Hálapénz, paraszolvencia (Hungary)

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Hálapénz, paraszolvencia
Location: Hungary
Hungary map.png
Author: Greta Danisova
Affiliation: School of Slavonic and East European Studies, University College London, UK

Original text: Greta Danisova, School of Slavonic and East European Studies, University College London, UK

Everyday informality in the Hungarian health system is based on the notions of hálapénz and paraszolvencia, terms referring to a common practice of informal payments. Unlike more general ‘tip’ or ‘tipping’ elsewhere in Eastern Europe, such as ''spropitné'' in Czech and bakshishi in Bulgarian (see baksheesh), the Hungarian terms hálapénz and paraszolvencia uniquely describe gratuities in the health sector. The Code of Ethics of the Hungarian Medical Chamber (2012) defines the practice, as ‘…any kind of advantage or allowance that is given to the doctor by the patient or his/her relatives subsequently, without being requested, if they do not influence the quality of the care by any means’ and adds that ‘expressing gratitude can only be voluntary’. Two features of gratuity stand out: its voluntary nature and timing. Gratuity cannot be requested and it should only be given after treatment. This distinguishes hálapénz, assumed to be given out of gratitude, from bribes or kickbacks, which aim to influence outcomes (for example fakelaki, mordida, or otkat).

The word paraszolvencia consists the prefix para meaning beside or beyond, and szolvencia from the Latin verb solvere, meaning to loosen, solve or ease something. Thus paraszolvencia refers to actions that solve (a problem or situation) outside of the formal framework. Before the Second World War, the expression was used to refer to a petty-cash fund distributed to subordinate doctors and assistants by senior doctors in private practices[1]. With the disappearance of private surgeries during the communist era, paraszolvencia came to refer to gift giving and became associated with hálapénz, literally ‘gratuity money.’ The distinction between sociability (monetary or non-monetary gratitude) and instrumental payments (made with a view of resolving certain issues) is subtle and often results in the interchangeable use of hálapénz and paraszolvencia in order to disguise that money has changed hands[2].

Advocates of public gratuity payments argue that they are part of the Hungarian culture and traditions based in tribal votive offerings and that the gratitude resulting from healing can be best expressed with gifting[3] (see also Pozornost', d'akovné, všimné). Critics trace the spread of the practice to the communist health care system ‘when the provision and financing of health care were completely nationalised’[4] and suggest that hálapénz developed to separate health care ‘tipping’ from corrupt payments for hospital beds, rooms and drugs, so that it would bear no legal consequences Ádám[5].

Hálapénz has an ambiguous legal status. The patients in question cannot be prohibited from expressing their gratitude by giving gifts to their physicians or nurses[6]. Like any tip, hálapénz is regulated by Hungarian Labour Law and sanctioned according to the Criminal Law, which states that the employees should not be given gifts by a third party (patients), unless the employer (the resident doctor) permits them. There is currently no precedent to any resident doctor prohibiting staff from accepting hálapénz. The only other example where the Criminal Law sanctions the practice of giving gratuity is when it is given before the treatment and is therefore a bribe (article 291, paragraph 1). A medical worker is liable for criminal prosecution if they request gratuity or if they privilege paying patients (i.e. by arranging better rooms, beds, care or advancement on the waiting list) over non-paying ones.

Since 1989, the Hungarian health care has been based on insurance, funded from income tax. Additional direct payments to medical staff are unnecessary but informal payments remain common. In 1998 patients paid approximately £8.3 million in hálapénz. In 2014 this amount was £23 million[7]. Hálapénz has become so widespread that certain treatments acquired set tariffs and discussing the amount of hálapénz the doctors were expecting to perform an operation has become ordinary among patients and in the media. In the beginning of the 2000s, halapenz.hu served as a common online forum for discussion of hálapénz[8]. Other websites with information about the ‘tariffs’ followed, sometimes supplemented by sophisticated calculators estimating the amount patients should pay for their treatments. Hálapénz is not distributed evenly among the doctors. The press estimates that 2,000 to 3,000 ‘medical barons’, who treat the hospitals as their private practice, take home ‘80 per cent of the hálapénz money, while others do not make anything due to their young age’[9]. The ‘medical barons’ may put a small proportion of their hálapénz to a petty-cash fund and then distribute it among nurses and paramedics, crucial to their work.

Hálapénz is inseparable from the state of the Hungarian health system. Gratuity payments both help the health system function and diminish its resources. For every 1,000 patients in Hungary there are 7.1 hospital beds available (the EU average is 5.2 and in the UK and US the number is less than 3) (ibid.). This high availability incentivises doctors to treat patients in hospital instead of in more cost-efficient out-patient clinics. The number of days patients spend in the hospital in Hungary is 5.2 days. Even patients undergoing routine surgery often stay more than a day. While in the UK and Denmark 80 per cent of patients are discharged 24 hours after a routine operation, in Hungary this rate is only 8 per cent. Since ‘the amount of hálapénz corresponds to the size of the injury and duration of recovery’ (ibid.), longer recuperation periods result in more gratuity. Hungary is among the OECD countries with lowest wages in the heath sector and faces mass migration of medical staff (OECD 2016). A shortage of approximately 5,000 nurses in Hungarian hospitals affects the quality and the speed of hospital treatments. Outdated hospital equipment raises the risk of medical malpractice suits, and poorly maintained hospital rooms risk infection[10].

It is often overlooked that hálapénz can be uncomfortable for the recipients as well. In 2015, 1001 doctors against hálapénz formed a Facebook group and published an open letter addressing the issues of low wages and poor working conditions leading to the dependence of medical institutions on the informal income from hálapénz payments. The medical staff initiative emphasised that some physicians treat gifts as deposit for successful treatment or surgery and that gratuity payments ‘have nothing to do with gratitude anymore, because everybody is paying out of worry for their security. More precisely, for the illusion of security…’[11]. Yet being under treatment is often not only stressful but also passive. Patients may feel subordinated due to their limited medical competence. Hálapénz personalises the service, empowers a patient and provides one with a ‘sense of ownership and to become active decision-makers in one’s own healing process. Deciding upon what, how and why to give makes them matter again”[12]. Patients that insist on giving ‘’hálapénz’’ even when the doctor is unwilling to accept it, use tactics such as posting the money or leaving gifts in front of the doctors’ residences.

Notes

  1. Kornai, J. 2000. ‘Hidden in an Envelope’, kornai-janos.hu, http://www.kornai-janos.hu/Kornai2000-Hidden-in-an-envelope.pdf
  2. Kincses, G. 2004. ‘A paraszolvencia kérdéséről’, Kincsesgyula.hu, http://www.kincsesgyula.hu/dokumentumok/paraszolvencia%20kereserol%20publikaciohoz%20004%2002.pdf
  3. Gaal, P. and McKee, M. 2005. ‘Fee-for-service or donation? Hungarian perspectives on informal payment for health care’, Social Science & Medicine, 60(7): 1445-1457
  4. Kornai, J. 2000. ‘Hidden in an Envelope’, kornai-janos.hu, http://www.kornai-janos.hu/Kornai2000-Hidden-in-an-envelope.pdf, pg. 4
  5. Ádám, G. 1986. ‘Az orvosi hálapénz Magyarországon’, Magvető, Series: Gyorsuló idő.
  6. Kornai, J. 2000. ‘Hidden in an Envelope’, kornai-janos.hu, http://www.kornai-janos.hu/Kornai2000-Hidden-in-an-envelope.pdf
  7. KSH. 2015. ‘Borravaló és hálapénz’, Statisztikai tükör, Budapest: KSH, 3-4, http://www.ksh.hu/docs/hun/xftp/stattukor/halapenz.pdf
  8. Burai, P. 2016. Facing and Overcoming the Limitations of Anti-Corruption Legislation (Ph.D. thesis). Budapest: Eötvös Lóránd Tudományegyetem.
  9. Lantos, G. 2016. ‘Az orvosbárókra megy el a pénz’, Index, 18 April, http://index.hu/gazdasag/penzbeszel/2016/04/18/korhaz_orvos_egeszsegugy_betegseg_lantos_gabriella_elso_resz
  10. Danó, A. 2016. ‘Döbbenetes állapotok fertőzés, orvoshiány és műhibák a magyar kórházakban’, Nol.hu, 1 February, http://nol.hu/belfold/dobbenetes-allapotok-fertozes-orvoshiany-es-rengeteg-muhiba-a-magyar-korhazakban-1599265
  11. 1001 Orvos hálapénz nélkül. 2015. ‘Nyílt level’, http://www.peticiok.com/az_1001_orvos_halapenz_nelkul_csoport_nyilt_levele_2015
  12. Burai, P. 2016. Facing and Overcoming the Limitations of Anti-Corruption Legislation (Ph.D. thesis). Budapest: Eötvös Lóránd Tudományegyetem, pg. 167

Further Reading

Ferguson, S. and Irvine, B. 2003. Background briefing: Hungary's healthcare system, Civitas, http://www.civitas.org.uk/pdf/Hungary

Gaal, P., Belli, P., McKee, M. and Szócska, M. 2006. ‘Informal Payments for Health Care: Definitions, Distinctions, and Dilemmas’, Journal of Health Politics, Policy and Law, 31(2): 251-293

Kincses, G. 2011. ‘A hálapénzről, és biztos nem utoljára’, Kincsesgyula.hu, http://www.kincsesgyula.hu/dokumentumok/A_halapenzrol_nem_utoljara.pdf

Lantos, G. and Kincses, G. 2016. ‘Így keresnek az orvosbárók évi 100 millió forintot’, Portfolio, 23 April, http://www.portfolio.hu/gazdasag/egeszseggazdasag/igy_keresnek_az_orvosbarok_evi_100_millio_forintot.230793.html