Free for all? : processes of change in health care provision in Hungary from 1987-2002
Recent reforms in Hungarian health care delivery officially began when the Reform Secretariat was established in 1987. Broadly speaking, the reform process aims to restructure the hospital-centred curative system into one based on primary preventative health care with greater importance placed on individual responsibility. The reform process aims to "change" the centralised socialist ideology of health care delivery to a more pluralist model with various players becoming accountable and leading to the "retreat" of the government as the central supplier. In order to understand the "changing" health care delivery system in Hungary the roles of different actors (state, local government, international organisations, health care workers and voluntary civil organisations) and their complex interactions in health care provision and reform need to be taken into consideration. This thesis develops an understanding of health care provision change in the framework of academic discourse of welfare states, governance and civil society. In so doing, this thesis shows that implementing health care reforms formulated at the national level into local care sites is by no means a straightforward translation. Indeed, health care reforms can be undermined and obstructed or shaped and influence by a variety of health care actors beyond the state. For example, this thesis reveals how notions of change are contested at the local level and how prevailing political cultures and informal social practices of for example, parasolvencia can undermine and obstruct reforms. In addition, reforms strategies can also be influenced and shaped by actors beyond the state in the form of alternative processes of change. Alternative processes of change in the context of this research mean the innovative role of voluntary civil health organisations, which are addressing legacy gaps in care, left by the former socialist system. Thus, this research is set in the context of the complex roles and interactions of different health care actors located in a variety of health care sites in Hungary. This exploration considers not only the "changing" formal health care system but also alternative mechanisms of change such as the role of civil health organisations and the power they have to influence the reform process.