Péter Takács, state secretary for healthcare, has been visiting hospitals across the country for two months to examine what condition they are in. He looks around, talks to managers and staff, and then steps in front of the camera. He does not announce measures planned by the government to improve the healthcare system, though. Instead, he asks everywhere what developments have been delayed, because, due to government corruption and the dismantling of democratic institutions, Hungary, for several years now, has not received some of the European Union funds it would be entitled to. Sometimes he shows a broken elevator, other times the topic is the failure to renovate an ambulance station or purchase equipment.

Takács always names those he believes are responsible: Brussels and the Tisza Party, whose “sneaky deal” to block EU funds “causes damage to Hungarian hospitals, doctors, professionals, and patients.” According to him, the Tisza Party is hindering preparations for future epidemics and “causing problems” for Hungarian nurses.

Although Takács blames Péter Magyar’s party, which came on the scene a year and a half ago, for the conditions prevailing in hospitals, the problems in healthcare did not begin recently.

The depopulation and ageing of certain areas of the country, the emigration of doctors and nurses, and the underfunding of hospitals are among the reasons why many hospital wards are forced to close temporarily or permanently. This is increasingly becoming a problem not only in small hospitals but also in large institutions, as we demonstrated with data in the first part of our series of articles. Our data was based on an analysis of a database in which we collected official documents on the closure of hospital wards.

Many healthcare experts – including, according to certain statements, state secretary Péter Takács himself – agree that the entire hospital system needs to be reformed. This would probably inevitably involve the downsizing, restructuring or even complete closure of certain institutions. But “hospital closure” has become such a politically dirty word in recent decades that even with a two-thirds majority, Fidesz has not attempted comprehensive reform for more than ten years.

While the government is currently trying to avoid the topic of healthcare and the sector does not even have its own ministry – it falls under the jurisdiction of Interior Minister Sándor Pintér –, Prime Minister Viktor Orbán is very much aware of the problems in healthcare, according to a source familiar with him who spoke to Direkt36. According to our source Orbán believes that in its current form, the system is more of a money pit, so it is not worth investing any more in it.

Orbán owes his two-thirds majority, which he has held for fifteen years, in large part to his successful efforts to make healthcare issues a political topic by rejecting hospital closures and holding a referendum on doctor’s appointment fees. At the time, he stated that saving healthcare is a “national cause.”

Orbán’s first state secretary for healthcare, Miklós Szócska, began work in 2010 with grand plans for healthcare reform and enjoyed the prime minister’s support for a long time. However, in the process of restructuring hospitals, he offended so many political interests that he was replaced after four years. In retrospect, healthcare professionals view his efforts as the moment when the government finally attempted to reform the system. Since then, Fidesz has not risked similar comprehensive changes and has only taken measures in line with short-term political interests.

We approached the health secretaries of the Fidesz governments, the Ministry of the Interior responsible for healthcare, and Viktor Orbán with detailed questions, but none of them responded to our inquiries.

The healthcare system is deteriorating due to neglect

In previous parts of our series on hospital closures, we have shown how healthcare is spontaneously being dismantled in many parts of the country. Many hospital departments are on the verge of becoming inoperable with the loss of a single doctor, and it is not only small-town hospitals that are affected. Larger, centralised institutions are often facing shortages of specialists too. In many specialities, retired doctors and ageing nurses are taking over patient care, and their eventual loss makes it impossible for the department to survive.

This is becoming more and more openly acknowledged by hospitals, which partly explains why, according to several of our sources in healthcare, decisions to close departments are increasingly appearing on the website of the National Centre for Public Health and Pharmacy (NCPHP). In such cases, the hospitals themselves notify the Centre that they are unable to operate a ward, and request that another hospital be designated to take their place. Before the Covid pandemic, this was less common because, according to a source with insight into health management, hospitals tried to arrange the reorganisation of patient care among themselves. However, some hospitals are now more brave admitting if and when they cannot function.

According to Eurostat data, the shortage of specialists is not a Hungarian phenomenon: it is a problem in all EU countries. But Hungary is in a particularly bad position, with almost one in five doctors aged 65 or over in 2022. This is the second-worst rate in the EU. Emigration has accelerated since the Covid pandemic, and the abolition of gratuity payments has also accelerated it.

Some hospitals are losing not only specialists but also patients, as some parts of the country are gradually ageing and losing population. Most experts agree that it makes sense to maintain inpatient wards in hospitals that perform at least 700 procedures a year, or two a day.

For example, according to health economist Dr László Csaba Dózsa, the dilemma for obstetricians is that if every hospital in a small town has an obstetric ward, it is not certain that there will be specialists (e.g. neonatologist paediatrician, PIC background – proper neonatal care) to help in case of complications, because most places have only one doctor and one assistant. If there are fewer maternity units in the country, but they have the right conditions, he believes that it will also be much better for mothers, because it will significantly improve the safety of care.

On top of this, financial problems are putting a considerable burden on health institutions. By the end of last year, hospitals had accumulated debts totalling 104 billion HUF. According to EU figures, Hungary spent only 6.7% of GDP on healthcare three years ago, putting it among the worst performers. Moreover, while in other countries the share of public spending on health has typically increased in recent years, the opposite is true in Hungary.

Department closures are also partly due to financial reasons. A department that is temporarily closed only loses part of its funding if it is closed for at least 30 days. If the closure is shorter than that, the hospital will continue to receive the operating costs, but the designated institution will not receive any extra money. In other words, in many cases, institutions are better off by temporarily closing an unsustainable department.

These are some of the factors behind the increasing number of hospital ward closures.

Health experts interviewed by Direkt36 agreed that there is an urgent need for structural change, as the current system is unsustainable.

According to experts — for example, Tamás Svéd, Secretary General of the Hungarian Medical Chamber — the problem is that closures are currently happening reactively, based on emerging resource shortages, and not guided by planned strategies. This situation is unfavorable both for patients and healthcare workers. Patients have legitimate complaints about the difficulty of figuring out which hospital they should go to at any given time. Moreover, they often have to travel 50-60 kilometers or more to receive care. Healthcare workers face the reality that their departments are being shut down, or that the remaining doctors have to work significantly over their capacity, heavily overloaded, to maintain continuous care despite the shortage of specialists. Paramedics also need extra energy and resources when patients must be transported to unfamiliar locations instead of the usual ones.

“It is a daily occurrence that hospitals are playing ping-pong with patients,” said Tibor Lengyel, President of the Hungarian Association of Paramedics. Another paramedic from a rural area, who wished to remain anonymous, told Direkt36 that the burden on paramedics is increasingly heavy. “The workload is unbearably high,” they said.

“The country is running out of residents” explained Tamás Svéd, referring to the fact that it is not necessarily needed to have a hospital near every village if the county’s large hospital and ambulance services work well. “If we were to reorganize care, some departments would definitely need to be closed, but this would happen only after a thorough assessment of exactly what and where to close,” he added. Healthcare analyst Zsombor Kunetz also spoke about this. “The situation could only be fixed in an organized way, but currently chaos is the organizer,” he said to Direkt36, referring to the fact that the departments that are currently closing are not those with too few patients, but those with too few doctors.

Experts interviewed by Direkt36 also agreed that county hospitals, university teaching hospitals, and national institutes should be the peak of care, where patients come from entire regions. In such a structure, small-town hospitals could focus on outpatient care, specialist care, and emergency or on-call services.

Short-term vote-winning rather than professional considerations

Such major transformations would require serious government resources and attention, but healthcare has long been a stepchild of the current administration. “Don’t do anything, just don’t let anything bad happen” a source who has witnessed discussions on the situation in the field, which Viktor Orbán has attended, told Direkt36. According to him, the prime minister was open and informed about the problems of Hungarian healthcare but did not have any substantive reaction to the expert material he received.

Orbán was sceptical about whether it was worth putting more money into the sector, to avoid “stealing or wasting” resources.

This is reflected in the attitude of the current government. According to the source, healthcare reform is a politically dangerous area because it could be a recipe for failure. He added that Fidesz has been communicating simplistic messages about healthcare for decades: “Closing hospitals is bad, the visit fee is bad,” he said, adding that he believes Fidesz has fallen into the trap of this communication, which makes it difficult to get complex reforms through the leadership and to the public.

The approach of the Fidesz party to healthcare has not always been passive. Their success in 2010 was largely based on the referendum against PM Ferenc Gyurcsány’s introduction of healthcare fees. Patients had to pay a so-called visit fee when they used specialist care, and if they neede inpatient care, they had to pay a daily hospital fee.

The then Socialist government expected this to reduce illegal gratuity payments and unnecessary doctor visits, and the funds collected could have been used to develop healthcare institutions.

Fidesz strongly criticised the measures and called for a referendum to repeal them. “So what do the visit fee and the daily hospital fee mean after all? It means, my dear friends, that we pay twice for the same thing!” – Viktor Orbán said at an event in February 2008.

The referendum was a success, with voters overwhelmingly opting to abolish the healthcare fees. Fidesz came to power two years later. By then, the party had concrete plans: its election manifesto included, for example, increases in the number and salaries of doctors and nurses, but rejected the idea of efficiency-oriented reorganisation and the previous reduction in the number of hospital beds. “Even in the medium term, hospital closures do not represent real savings. It is not true that there are too many hospitals and too many hospital beds in Hungary,” the election manifesto reads.

“We must put the healthcare system on an infusion. If you open the newspapers, every day some serious health leader will speak out and say that the Hungarian health care system has weeks to go if something is not done,” Viktor Orbán told TV2 a week after his two-thirds victory in 2010.

“Saving the health sector, for example, is a national issue for us,” Orbán said.

Healthcare in the grip of politics

After the grand plans, however, it turned out that the measures needed were at odds with the goals of political communication.

In the Orbán government of 2010, the Ministry of Health was abolished and merged into the Ministry of National Resources, with Miklós Szócska as the new state secretary for health. He wanted to deal with the oversized and randomly organised system. He also considered the downsizing and rationalisation important because the long-term effects of the human resources crisis in the health sector were already visible: doctors and specialists were gradually leaving or retiring.

Szócska came from outside politics; he specialised in the organisation of healthcare. He combined the implementation of hospital reform with a series of tours of the country, meeting hospital executives and middle managers, local politicians, and citizens at public events to discuss the best way to organise healthcare for local people. He visited small and large hospitals with his team. Their starting point was that in a country of this size, it does not make sense to have more than a hundred hospitals, often only 10-20 kilometres apart. According to a source with insight into the events, there was a maternity ward where three people were lying in bed when Szócska and his team visited, one of them male.

As there were several wards where the average number of cases per day was below the minimum level, these were considered a waste of resources and problematic from a patient safety point of view. Indeed, it is a risk for patients if hospital staff do not routinely carry out interventions daily, because they are more likely to have difficulty in treating complications. They wanted to adapt the system to local needs, with more important and complex care being organised in central hospitals and simpler day-to-day care tasks in smaller institutions.

During Szócska’s time as state secretary, the number of Hungarian hospitals was reduced to less than 100. Eleven hospitals were merged into larger institutions and active inpatient care was abolished in 14 places.

“These were very tough confrontations,” a source familiar with the restructuring process told Direkt36. The main problem was that local politicians often did not want to accept at first that hospitals in their cities should be restructured – because that would have cost them votes. It was necessary to make local politicians understand that “there is no closure, but a change of function and development” and to explain to them that “there is and will be no more money and no more specialists”, said a source with insight into the events. It was also argued locally that if, say, a 24-hour outpatient department were to replace the inpatient wards in the hospital, residents would feel that their access to everyday care improved.

Szócska also warned that rationalising the system is an ongoing health policy task, and that if action is not taken then, it could come back as an even more serious issue later.

“There were a few politicians who did not understand the importance of the policy, and wanted to take the easy way out to maximise votes,” the source recalled, adding that it was often not only local politicians who were “clueless”, but even those higher up in government.

Szócska’s activities enjoyed the prime minister’s support for a while, according to a source with insight into the period, but he was replaced after the 2014 elections. “It is a big problem that this whole capacity craze has fallen into the trap of politics,” said a source familiar with the period.

After the reform era

Subsequent health secretaries of state have not attempted to fundamentally reform the system, but have sought to bring about change through small-scale measures.

In 2014, Fidesz asked Gábor Zombor, the then-mayor of Kecskemét and former chairman of the parliament’s People’s Welfare Committee, to become state secretary for health. Zombor focused more on reducing the debt of the institutions and raising the wages of the health workers. After one year, the state secretary resigned for personal reasons. He was succeeded by Dr Zoltán Ónodi-Szűcs, who chose the approach of “not closing institutions, but finding the right function for them”. He promised to implement a five-point program, including a review of the minimum staffing and equipment requirements for hospital care, the development of primary care, and the creation of a hospital chancellery system.

In 2018, Anikó Nagy, then director general of Heim Pál Children’s Hospital, became the state secretary for health but resigned from her post later that year. She was succeeded by Ildikó Horváth, then medical director of the National Korányi TB and Pulmonology Institute. It was during her time that the Covid pandemic hit the country. The state secretary was not involved in the management of the pandemic: she was not part of the Coronavirus Operational Task Force and, despite the crisis in the health sector, she made few public appearances.

Press conference of Sándor Pintér, Viktor Orbán and Miklós Kásler on the crown virus in March 2020. Orbán’s Facebook page

Gradually, Sándor Pintér, minister of the interior, took over, and the fight against the epidemic took on an increasingly law-enforcement character. “In a crisis like this (…), it was necessary to choose the actor, the organisation around which to build the defence, which would be the driving force. I chose the Ministry of the Interior and the police,” Viktor Orbán explained in a video released earlier this year to mark the fifth anniversary of the virus’ emergence.

The video describes the fight against the coronavirus as a success, but in reality, the pandemic hit Hungary’s – and many other countries’ – health systems unprepared. Initially, protective equipment and disinfectants were scarce, and hospital workers often struggled to fight the virus, lacking adequate protection. The government was also quick to make decisions, sometimes on quarantine measures, sometimes on equipment purchases. More than 16,000 ventilators were stockpiled, most of which were never used. Even those that were used were sometimes a problem for hospitals, as we reported in our December 2021 article.

The decisions were primarily politically motivated. The government did its utmost to ensure that as little information as possible got out of the tightly controlled hospitals. The press was not allowed into health institutions, and staff were forbidden to comment on hospital conditions. Several experts also pointed to shortcomings in the reporting of pandemic data. As a result, little was known about what was happening in hospitals, despite the serious situation in several institutions, such as the hospital in Tata.

Sándor Pintér came to the health sector together with Covid

After the end of the outbreak in 2022, following another election victory for Fidesz leading to a parliamentary supermajority, the Ministry of Human Resources was abolished, and the minister of the interior took over the health sector. In his parliamentary debut, Sándor Pintér himself admitted that he was not familiar with the field. On his appointment as minister, he told the welfare committee that he wanted proper preparation and order in the implementation of decisions, but also said that “we have statistical problems”, i.e. lack information such as the exact number of doctors working in Hungary.

The ministry, under the leadership of Pintér, has embarked on a series of administrative reforms affecting the health sector, with the creation of the National Hospital Directorate General (NHDG), to which almost all management and financial tasks have been transferred. The government established a new employment status for healthcare workers, cracked down on the already illegal but widespread practice of patient-to-doctor gratuity payments, and launched a multi-stage pay rise for doctors. In addition, the functions of municipal and county hospitals were re-regulated, with care organised around central hospitals. According to Balázs Rékassy, a health economist, the latter effort echoes the Semmelweis Plan’s ideas of regional centre reform, but the new leadership has not started closing hospitals. Another problem is the lack of a transparent health strategy, he says, and the plans of the Interior Ministry are not public. “No hospital director, no head of department knows where the ship is going”, and this undermines the confidence of health workers.

For the last three, the healthcare portfolio was handled by state secretary Péter Takács, a former hospital director who has held senior positions in the ministry. Takács has a different character from his predecessors: he is a bold politician and does not shy away from public political debates. He has clashed openly with the Hungarian Medical Chamber on several occasions, and more recently he has been attacking the Tisza Party led by Péter Magyar in videos and social media posts.

Péter Takács visits the lift of the Hetényi Géza Hospital in Szolnok in April this year. Source: Facebook page of Péter Takács

Like his predecessors, Takács avoids the term hospital closure.

“The question is whether modern medicine thinks that there is a need for an inpatient ward that is just about to disappear in a city hospital… And while the average citizen has a problem that requires hospitalisation once every 12 months, we are used to having a hospital with a surgical inpatient ward ‘on every corner’,” he told Népszava two years ago.

As state secretary, Takács initially took a similar path to that of Miklós Szócska.

He promised, for example, to visit every county to work with local people to find out what a safer, more sustainable care system for patients could look like. It is also clear from his statements that he has no easy task. “All these attempts at structural change are always down to local politics, but we are putting a lot of energy into this now,” he said in 2023.

But Takács’s announced plans are overshadowed by the fact that Viktor Orbán has already made it quite clear in 2021 what he thinks about the transformation of the health service. That’s when a health document leaked out that could have been politically uncomfortable. The NHDG draft did indeed call for major changes in inpatient care. For example, it would have abolished active inpatient care in seven hospitals, made daytime deliveries in small-town hospitals compulsory, and required maternity patients to go to larger county hospitals on call. The prime minister personally denied that these plans would be implemented.

“No reform, that’s my motto. There will be no health overhaul or reform. There is no need for restructuring.” – he said.

In the first part of our series, we presented the daily struggles of hospitals based on more than a thousand official documents. In the second part, based on personal stories and testimonies from healthcare workers, we examined how healthcare services are deteriorating in small hospitals across the Southern Great Plain, from Orosháza to Szentes.

Editor of the series: Zsuzsanna Wirth.