political roots. How can we explain the fact that the rapid spread of tipping began precisely in the 196Os?The probable answer is that it is precisely during this decade that medical-professional considerations gained increasing significance alongside with, often in opposition to, bureaucratic perspectives; a tendency which led to the ‘softening’ of administrative direction. While the structure of the organization remained more or less unaltered, the method of direction changed. The professional goals of health system politics no longer diverged so dramatically from the practical concerns of medical care; campaigns against popular epidemics partially made room for the cure of individual illnesses. The medical provision of villages, previously neglected for political reasons, improved somewhat; within the framework of professional programmes, new hospitals began to be built throughout the country. These changes demonstrate that the health system administration was probably able to operate more successfully the mechanisms of the nation’s health network because it acted in a more profes-

Interpreting

inequalities

in the Hungarian

sional manner than before. The increasing dominance of professional considerations and of experts brought with it an upgrading in the role and circumstances of practising physicians. A new type of relationship developed between doctors and the ruling administration which was no longer based purely on coercion and fear, as in the 1950s but on a partial integration of physicians within the power structure. The common practice of tipping, therefore, should not be interpreted as a primarily economic phenomenon-as so many people seem to do in Hungary-but rather as an integral part of the consolidation that emerged during the 1960s. According to this quiet compromise, doctors gave up their professional autonomy, accepted an alien administrative direction, and continued to be poorly paid; but in exchange for this cooperation, as compensation, they received tacit permission to accept separate compensation from patients. This compromise transcended the framework of the medical profession and began to function as a genuine social contract, for it entrusted a formerly powerless lay population with the possibility of intervention within the circumstances of its own medical treatment. True, not for free this arrangement made it possible at the same time for the health system leadership to exercise control over both the population and the physicians. That is to say, if the population ever tried to break the terms of an unfavourable contract-as it in fact attempted to do through repeated complaints against tipping in the daily press-it nevertheless faced the danger that it would lose its small, hardwon margin of control over its own health care and would once again be subordinated to impersonal, bureaucratic regulations. This was all the more contrary to the interest of the population since it could now understand the nature of the interest mechanisms operating within the health system and thus could no longer believe in the good intentions of the administration’s organizational or professional promises, which were based on a denial of such interestedness. Practising physicians, on the other hand, lived in fear that one day they might be called to account for the tolerated, but nevertheless illegal, practice of tipping. From time to time, the administration hauled one or two doctors over the coals and through such methods of intimidation-paradoxically in the form of so-called committees of medical ethics-it was able to protect this institutionalized system of corruption. All things considered, we can conclude that compared to the previous period, doctors were successful in bettering their positions-both ‘upward’ and ‘downward’-through this compromise with the power structure. On the one hand, they were better able to validate their professional concerns in their relationship with the administration; on the other, they were able to achieve professional status and economic compensation from the population. The real loser was the population. for the slight advantage which tipping secured for it could not balance the real disadvantage represented by the state’s inability to provide for it appropriate medical care free of charge. The administration permitted here a bargaining situation to come into existence where the patient was allowed to minimally bolster his extreme defencelessness through the use of the

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uncertain, individual. ultimately unpredictable instrument of tipping. Moreover, the more commonplace the practice became, the more evident it appeared that one needs to tip not so much in order to get advantages-be that nothing more than a smile from the doctor-but rather in order to avoid disadvantages-be that rough treatment or anything else. What is certain is that tipping, as money spent, represented a loss of resources for the health system institution. For tips could not help in the construction of hospitals, in the creation of new beds, in the purchase of updated instruments; in other words, could not improve those conditions of medical care which had made necessary the practice of tipping in the first place. Not only in its origins, but also in its consequences, tipping symbolized an anarchic situation which was characterized by ‘neither planning nor market’; which stressed ‘neither equality nor achievement’. The population could justifiably feel that it suffered from all the disadvantages of both forms of control, both principles, without being able to enjoy the advantages of either one: it had to pay for that which it was officially supposed to receive for free, but even when it paid, it did not get more than it would have received in any event, probably very little in either case. We cannot understand the question of tipping if we do not keep in mind that it formed part of a larger debate which concerned the so-called second economy. The population was forced to pay not only the doctor, but others as well if he was to receive in actual fact services declared to be free by the state. In the context of shortages, which were the inevitable economic consequences of systems based on centralized distribution, tipping was the embodiment of the eliminated market; it made up for its lack. Society was divided into two camps in evaluating the phenomenon. Followers of administrative centralization condemned it in all areas, while supporters of the second economy saw in it signs of society’s selfregulating abilities, even if in a distorted form. Unfortunately, the example of tipping serves to prove that the second economy was able to influence the emerging inequality between state and society only in an ambiguous way. It is beyond dispute that it created self-interestedness and additional revenue at a time when official sources had dried up. It is further indisputable that the sum required by tipping was within everyone’s means and represented a smaller amount than the market value of the services received. Unfortunately, we know the least about how the different social groups were able to validate their interests; that is, whether the indisputable increase of efficiency actually increased equality of services or not? The economic explanation thus obscures questions and has the tendency to interpret inequality as a function of the inequality of administrative regulation which the market was able to correct. It is more probable, however, that the market does not alleviate every problem created by administrative regulation either. We saw that this was the case in connection with tipping and the lack of investment in medical infrastructure. However, under certain conditions, the market itself can create new kinds of inequalities. Thus, the chances of certain

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groups can be bettered by the market but these are often precisely those groups who were able to manipulate the system of administrative regulation for their own ends. And the chances of others can be decreased by the market, often of those who were also victims of administrative regulation. Those who would like to understand the problem of equality in the health system in Hungary need to find answers to these questions. As we saw earlier, such investigations could not even begin at this point, if for no other reason than because both the government and the population perceived and conceptualized inequalities in opportunity and in the assertion of interests through purely economic categories. INEQUALITIES WITHIN THE STATE OF PUBLIC HEALTH

The general question of public health never became the object of the same kind of broad debate and public concern as tipping. This happened in part because health received serious attention neither from official and professional circles, nor from the population. There existed isolated, individual conceptions without the possibility of engaging in debate with one another or of linking up with some kind of larger social movement comparable to the connection between tipping and the second economy. The health system administration inscribed the preservation of health as a function of the state which needs to be asserted by the authorities independent of the participation of the population; what is more, even in opposition to its will. Screening for tuberculosis, school check-ups, compulsory workplace examinations can be cited as characteristic activities. This perspective does not recognize inequalities. From the 1960s representatives of the medical profession began to criticize the way of life and eating habits of the population, considering these the most serious factors endangering the general state of health. In this way, inequalities in health gained a medical explanation, they became medicalized and individualized: everyone can blame himself if he does not live in a healthy way. The medical and the administrative perspectives were closely linked here. Thus, if for some reason the health system administration was forced to bypass the official organizational explanation, then it invoked medical, lifestyle issues. Doctors, on the other hand, attempted to supplement their critiques of modes of life through administrative methods, using screening and compulsory advising as a way of identifying the most endangered among the population. I repeat, these issues did not receive publicity; they simply functioned as medical-professional and official-organizational points of view, intentionally isolated from social issues. It is characteristic, for example, that the high infant mortality and high general mortality among gypsies was described as an administrative problem. County administrators responsible for health provisions noted the shocking statistics but they examined no social factors so that the high mortality was thematized as the expression of regional and ethnic variations. We have to admit in a self-critical vein that one of the earliest sociological studies which investigated gypsies in Hungary also

excluded the problem of the state of health among gypsies, touching on the question only insofar as it represented a visible consequence of their economic situation. Unfortunately, other sociological studies concerning mobility, housing, etc., also fail to integrate health as one of the factors of social inequality. Thus, as we have already mentioned earlier, sociology has not played that generalizing and integrating function in the uncovering of inequalities in health which it played in Western countries. For us, however, the primary question at this point is why did the population pay so little heed to its own health? The answer is supplied by a rather shocking finding in a recent survey. One of the rare sociological studies in this field has shown that the population considers health only fourth among other desired values. This is surprising precisely because comparable studies elsewhere always indicate health to be the most important value. Only the elderly referred to health as a primary value in our study. This is noteworthy simply because their health was already undermined and therefore the source of tangible, daily worries. We have to assume that the majority of the population did not fully realize the dangers awaiting it. This assumption is confirmed when we examine what the ruling values consisted of. Success, economic affluence, stability. In this list health was not only ranked last but it was placed in a negative relationship to the others since the price for achieving the preferred values often meant the sacrifice of health. Not only was health not considered a value but sometimes it was even seen as a liability; for instance, in cases when illness was the only means of staying away from a badly paid and strictly supervised job. For many, sickness presented the only mode of improving their life situation, allowing for the possibility of earning added income for home construction or in other cases, simply for recovering from the exhaustion of an over-burdened work load. We can more fully understand this situation if we keep in mind that the government was unable to improve wages, could not provide adequate, free health care, education, housing, etc.; but it did not forbid people from taking on second and third jobs on top of their regular work and thus from improving their economic situation through ‘self-exploitation’. (According to surveys, 70-80% of the population has second or third jobs.) In light of all this, it now becomes evident how the material aspirations of the population and the ruling economic mode of explanation helped create a situation in which health risks became invisible and the problems of health an undiscussed issue. This situation and state of affairs can be summarized in the following way: people want to make a living; what is more, they would like to live well and very often-in the vast majority of cases-they have no choice but to do this at the risk of their own health. In this situation, neither the government nor the population was motivated to give expression to the inherent dangers to health. The predictable profits to be derived from earnings and material increase on the one hand, and the unpredictable effects of risking, perhaps permanently damaging, one’s health on the other, created a negatively defined interest. The medical warnings of physicians appeared as merely

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empty preaching. all the more so since the same physicians overworked themselves in second and third jobs in the same way as those they criticized. The connections between health issues and social factors thus continued to remain obscured. Not only working conditions, but the crisis within family life, political institutions. values, continued to take their human toll without explanation; no one wanted to recognize the connections, to take note of them. The tension had to surface somewhere, of course, and it did so in an area that was impossible to ignore or to deny. This was the high mortality rate, which during the past two decades not only did not improve. but actually worsened. And it also became evident that the mortality figures affected middle age males more than other sectors of the population. It was this problem-the growth of mortality-which blossomed into a public issue that riveted the entire population’s attention. More accurately, since the growth of mortality and the decrease of natality together caused the absolute decrease of population, the tension emerged as the problem of the decline of population. A passionate demographic debate ensued, in which the statisticians represented the economic point of view. wanting to improve the situation through a decrease of mortality; while literary men stood for a political perspective, wanting to avert population decline through an increase of natality. This division closely reflected traditional divisions within the Hungarian intelligentsia, in which writers were the defenders of national values while statisticians were spokesmen of the state. The writers gave articulation to the problem of mortality only insofar as the illustration of their immediate goals required this: they evoked visions of the death of the nation. The discussion of the unusually high percentage of suicides served the same goal: as a symbol of the disintegration of the nation’s will to live, it acquired a political-moral connotation. In contrast to this. the statisticians did not pay much attention to natality figures, emphasizing that these were comparable to the figures of other countries. As for the worsening mortality rate, they burdened the health system with responsibility and demanded better medical provisions. In comparison to the health system administration’s defensive attitude, which places the blame on the population, statistics represented a more general perspective, corresponding to that of the central government, which faulted both the population and the health system provision for the increase in mortality. However, no matter how broad the perspective. no matter how exact were the methods available to statistics, the problem remained that its categories were not supplemented by sociological categories and therefore remained attached to the existing power structure. Since it could only register what exists. it was unable to provide answers to the social causes of mortality. Literary publicists, on the other hand, though genuinely sensitive to the problem of mortality, tended to see it in terms of the national existence as a whole. which was too large a framework for analysis. At the other extreme, literary practitioners depicted the unfolding of individual fates, which

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proved to be much too concrete: such portraits could hardly be substituted for a sociological approach. The genuine connections between mortality figures and the state of health thus remained in obscurity. Attempts to understand this complex causal network independently of the characteristic risks and dangers attributable to different social and cultural groupings were bound to prove futile. The inadequacy of statistics, which only recognized groups according to sex and age, only now took its revenge; it was able to come up with only a very unsatisfactory explanation for a complex social process. We do not know the life histories of the population in question, we do not know what caused in them those damages which killed them before their time. From this perspective, appeals to conscience, without the demonstration of sociological connections, which literature and journalism commonly make, prove to be just as one-sided as statistics which registers end results without explaining the road leading up to it. Today, we still lack even an approximate picture of what social problems cause the worsening of the population’s state of health; of why adequate provisions to deal with this are lacking; and finally, of how all this leads to the shocking increase of mortality. EPILOGUE

Our thesis has been that the health system, viewed as a social sub-system, conforms to characteristically Hungarian social realities in the realms of economics and politics, as well as in value-orientation. Our task has been to expose these points of connection and to analyse inequalities within the health system in the context of this social system. The somewhat oversimplified periodization served this purpose as well. It was conspicuous that 1987 served as a historical division. What has happened since? The newly established Ministry of Social Welfare and Health, as its name indicates, interprets the connections between the health system and social problems in a broader and more flexible way than before. The predominantly medical point of view has come to an end in the health system. The new ministry does not want to isolate itself any longer from society, and within a relatively brief period it has worked out a programme for the protection of the population’s state of health. Though we cannot yet know how effective it will be, nor how serious an obstacle to change economic and social hardships will prove to be, we nevertheless have to place value on the fact that in place of silences and partial explanations, there has come into existence a responsible, institutionally innovative response to the difficulties causing social tension. We are witnessing significant changes within society as well. In the course of the 198Os, there has emerged a new middle class which is extraordinarily sensitive to questions related to the health system; which is exacting in its standards of human relations; and which is committed to the restructuring of political institutions.

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A new type of dialogue between society and the state has come into being which only represents a possibility as yet. but something new has begun. Finally. I have been unfair towards sociology, for during the past two or three years some interesting books and articles have been published which can be regarded as among the first truly serious sociological analyses of inequalities within the health system. The most important among these are listed in the bibliography. REFERENCES I.

Csaszi L. The case of Hungary. In The Health Burden Inequaliries (Edited by Illsley R. and Svensson P.-G.). WHO Regional Office for Europe, Copenhagen, 1986. qfSocial

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BIBLIOGRAPHY

Losonczi A. The Anaromy of Defencelessness within the Healfh System (A kiszolgitatottsig anatomiaja az egeszsegiigyben). Magvetii, 1986 (in Hungarian). Szalai J. The Diseases of the Healrh S.vssrem (AZ egeszsegilgy betegsegei). Kozgazdasigi Kiado, 1986 (in Hungarian). Ajkay 2. Fire Studies for rhe Reform of the Health System (t)t tanulmany az egeszsigiigy reformjiert). Medicina. 1987 (in Hungarian). Szalai J. Inequalities in access to health care in Hungary. Sot. Sri. Med. 22, 135-140, 1986 (in English). Orosz E. Critical issues in the development of Hungarian public health with special regard to spatial differences. Centre for Regional Studies of the Hungarian Academy of Sciences, Discussion Papers, No. I. Pets, 1986 (in English). Munich 1. (Ed.) Problems of Social Inlegrarion in Hungary (Tarsadalmi beilleszkedesi zavarok Magyarorszigon). Kossuth Kiado, 1988 (in Hungarian).