*Éva Gellèrnè Lukács1, Laura Gyeney2, Gábor Kovács3, Sándor Illès4
Third-country nationals in the Hungarian public health care sector
1Postgraduate Institute, Faculty of Law, Eötvös Loránd Tudományegyetem University, Budapest
Head of Faculty: prof. Miklós Király
2Faculty of Law, Pázmány Pèter University, Budapest
Head of Faculty: prof. András Zs.Varga
3István Szèchenyi University, Győr
Head of Faculty: prof. Judit Fazekas Lèvaynè
4Director, Active Society Foundation, Director, Budapest
Health care effects of international migration are the emerging themes within mobility studies. Unfortunately, there is scarce information on health situation of international migrants in Hungary. This paper tries to fill in this gap partly. The research deals with the access of third-country nationals to the Hungarian public health care system and the practices in reality. The authors carried out field works with the holistic approach in National Ambulance Service and Semmelweis University due to approximately half of the medical treatment for third-country nationals occur in Central Region. The volumes and rates of Ukrainian, Serbian, American, Russian and Chinese nationals are the dominant groups both institutions. Most third country citizens appear at the Obstetric Clinic because of childbirth. The second most demanded health care provider is the Central Laboratory. The third largest number of cases measure in the Transplant Clinic as a consequence of ageing process. According to the interviews, we suppose that the high standard of services make these clinics attractive to third country citizens. Lastly, we identify the main factors affecting the provider and supplier side of public health care system in Hungary.
The research, on the findings of which this article is based on, aimed at examining the access of third-country nationals to the Hungarian public health care system1. The zero hypothesis of the research emphasised that access of third-country nationals to the Hungarian health care system goes along the same lines (procedures) with Hungarian insured persons, albeit certain cultural, linguistic and administrative differences (difficulties) might occur. The research tried to reveal data, trends and specific characteristics which would support or tinge the hypothesis.
Various data types and methods were used during the research. Firstly, field work was carried out with multiple methods, according to the requirements of the holistic approach. With the help of in-depth interviews valuable quantitative and qualitative information was obtained from publicly financed service providers. Secondly, in order to provide for a basis of comparison, quantitative data from larger administrative sources was also collected and also the legal rules in force were analysed. The basic macro data of the project erected, on the one hand, from the National Ambulance Service (NAS). Hence NAS is the sole Hungarian publicly financed emergency health care service provider, data handed over by the NAS shall be looked at as representative. On the other hand, data was provided by the Semmelweis University Budapest (SE), Hungary’s oldest medical school and one of its largest health care provider that runs 27 clinics.
The general characteristics of the data were as follows: full scope and register-based. Firstly, it meant that the inevitable distortions of data types did not burden the validity of information. Secondly, time series could have been created in order to discover short and medium term trends related to demographic and labour market situation, legal status of third-country nationals. Hence dual citizens tend to resort to health care benefits on the basis of their Hungarian nationality (e.g. Serbia, Croatia, The Ukraine, USA) data reflect the actual citizenship without Hungarian nationality.
Review of literature
The selective structure of migrant subpopulation is mostly valid for the health conditions of mobile people in modern era. The health status of migrants with the decision of free will is better than that of the inhabitants of the receiving or sending areas in general (1, 2). The interrelation between health and migration is a multifaceted part of scientific exploration. There has been growing interest on these relations in Hungary since the change of the political regime. The topic of health conditions of foreign immigrants were underexplored (3). The health status of Hungarian emigrants was completely out of the scope of research and public debates. In contrast, international migration of health professionals has been in the highlight of migration studies and media coverage due to the continuous emigration of Hungarian health personnel (4-7). In fact, Hungary’s accession to the European Union and the Schengen Area created a completely new international migration situation both for third-country nationals and for the destination countries (8-10). In the context of defending national interest more and more information became necessitated for Hungarian authorities and other bodies, including on the volume of third-country nationals’ access to the health care system, in order to judge the potential effects. There is scarce information on the health situation of international migrants in Hungary. This paper tries to partly fill in this gap by giving some facts and figures on the participation of third-country nationals in the Hungarian public health care system.
Both statistical data collected during the research and the interviews showed that if third-country nationals decide to obtain health care services in one of the publicly funded health care providers in Hungary, they are likely to acquire it in the Central Region. In the capitol Budapest and in the county surrounding Budapest (Pest county) approximately half of all medical treatments of third-country nationals occurred. SE and its institutions provide 80% of the public health care services for non-Hungarian and non-EU nationals in Budapest. In this geographical region data from 19 clinics, 3 hospitals and 2 health centres were processed thoroughly.
Looking at the regional service suppliers, almost exclusively universities’ clinic centres provide in kind health care services, e.g. Szeged University that is situated very close to the Hungarian-Serbian border. Third-country nationals rarely attend other hospitals, and these in-patient cases mostly fall within the sphere of emergency care. The contribution of regional out--patient clinics is also minimal in this field. For example third-country national patients are not recorded to receive treatment in the Western counties (counties Győr--Moson-Sopron, Fejèr and Baranya). Data on in-patient and out-patient care from the countryside derived from the database of the National Health Insurance Fund and 3 county-level centres. Moreover, data provided by the 18 county-level branches of the NAS have been analysed. Interviews revealed that – in addition to linguistic problems- in these institutions there is a lack of actual knowledge on the legal background of providing health care benefits for non-Hungarians, especially as regards the method of accounting. This applies equally to the acceptance of travel insurance and health care cards used by non-Hungarian citizens.
National Ambulance Service
Pursuant to Act CLIV of 1997 on Health non-Hungarian nationals staying or residing in Hungary shall be given immediate medical care if their medical status threatens their live, physical or mental integrity. The intervention shall be provided on the basis of the same criteria as for Hungarian nationals, including ambulance services. Ambulance service – due to its character – is unplanned care, consequently, the analysis of the statistical data of the sole Hungarian public provider, NAS, gives real information on the volume of unplanned medical cases of third-country nationals in Hungary. The reliability of the data is ensured by the fact that this service is provided by a state-funded organisation and all ambulance services belong to this organisation. Ambulance service as a task is base-financed, so data is not distorted by the anomalies in the reporting of financing scores. NAS has 230 stations in the 7 regions of Hungary and employs more than 7000 ambulance officers. It provides national emergency healthcare services which cover the whole territory of the country. It gives services for approximately 1 million patients yearly.
Data of the NAS give a comprehensive and complete overview on the characteristics of persons in need of ambulance services. The following four elements are presented here: the total number of cases in which third-country national patients were involved, spatial aspect (share of patients per regions), distribution per nationality and the types of healthcare needed by migrants in the years of 2011 and 2012.
Table 1 shows the total number of cases in which third-country national patients were involved in the years of 2011 and 2012 by months.
Table 1. Total number of cases of NAS in 2011 and 2012 by month (except October to December 2012 which data was not available during the research) (1: 175).
The rate of third-country nationals is low in the NAS’s service, it amounts to 100-200 cases per month, out of the appr. 1 million cases per year. The number of cases increases in the summer and in the beginning of autumn. It is likely to be attributed to tourism because in these seasons a lot of third country nationals visit Hungary, primarily the shores of Lake Balaton (11). This sequence is well observable in both of the examined years.
Table 2 contains the spatial aspect of data in the years of 2011 and 2012.
Table 2. Spatial aspect (regional split up) of cases of NAS in 2011 and 2012 (16: 177).
|Northern Great Plain||22.15%||18.75%|
|Southern Great Plain||11.43%||12.12%|
The overwhelming majority of third-country nationals (almost half of all cases) were treated in Central Hungary: in the capitol Budapest and in its surrounding county Pest. The proportion of the Regions of Northern Great Plain and Southern Great Plain is also significant – the share of the remaining four regions amounts altogether to appr. 20 percent.
Table 3 presents the share of third-country national patients based on their nationality.
Table 3. Share of third-country national patients in 2011-2012 by nationality (16: 178).
|Ex-Yugoslavia (Serbia, Montenegro)||9.37%|
|United States of America||8.52%|
|Ex-Yugoslavia (Serbia, Montenegro)||7.54%|
|United States of America||6.80%|
There is no relevant difference between the most numerous nationalities in the examined two years. The share of Ukrainian, Serbian, Russian, American and Chinese nationals is the highest. The significant percentages of other citizens echo the large heterogeneity of internationally mobile people arriving in Hungary with different status (12).
It is to be noted that the split up by nationality and by region of the NAS data shows strong correlation with the administrative data gained from the National Health Insurance Fund (NHIF) on the total numbers of third-country national patients in Hungary. The data of the NHIF from 2006-2010 (tab. 4) stresses that the aggregate share of the most considerable nationalities is outstandingly high, and these nationals came from seven countries, namely Ukraine, China, Vietnam, former Yugoslavia, Serbia, Russia and Mongolia. Also, the geographical concentration is essential, almost the entire third-country population was treated in Budapest and in five counties (Szabocs-Szatmár-Bereg, Pest, Csongrád, Bács-Kiskun and Hajdú Bihar). Besides Budapest having the leading role, these counties are remarkably characterised by having a well-known university clinic or large hospital in their territory.
Table 4. Aggregate data on third-country nationals medical care in Hungary between 2006-2010 (16: 26).
|Type of treatment||Number of care recipients||Proportion of the seven most considerable nationalities of care recipients (%)||Proportion of the care recipients treated in the six most considerable counties (%)||Proportion of Budapest (%)|
|Acute care||11 776||82||94||61|
|Dental care||18 123||86||86||55|
|Out-patient care||72 306||79||85||57|
It is to be traced that the appearance of third-country national patients echoes some of the former socialist countries of the past century. It is suggested that the research, parallel to describing current trends, also faced the heritage of the past, almost 50 years long history.
The Semmelweis University (SE) as a central provider
Based on the countrywide statistical findings as regards nationality and geographical split up of third-country patients (as described above), our research foresaw an in-depth assessment of the situation in the largest health care institution of Budapest, in the SE. This seemed reasonable hence SE covers six percent of the entire population’s health care needs, which translates to around 2.3 million cases per year, with its 27 clinics and more than 8000 employees. The SE submitted its full-scale statistical data from the year of 2011 regarding patients from third countries. The statistical data respond many relevant questions, it shows the different nationalities of patients in the public health care system, as well as lists those clinics where these services were obtained. Table 5 gives a general overview on the absolute number of cases, attributed to the clinics providing professional health care.
Table 5. Absolute number of third-country national patients in the clinics of the SE in 2011 (16: 219).
|Clinic||Number of cases|
|Internal Medicine Clinic||432|
|Vascular Surgery Clinic||25|
Pursuant to the data from 2011 appr. 7500 patients were third-country nationals out of the total number of patients, appr. 2.3 million. This amounts to an appr. 0.32%. Most third country nationals appeared at the Obstetric Clinic. Although the large number of obstetric cases reflects the number of childbirth (birth in hospital as a general example) it may also suggest the demand for in vitro fertilization. However, there is no separate data available in this topic. The second most demanded health care provider is the Central Laboratory. The number of cases indicates that diagnostic and laboratory tests are essential, as there is no proper medical care without laboratory diagnostics. The third largest number of cases is attributed to the Transplant Clinic as a probable consequence of the ageing process. The percentages of cases attributable to clinics on the basis of table 5 result in 19% of the cases for the Obstetric Clinic, 18% for the Central Laboratory and 10% for the Transplant Clinic. It is even more visible that almost one fifth of the cases are related to obstetric cases. According to the interviews, the high standard of services makes these clinics attractive to third-country nationals.
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