In Hungary’s North Great Plain (Észak-Alföld), the poorest region in the country, relationships between regional authorities and health stakeholders can be considered to be good; meetings and information exchanges take place on a regular basis. Examination of the region s OP shows, however, that most health-related considerations occur in relation to direct spending on health care. Focusing too strongly on this kind of investments may result in more cross-cutting approaches aimed at recognising and optimising health gains from non-health investments being crowded out.

The objectives of Hungary's National Strategic Reference Document were translated into 15 operational programmes, out of which seven are regional programmes. The Regional Operational Programme for the North Great Plain is financed through the European Regional Development Fund (EUR 975 million).

The regional OP was developed by the North Great Plain Regional Development Agency and was approved by the North Great Plain Regional Development Council. The programme was subject to consultation within the region with stakeholders and was consulted with the line ministries. Health-stakeholders were fully involved in the preparation process, mainly with regard to direct investments in health care services and infrastructure.

Although the majority of references to health occurs in relation to direct spending on health care, health gains from non-health investments are also given consideration in the regional OP. As an example, considerable population health benefits are foreseen from the planned infrastructural developments under Priority Axis 2 Tourism Development.

It was noted during the interviews that the relationship between the regional authorities and health stakeholders is well-developed, mainly with regard to the provision of health care services. Stakeholders from the University of Debrecen’s Medical and Science Centre, which owns and operates health care services, are involved in the work of the Regional Monitoring Committee and receive information through regular newsletters.

 

 

Background information

The Észak-Alföld[1] region is located in the East of Hungary and includes three counties: Hajdu-Bihar, Jasz-Nagykun-Szolnok and Szabolcs-Szatmar-Bereg.[2] The region shares external borders with Slovakia and Ukraine on the North and Romania on the East. This provides the possibility for interregional cross-border cooperation between key cities (e.g. Debrecen and Oradea).

Figure 1 : Hungarian regions, by Cohesion Policy Status 2007-2013

Source: DG Regional Policy - Inforegio

The North Great Plain Region is Hungary’s second largest region both in term of population and are; population density is below the EU average. It also has a younger-than-average population by Hungarian standards. In 2007, the region has the country’s second lowest life expectancy rate for both men (68.4 years) and women (77.3 years);[3] these figures are below the EU 27 averages of 75.8 (men) and 82 (women).

Table 1 : North Great Plain Region at a glance

Population (inh., 2010)

1,508 million

Surface area (km2)

17,729 km2

GDP per capita in EUR (PPS, 2008)

10,000

GDP per capita as % of EU 27 (PPS, 2008)

40%

Cohesion Policy status

Convergence

Life expectancy at birth, male (2007)

68.4

Life expectancy at birth, female (2007)

77.3

 

Sources: Eurostat, Fifth Report on economic, social and territorial cohesion and North Great Plain Operational Programme

The North Great Plain region is among the poorest in the EU, with per capita GDP of 40% of the EU 27 average in 2008. The region has strong agricultural potential, as 21.7% of Hungary’s agricultural land is located in the region. However, agricultural production is facing problems such as poor production security and low number of high value-added (i.e. processed) agricultural products. The region has undergone significant development, but it still remains below the Hungarian average in terms of industrial production per capita. Lack of infrastructure hinders further development of economic potential in key sectors such as tourism. Research and development, particularly in the fields of life-sciences and innovative technologies are key areas for further development.[4]

Figure 2 : GDP per capita in PPS (EU 27 average =100)

Source: Eurostat; GDP per capita in PPS is Gross Domestic Product in purchasing power standards.

In terms of overall development, the North Great Plain Region is well below the EU average according to the EU’s version of the UN’s Human Development Index (HDI). This index includes healthy life expectancy, household income and educational attainment levels. The North Great Plain Region scored 21.2 out of 100 compared to the average value of 62 for EU regions.

 

 

Policy and institutional overview

Cohesion Policy

The North Great Plain Region is one of the six Hungarian regions receiving assistance under the Convergence objective during the current programming period. The regional –level North Great Plain Operational Programme (NGPOP) has been allocated EUR 975m from the ERDF or 3.9% of the total ERDF assistance to Hungary. Structural Funds planning in the region is based upon a regional strategic framework document, which is the region’s contribution to the National Strategic Reference Framework (NSRF).

Under the previous programming period (2000-2006), a single OP (Operational Programme for Regional Development) was prepared to cover regional development. This OP applied to all regions of Hungary, with a total budget of around EUR 600 million (ERDF and ESF funds). For the on-going programming period, the NSRF objectives have been translated into 15 OPs, out of which seven are regional programmes, seven are national-level sectoral programmes and one is a general implementation operational programme. Of the 15 operational programmes, two are co-financed by the ESF, and 13 by the ERDF and the CF.

In addition to the fund from the regional OP, the North Great Plain region also receives considerable funding, from the ERDF, ESF and  the Cohesion Fund (for transport and environment infrastructure), through the nationally-managed sectoral OPs. An overview of the relevant sectoral OPs is provided in Section 3.

Managing institutions

Ultimately, the national government is responsible for the strategic planning and monitoring of EU-funded programmes in Hungary. It does so through a number of specialised agencies established for this purpose, including a National Development Agency (NDA), which plans and implements the NSRF. A subsidiary directorate of this agency is the Managing Authority for the North Great Plain regional OP. There are two Intermediate Bodies which are responsible for the administrative, financial and technical implementation of the OP: (1) the Észak-Alföld Regional Development Agency Kht.[5] and (2) the VATI Hungarian Non-Profit Company for Regional Development and Town Planning.[6]           

Health sector

Overview of institutions

The Hungarian health care system is based on the principle of ‘national solidarity’, which means that the insured persons do not pay risk-proportionate insurance premiums, but an income-proportionate contribution to the health care system.

The institutional set-up of the Hungarian health sector follows a centralised model[7], where the State Secretariat for Health Care System within the Ministry of National Resources holds the main responsibility for the functioning of the health care system and is in charge of monitoring the health insurance system.

The National Health Insurance Fund (NHIF) controls the calculation and payment of benefits under the supervision of the Ministry of National Resources as a separate administrative organisation. Hungary’s health insurance fund is a separate budgetary line within the State Budget, approved by the Parliament usually for one calendar year. Curative-preventive care constitutes the biggest expenditure item.

Other major administrative bodies are the National Ambulance Service, the National Blood Transfusion Service and the National Public Health and Medical Officer Service. Outside the Ministry for National Resources, a National Board of Public Health (NBPH) exists is the advisory council of Government with regard to public health issues. Administration services operate in each county and are namely responsible for health protection, education for health and health promotion.

Healthcare in the North Great Plain Region: Main Figures[8]

Amount allocated from the national budget to health: €1.254 billion

969 private GPs

15 public hospitals (owned by local governments, universities), with approximately 11,000 beds

There are 112 healthcare professionals and 4.78 doctors per 10,000 inhabitants

Overview of public health policies and objectives

The National Public Health Programme 2005-2015[9], has the overall aim of improving the population’s state of health. The main focus of the programme is on alcohol and drug prevention; the promotion of active life; the reduction of the number of smokers; the promotion of healthy nutritional habits and improving food hygiene; the creation of a healthy and safe built environment; and the improvement of public health security and the protection against diseases.

With regard to the specific circumstances of the North Great Plain Region, the main characteristics are: population’s poor state of health (e.g. high number of people with disabilities, alcohol and drug problems), unsatisfactory health care (i.e. absence of prevention and protection centres, lack of rehabilitation institutions) and uneven territorial distribution of healthcare services.[10] In order to address these difficulties the region needs to curb territorial imbalances and adjust health care services to local needs.[11] Improving the institutional framework for rehabilitation and developing outpatient care are crucial to achieve these objectives.[12]

 

 

Health in the Structural Fund programmes

A review of the regional OP for North Great Plain shows that the majority of references to and consideration of health occur in relation to direct spending on health care. The development of health related infrastructure is one of the largest spending categories within the development of human infrastructure priority. According to DG Regional Policy data, Hungary has allocated 5.3% of its 2007-2013 Cohesion Policy funds to the health infrastructure category; this is the highest percentage among the EU 27. The development of health infrastructure (e.g. hospitals) is mainly supported through the national-level Social Infrastructure OP.

The North Great Plain Operation Programme and Health

The overall aim of the regional OP is to strengthen regional competitiveness and redress territorial imbalances within the region; the programme has five specific objectives and five priority axes. Specific objective no. 4 (developing human resources) pays particular attention to the amelioration of the general health condition of the population, as it contributes to the region’s competitiveness and reduces inequalities.

In order to improve health infrastructure, Priority Axis No. 4 (Development of human infrastructure) sets two objectives:

Streamlining and developing the institutions that provide health services

Providing accessibility to these institutions

Financial support is therefore envisaged for infrastructural investments facilitating the operation and accessibility of health care institutions.

There are references within a number of the priority axes of the OP aimed at non-health objectives to expected health gains or benefits for key health determinants for the region.

Priority Axis 2, tourism development foresees a number of interventions whereby health-related services can be improved. As an example, the priority supports the infrastructural development of existing thermal baths and spas, along with the development of healing and wellness centres. The OP states that these infrastructural developments not only contribute to economic development, but contribute to improving the health of the region’s population.

Priority Axis 3, improving transport conditions highlights that improving the transport conditions would contribute to the amelioration of the region’s health conditions by providing access to health services. The programme finances the improvement of secondary roads (roads marked with digit number 4 and 5), whereas the development of main roads (1, 2 and 3 digit marked roads) are financed through the Transport OP. The SWOT analysis that forms a basis for the OP investment priorities points out that a consistently high number of vehicles on the roads results in increased noise and air pollution, and increases the risks of road accidents.

Priority Axis 5, urban and regional development aims to improve inter alia the quality of the built environment, which the OP links with a healthier living environment.

Operational Programmes and Health

As noted above, Hungary has 15 OPs overall. Seven are regional, another seven are for specific sectors, and one covers general implementation of the funds. Direct investment in health is mainly contained in two of the sectoral OPs: Social Infrastructure (ERDF) and Social Renewal (ESF).

Table 2 presents an overview of the seven sectoral OPs and the investment priorities that consider health and some of the main determinants of health. A more detailed review of the regional OP for the North Great Plain is provided in Table 3.

Table 2: Overview of the Hungarian sectoral OPs

 

Operational Programme                 

Health consideration

Financed by

Economic Development OP

Priority Axis 1: R&D and innovation to encourage competitiveness

Stimulating projects to be implemented in the fields of health care out of research & development activities

ERDF

Transport OP

Horizontal objective in line with Transport Policy

Improve quality of life through safeguarding health and increasing transport safety

ERDF

Social Renewal OP

Priority Axis 6: Health preservation and human resource development in health care system

Improving health and encouraging health conscious behaviour

Development of human resources and services to support restructuring of health care

ERDF/ESF

Social Infrastructure OP

Priority Axis 2: Development of Infrastructure for the Health Care System

IT developments in the health sector and the development of regional out-patient care centres, in-patient care centres and infrastructure for specialised treatments

ERDF/ESF

Environment and Energy OP

Priority Axis 1: Healthy and clean settlements

Ensure a satisfactory quality of life, a healthy environment and better life circumstances, with a focus on waste management, wastewater treatment and drinking water supply

ERDF

State Reform OP

N/A

N/A

Electronic Administration OP

N/A

N/A

 

Table 3 below summarises the key priorities and intervention areas of the North Great Plain Operational Programme, as well as their correlation with the proposed briefing sheet topics. Whenever applicable, the table also shows how health is considered within each priority.

Tables 3: Overview of North Great Plain Operational Programme

OP for North Great Plain

MA: NDA’s Directorate General Managing Authority for North Great Plain Programmes

Total EU allocation: EUR 975m (total amount 1.1 billion with a national contribution of 15%)

Priority Axis

Funds (€m)

Percent of total

Content of priority

Briefing Sheet topic(s)

Health considerations in the priority

Regional Economic Development

164.9

14.38%

Establishment of a favourable infrastructural environment

Promotion of regional cooperation

Improvement of the availability of information for and innovation potential of economic players.

RTD

ICT

Education &Training

Institutional capacity

Employment

 

Tourism Development

208.4

18.17%

Extending the tourist season

Increasing the area of tourism destination

 

Culture & Heritage

Education &Training

Improvement of health tourism and related infrastructure, which would contribute to improving the health of the region’s population (supplementary health-care, rehabilitation).

Improving Transport conditions

199.9

17.4%

Improvement of access to regional centres to educational and service centres

Stopping the deterioration of the proportion of communal transport within the whole of public transport

Transport

Providing access to health services through road development.

Establishing bicycle lanes (road safety)

Safety and pollution reduction as key health issues

Development of Human Infrastructure

236.2

20.6%

Development of the educational and healthcare infrastructure

Improvement of the quality of public services in the settlements of the region

Education &Training

Social Infrastructure

Employment

Vulnerable groups (e.g. Roma population) with poor health conditions.

Ensuring infrastructural conditions for health care services (accessibility)

Urban and Regional Development

296.2

25.82%

Improvement of the quality of the built environment

Protection and development of the natural environment

Strengthening the social role of non-governmental, civil organisations

Urban and rural regeneration

Infrastructure: waste

Infrastructure: water

Industrial Pollution

Institutional capacity

Social Infrastructure

Creating a safe environment (e.g. renovation of houses).

Establishment of a healthy living environment.

Ensuring protection against air and noise pollution in towns.

 

Technical Assistance

41.3

3.6%

N/A

N/A

N/A

 

 

Integrating health in the programmes

The section covers the process and experience on integrating public health considerations into the planning of Structural Fund programmes in North Great Plain Region. Much of the information was gathered through structured interviews with a representative of the University of Debrecen Medical and Health Science Centre and a representative of the North Great Plain Regional Development Agency. The list of interviews conducted is included in the ‘References’ section of this case-study.

Consultation with health sector in the 2007-2013 programmes

According to Hungary’s NSRF, a wide range of stakeholders was consulted during the process of preparing the strategy and the programmes. These include ministerial staff (e.g. planning department of the ex-Ministry of Health), the Hungarian Academy of Science, regional development councils, scientific research institutions and advisory bodies. Workshops were organised for discussions in 13 fields, including a section on health (improving the health status of the population) and one on regional development (medium term objectives of balances regional development). Social stakeholders were also consulted during the preparation process.

A the regional level,  the OP was developed by the North Great Plain Regional Development Agency and approved by the North Great Plain Regional Development Council. During the preparation process, the Development Agency decided to involve stakeholders in the form of a ‘Virtual Network of Planning’. Through this network, more than 120 experts provided expertise to the Development Agency. The Virtual Network of Planning operated through 8 thematic groups. In addition to the network of experts, a Regional Working Group was set up that gave expert opinions to the Development Agency prior to its meetings. During the preparation process, the Development Agency conducted a series of public and professional debates on the NGPOP. The draft programme was consulted within the region and with the competent ministries. Health stakeholders (e.g. the University of Debrecen) were fully involved in the consultation process.

Role of the health stakeholders in the region

In line with the focus on direct investment in health care found in the programming documents, regional officials also consider the main health-related stakeholders to be those involved in the provision of health care services. In this sense, the Medical and Health Science Centre of the University of Debrecen, which owns and operates key health care services in the region, is involved in the programming, spending and monitoring of Structural Fund programmes. According to interviewees, the partnership between the regional programme managers and the university health centre is well-developed. However, it appears that there is limited cross-sectoral cooperation in other areas related to public health, beyond the provision of health care services.

Local authorities are also important Structural Funds beneficiaries, but, as pointed out by the representative of the North Great Plain Regional Development Agency, they have many investment priorities and are therefore unlikely to prioritise cross-sectoral public health programmes over other larger, more demanding investments such as those in key infrastructure. NGOs and/or civil society actors, who would be in a strong position to carry out public health initiatives, generally lack the financial strength to carry out Structural Fund programmes, according to the agency. Another possible beneficiary could be religious organisations, which are becoming more active in the field of public health.

References

Health policy and other documents

43/2003 (IV.16.) Parliamentary Decree on the Bela Johan National Programme devoted for the decade of health,Parliament, April 2003

http://www.oefi.hu/nepeuprg.pdf

Health and Structural Funds in 2007-2013: country and regional assessment (Hungary), EUREGIO III project for DG Sanco 2009

http://ec.europa.eu/health/health_structural_funds/docs/watson_report.pdf

National Cooperation Programme 2010, Hungarian Government, May 2010

http://www.kormany.hu/download/c/27/10000/a%20nemzeti%20egy%C3%BCttm%C5%B1k%C3%B6d%C3%A9s%20programja.pdf

Study of the state of health in each Hungarian region, National Institute for Strategic Health Research, 2003

http://www.eski.hu/new3/adatok/regio/Regiotanulmany_I_3.0.pdf

Structural Funds programme documents

New Hungary Development Plan, Hungarian Government, May 2007

http://www.nfu.hu/the_new_hungary_development_plan_

North Great Plain Action Plan, North Great Plain Regional Development Agency, October 2008

http://www.eszakalfold.hu/statikus.php?id=229

Strategy of the North Great Plain, North Great Plain Regional Development Council, February 2005

http://www.eszakalfold.hu/statikus.php?id=232

The North Great Plain Operational Programme, North Great Plain Regional Development Agency, 2007

http://www.nfu.hu/doc/364

Interviews

Andras Ibranyi, Project manager, North Great Plain Regional Development Agency, interviewed on 20 May 2011

Dr. Biro Klara, Strategic Director of the University of Debrecen Medical and Health Science Centre, interviewed on 23 May 2011



[1]The English name of the region “North Great Plain” is used throughout the case study except in the case of original names of institutions.

[2]There are 19 counties in Hungary. On average three counties constitute one statistical region.

[3]Resource used: North Great Plain Operational Programme

[7]Note that the institutional set-up of the health sector is highly determined by the orientation of the governing party. In general, left-wing governments are in favour of liberalizing the system, whereas right-wing governments prefer more centralised models.

[8]National Institute for Strategic Health Research : Study on the situation of health sector in the Hungarian Regions

http://www.eski.hu/new3/adatok/regio/Regiotanulmany_I_3.0.pdf(Note: the study is from 2003, thus the information provided might be outdated).

[9]Resource used: Decree of the Parliament 46/2003(IV. 16.) on the National Health Programme of Hungary (so-called Program for the decade of Bela Johan). Available at URL: http://www.oefi.hu/nepeuprg.pdf

[11]Resource used: Strategy of the North Great Plain- http://www.eszakalfold.hu/statikus.php?id=232

[12]Information gathered through a structured interview with the Strategic Directive of the University of Debrecen Medical and Health Science Centre.