Over the past few years, officials in the Orbán government have sought to present the Hungarian healthcare system in a positive light. For example, last year Péter Takács, the former State Secretary for Health, told the pro-government news outlet Index: “Hungarian healthcare is in better condition than people assume based on public discourse or what appears in the left-liberal press. This is my conviction, and the facts support it.”

In reality, however, the government was also aware that the situation was poor. They could have known this because, ten years ago, an inspection found that the overwhelming majority of hospitals had already failed to meet the conditions required for safe patient care.

The report on the inspection was classified on the grounds that it had been prepared “to support decision-making.”Despite repeated requests over the years, the authorities refused to release it. However, following the elections, the National Centre for Public Health and Pharmacy (NCPHP) provided us with the document.

The inspection was carried out in 2015 by the predecessor of today’s NCPHP, the National Public Health and Medical Officer Service (NPHMOS).

The inspectors examined whether hospitals complied with the legislation that defines the minimum requirements for healthcare services. The regulation specifies, for each medical speciality, the basic requirements that must be met to ensure safe patient care. These include medical equipment, hospital infrastructure, and the minimum number of healthcare professionals required.

The 180-page inspection report obtained by Direkt36 revealed systemic problems in hospital care:

• There was not a single hospital in the country that fully complied with all of the minimum requirements.
• In nearly one-third of hospitals, public health and hygiene requirements were not met. Problems frequently arose regarding the quality and cleanliness of textiles used in patient care, while neglected infrastructure also posed difficulties in several hospitals. These hygiene deficiencies are among the factors responsible for the spread of hospital-acquired infections.
• Even in 2015, staff shortages were the greatest problem: in more than half of medical specialties, the number of specialist physicians and healthcare professionals did not meet the required minimum levels.
• In half of the hospitals, even the most basic resources were lacking. Essential equipment such as defibrillators, ventilators, resuscitation equipment, and even life-saving medications were missing.
• There were entire counties where certain medical specialities were completely unavailable; for example, there was not a single pediatric cardiologist.
• In some places, the intensive care on-call service operated without a specialist physician being continuously present on the ward.

According to a source who worked in healthcare administration at the time, the NPHMOS survey reached the decision-makers but was ultimately shelved. The reason was that they considered the minimum requirements established in 2003 excessively strict, and therefore did not take the report’s devastating findings seriously. For political reasons, however, the minimum requirements have never been revised, and the report remained classified. Healthcare experts, on the other hand, say that these requirements are both achievable and necessary to ensure patient safety.

The situation has only deteriorated further in recent years. Following the years of the COVID-19 pandemic, large numbers of healthcare professionals left the sector, the number of active hospital beds has continued to decline, and hospital departments have been closing one after another.

Former State Secretary for Health Péter Takács sees the situation differently. Speaking to Direkt36 about the findings of the ten-year-old inspection, the politician said: “In 2015, we had not yet managed to put Hungarian healthcare back on its feet. It was an enormous task… Of course, we were not finished.”

We sent detailed questions to the National Centre for Public Health and Pharmacy, the National Directorate General for Hospitals, which oversees Hungary’s hospitals, and the Ministry of Health, but none of them responded to Direkt36’s inquiries.

Crumbling plaster, missing or expired equipment

“There is no active inpatient care provider in Hungary today who, in all the specialties it operates, is able to ensure both compliance with public health regulations and the minimum material and personnel requirements” – reads the striking summary sentence in the document summarizing the 2015 nationwide survey. In other words, according to the investigation, not a single hospital fully complied with the legal regulation setting out the conditions for safe medical care.

The National Public Health and Medical Officer Service examined more than 1,700 departments of 100 inpatient care hospitals. The report prepared from this presented the main problems by specialty, but did not name specific hospitals.

Public health conditions – such as compliance with epidemiological rules and basic hygiene – were not fulfilled in 19 percent of the examined departments. The most frequent problem was the quality and cleanliness of healthcare textiles. This includes numerous textiles used in hospitals, from towels and bed linen to surgical drapes.

In nearly two dozen hospital departments – including maternity wards – the investigation also found that renovation would be necessary due to unclean, mouldy walls. In stroke care, life-saving medications were missing in several places.

Most often, the lack of public health conditions lies behind hospital infections. In recent years, we have dealt with the increasingly serious problem of hospital infections in a series of articles, and we also made a documentary about our investigation.

Not only hygiene was a problem, however; in many cases, material conditions were also not ensured in hospitals. This means the existence of equipment necessary for patient care.

“There is no specialty where every provider has all the material conditions defined in the regulation,” the investigation established.

The most common deficiency was the defibrillator; it was not available in 241 departments, which is 14 percent of all examined departments. This device can be life-saving, as it assists resuscitation. According to healthcare analyst Zsombor Kunetz, it is “nonsense that there are no life-saving devices in departments where they would otherwise be needed.” He added that in resuscitation, even minutes can matter, so it is not necessarily sufficient if a defibrillator is available on another department in the hospital.

By 2015, several thousand doctors and nurses were missing from the system

According to the investigation, in most hospitals neither medical staffing nor nursing staffing requirements were fulfilled. “If those conditions are not in place, it is a serious problem”– said healthcare manager Gabriella Lantos about the data.

Compared to the minimum staffing levels, 1,565 full-time specialist doctors were missing nationwide from the examined institutions, which represented a 20 percent shortage at the time. Moreover, since many doctors were already working part-time, in reality this number may have been even higher. Out of 53 specialties, only 10 had no doctor shortages; in the remaining 80 percent of specialties, staffing requirements were not met.

The most critical situation was in infant and child otolaryngology, where more than 75 percent of specialists were missing.

In several child-care specialties the shortage was very high. In pediatric cardiology, for example, in two counties there was no specialist at all, while elsewhere only one doctor covered an entire county. In obstetrics, 40 percent of the prescribed minimum staffing was missing, and in surgery approximately every third doctor was missing.

The shortage among nurses was somewhat smaller, but still nationwide 10 percent were missing compared to the minimum staffing level – which means three thousand people. Nearly one third of this was missing from emergency care, where patients arriving with sudden, severe complaints are treated. In these departments more than one thousand people were missing.

Pediatric cardiac surgery departments were available in only two hospitals, while according to the data the required staffing level was missing by 100 percent. In other words, cardiac surgical care for children was ensured through the involvement of other departments or through organizational mergers. An example mentioned in the document is the case in Szeged, where children waiting for cardiac surgery were operated on in the adult clinic due to staff shortages. They were then treated alongside adult patients for a few days before being transferred to the paediatric clinic.

Several pediatric wards also had significantly fewer nurses than required by law.

This means that the government should have been aware, at the latest from this decade-old investigation, that there was such a severe shortage of staff that it could even pose a risk to safe patient care. However, this was never communicated openly. Péter Takács, the former state secretary for healthcare, acknowledged last year that there is a shortage of nursing staff, but claimed that there is no shortage of doctors. No concrete figures have ever been published by the Orbán governments on how many professionals are missing from the system.

The consequences of the staffing shortage are felt directly by patients. According to Gabriella Lantos, the lack of doctors leads to long waiting times and surgical waiting lists, while the shortage of nursing staff can also affect patient recovery. If nurses are overburdened, there is no one to change dressings at the scheduled time, which can easily lead to infections. Zsombor Kunetz told Direkt36 that when there are not enough professionals, patients may have to be transferred to other hospitals, meaning they receive care much later.

The lack of minimum staffing requirements also affects hospital workers, not just patients. A surgeon working at a university clinic told Direkt36 that the workload has been steadily increasing, while the conditions of patient care have significantly deteriorated over the past decade. Hospital infrastructure is outdated, and in the shortage of professionals is becoming an increasingly serious problem. “This system is carried forward by those who are in it and keep working even when conditions are poor. Even when there is no air conditioning and it is hot, we keep going rather than leave patients without care,” the source added.

Regional inequalities, non-existent hospital beds

The survey showed significant regional differences in hospital care. While Budapest had more specialists than necessary in several cases, counties farther from the capital struggled with doctor and nursing shortages.

Some specialties were not available in every county. For example, inpatient orthopaedic care was not available in Nógrád and Pest counties, and geriatrics was unavailable in 11 of the 19 counties.

During the survey, not all hospital beds found matched those authorized in the license. “There are beds that are authorized but do not physically exist in the institution at all” – is written in the report. This indicates that the official number of beds did not in every case reflect real capacity, meaning that in some institutions fewer beds were actually available for treating patients.

The investigation found problems with ensuring continuous care. In some cases, on-call arrangements operated in a way that the specialist physician was not continuously present in the hospital, but was only called in when needed. In other cases, only combined on-call systems were in place, meaning that no specialist was continuously present on the ward. In hospitals in Győr-Moson-Sopron and Vas counties, intensive care units also operated in this way. These units treat patients in severe, potentially life-threatening conditions.

Difficulties in complying with the regulation

The professional minimum requirements regulation, still in force today, came into effect in 2003. The aim of the framework was originally to guarantee a consistent standard in patient care.

It was already known before the 2015 nationwide survey that many hospitals were unable to comply with the requirements set out in the regulation. For example, Judit Paller, then Chief Medical Officer, said at a professional conference in 2012 that no hospital in Hungary fully meets the minimum requirements. The Chief Medical Officer drew attention to the need to amend the regulation.

“It is not important that everyone complies with this at any cost, but that where care is provided, the patient can be safe,” she said in an interview to Medicalonline. She also added that until amendment, the validity of the regulation would not be suspended, but compliance with the conditions would not be checked for the time being, so as not to make patient care impossible.

In 2015, the newly appointed State Secretary for Health, Zoltán Ónodi-Szűcs, promised the implementation of five points in healthcare. One of these was the development of new minimum requirements. It was promised that the new regulation would be enforceable and feasible.

A source working in the healthcare administration at the time stated that the revision of the regulation had indeed begun, and new requirements were developed in several specialties, which – unlike the previous regulation – did not focus on how many beds or doctors were assigned to a ward, but on whether appropriate practice was available for the safe performance of a given activity. However, in the end implementation stalled for political reasons. “No one wanted to take on the political battle that if the numbers in the minimum requirements start decreasing, the opposition and everyone else would argue that patient safety is being endangered” – said the source familiar with the plans. According to the source, the healthcare leadership could easily have been accused of changing the rules only because hospitals were unable to meet the earlier, stricter requirements.

In 2016, when some findings from the 2015 survey began to appear in the press, the state secretary said he considered the data to be exaggerated and added that the regulations had become outdated.

According to a source familiar with health governance at the time, the findings of the survey reached the decision-makers, but no meaningful action followed, and the investigation was shelved. The source said that the concept of the minimum requirements regulation was considered flawed, as it failed to take into account many important factors for patient care. For this reason, the survey itself was also not taken seriously.

According to the source, the regulation was often referred to as a “maximum regulation,” because its requirements were considered excessive. In 2016, György Velkey, former president of the Hungarian Hospital Association, also said in an interview that the regulation was very uneven.

Péter Takács, former State Secretary for Health, also holds this position. Speaking to Direkt36 – he is currently an opposition Member of Parliament – he said that “the mistake was that the profession wrote not a minimum but an optimum regulation,” meaning that instead of collecting the basic conditions necessary for quality patient care, a “kind of wish list” was created.

In the past 20 years the rules have been amended several times, but a completely new regulation has not been created to this day. During Takács’s time as state secretary, the minimum requirements were also not changed in the past four years. “We had more important things to do,” he said.

Healthcare experts interviewed by Direkt36, however, consider the requirements realistic. Gabriella Lantos and Zsombor Kunetz both said that these requirements could be met and also represent guarantees of patient safety. They argue that the problem lies rather in the weak enforcement of these requirements, and that the Fidesz government has also eased staffing requirements for doctors and nurses in several specialties. For example, changes were made in both emergency and intensive care regarding required staffing levels.

They also said that there are hardly any inspections in place to assess how hospitals comply with the requirements. This is the task of the NCPHP, and the authority publishes an annual plan on what inspections are expected. Based on recent years’ inspection plans, however, no nationwide multi-specialty survey similar to the 2015 assessment has been carried out in inpatient care.

Takács Péter confirmed to Direkt36 that no nationwide hospital survey similar to the 2015 one was carried out during his time as state secretary, i.e. in the past four years.

Lantos Gabriella said that “if the state would enforce its own laws, those places where the conditions are not met should be closed.” This, however, did not happen; according to the expert, because “politics would not have allowed hospital closures.”

She noted that hospital closure became such a politically sensitive issue during the Fidesz governments that even with a two-thirds majority no comprehensive reform was attempted.

The problems identified in the 2015 survey have not disappeared; in fact, the situation in healthcare has continued to worsen. According to data from the Hungarian Central Statistical Office, there were several thousand unfilled positions in 2024. However, the actual shortage is likely much higher. The Hungarian Medical Chamber of Healthcare Professionals estimates that tens of thousands of professionals are missing.

Migration of medical staff accelerated after the COVID-19 pandemic, and the abolition of gratitude payments also contributed to this. As highlighted in our earlier series on hospital ward closures, staff shortages remain a serious problem in healthcare. Since 2020, one third of ward closures occurred due to a lack of doctors or nurses, or missing medical equipment. In many hospitals – especially in rural areas – the operation of entire wards depends on a single doctor. Hospitals also often close entire wards or “temporarily suspend” beds because there are not enough staff to provide care.

The recently formed Tisza government has also addressed the issue of minimum requirements. In May, the chamber of healthcare professionals presented a more than 50-page document outlining the problems in healthcare provision and proposing solutions.  According to them, staffing minimum requirements in inpatient care are not met, and “overload endangers patient safety and is also a key factor in burnout.” Zsolt Hegedűs, Minister of Health, confirmed on his Facebook page that realistic minimum requirements are needed. “Patient safety starts with having enough properly trained and respected healthcare professionals at the patient’s side” he added.

Illustration: Máté Fillér/Telex