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BIRTH BRIBES IN BUDAPEST

CASH IS THE BEST MEDICINE | January 29th 2008

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The Hungarian health system is in a parlous state, Adam LeBor writes. Doctors are poorly paid, prices are high and bribes are often expected. Perhaps this helps to explain the country's low birth-rate ...

From ECONOMIST.COM*

It's easy to spot the gynaecologists and obstetricians' vehicles in the hospital car parks--they are usually the row of shiny new Audis, BMWs and Mercedes. Childbirth is a popular speciality among Hungarian medics, possibly because it brings the some of the greatest dividends in the bizarre system of medical tipping here, known as hálapénz. Hálapénz translates literally as "gratitude money", and it seems to have originated many decades ago. Sometimes hálapénz was not even money: poor peasants, for example, who could not afford to pay hard cash might hand over goods instead, such as freshly caught fish.

Nowadays doctors prefer hard cash to a brace of trout, especially as their salaries are a fraction of what their counterparts earn in the West. A doctor's take-home pay is about 120,000 forints ($673) a month. The low wages paid to professionals such as doctors and teachers date back to the 1950s. The ruling Communists deliberately slashed the wages of anyone considered an intellectual, partly out of spite, and also to ensure that they were too busy paying the bills to have any energy left for political dissent.

As usual, it was, and still is, left to the workers to pick up the bill, which is especially high during pregnancy. Hungarian politicians frequently complain about the country's low birth rate, at around 9.7 per 1,000 people, compared, for example, with around 14 per 1,000 in the United States.

Perhaps Hungarians might have more children if it did not cost so much. Doctors often charge around 7,000 forints for each monthly examination. Birth costs around 80,000 forints--more than the monthly minimum wage--for the doctor, and perhaps another 10,000 forints for the midwife. This even though the patients and their employers have already paid their social insurance and the medical staff are state employees, working in state hospitals.

None of this even guarantees decent attention, as evinced by the mother left alone in labour that I once saw, moaning in agony, while next door her doctor played on his computer.

Like all forms of corruption, hálapénz is a sleazy affair. Birth bribes and monies for operations are usually handed over in envelopes after the event. Many medical staff hate hálapénz, and find it humiliating, especially those dedicated doctors and nurses working in deprived inner-city areas who know their patients cannot afford to pay them extra. There are few situations more embarrassing than trying to hand over several banknotes to a doctor or nurse, and having them wave the money away.

Hálapénz is also a touchy subject. The Hungarian Chamber of Doctors says it is opposed to hálapénz, but money and power is always a heady combination. Insiders reckon that most hálapénz goes to perhaps 20% of doctors, mainly specialists.

Back in 2004 a health-care activist set up a website that detailed the bribes that gynaecologists and obstetricians in hospitals around the country expected to be paid. It listed their names, telephone numbers and assessed their medical skills. Officials soon decided that the website was illegal and it was shut down.

What everyone does agree on is that much of the Hungarian health system is in a parlous state. Several winters ago I broke my elbow and had an operation, which necessitated a stay of five days in a Budapest hospital. The actual medical care was fine. The ancillary services were not: sheets changed once, no light bulbs or paper in the toilet, nurses who smoked, "dinner" consisting of a roll and a slice of cheap processed meat.

One reason why there is no money for toilet paper is that Hungarians have one of the highest per-capita rates of doctors' visits in Europe, according to statistics compiled by the Organisation for European Co-operation and Development. The average Hungarian visits a doctor 12.6 times a year, compared to the United Kingdom at 5.1 and the United States at 3.8. Which is why the Socialist government has now taken the un-socialist step of implementing a fee of 300 forints for each visit to the doctors, causing national outrage.

But larger plans to reform the whole system, which would eventually abolish hálapénz, are running into the sand. President Laszlo Solyom has refused to sign the government's health service bill, which would allow private insurance companies into the system, arguing that it fails to guarantee universal healthcare. The bill has now gone back to parliament for minor amendments. After decades of state provision, despite all its flaws, many Hungarians, it seems, are not yet ready for a radical change. Budapest's fancy-car dealers will stay in business for a while longer.

(*Adam LeBor is a journalist based in Budapest and the author, most recently, of "City of Oranges". This column is part of his week-long diary about Budapest, published on Economist.com.)