Travel Medicine in Hungary
Peter Felkai, M.D., S.Sc
The health care system during the socialist period
With the downfall of the Socialist regime in 1989, Hungary transformed itself from an "unknown far away land" into a popular tourist destination. Simultaneously, a new medical specialty, travel medicine, emerged to help improve the management of medical care of tourists visiting Hungary and to care for Hungarians travelling abroad.
But even under the socialist system, Hungary was a rather well organised country, often dubbed the "happiest barrack in the socialist camp". The medical system functioned well. The health care system was state-run. Teaching at the medical schools followed the German tradition, a strict hierarchy in both training and research. Everyday health care was organized according to the Soviet model: no private care (except for a few dentists). The system was divided into two parts. Primary care was provided by general practitioners; they were called district doctors because they cared for people within a geographical area. People within the district had to see that doctor. No choice. Specialty care was given in specialists' offices and in hospitals. Then as now there was only one social security insurance company, run by the state.
Under socialism, the fields of infectious diseases and tropical medicine were well developed, in part because under the socialist brotherhood many Hungarian doctors worked in less developed countries in Africa and in the Middle East. Vaccination programs in Hungary were mandatory, and were (and remain) more inclusive than in some other European countries.
With the fall of the "Iron Curtain" in 1989 and the restoration of democracy, the information gap in medicine between East and West disappeared. But new "curtains" have arisen, making the management of health care of travellers difficult. The Hungarian health care system has developed much more slowly than the rest of the economy. And the health care system is different from that in other countries, with dissimilar therapeutic protocols and insufficient diagnostic facilities. Language barriers remain. Repatriating ill travellers is difficult, in large part due to complicated regulations regarding payments. Standards of medical facilities are uneven, with ill-defined separation of private and public healthcare facilities. Treating foreign patients is a lucrative business. Many healthcare providers are eager to engage in it, with or without a licence. Foreign insurance companies experience difficulties finding reliable medical providers in Hungary.
Also, while the present government has improved the quality of medical care, the "hotel" function of public hospitals in Hungary remains poor. Entrepreneurs have recognised the huge demand for better conditions and faster access to treatment. They have set up various types of private services, focusing on improving hospital accommodation and the quality of nursing, the more profitable aspects of medical care, without providing appropriate professional services.
In 2004, Hungary joined the EU, bringing many benefits to Hungary. But as the Eastern boundary of the EU, Hungary saw the arrival of an ever-larger number of migrants and refuges. This has created many problems for the Hungarian health care infrastructure. While Hungary's traditional medical care system can hardly provide adequate medical care to local inhabitants, the system has had to care for the migrants and refuges. And certainly it was not prepared for caring for the many travellers who started visiting the country.
The "birth" of a new speciality
Prior to 1989, Hungarians were permitted to travel to the West once every three years. In 1978 travel insurance was launched by the state. This insurance required travellers to pay bills abroad in foreign currency and then be reimbursed in Hungarian currency back home. In the late 1980s, this kind of insurance was replaced by new private insurance companies. These companies provided new forms of travel insurance, including more traveller friendly "assistance" policies. With the change in the political regime in 1989, travel restrictions disappeared.
In 2004, inexpensive airfares and last minute travel bargains began to appear. Suddenly Hungarian tourists - including entire families and elderly people - had a wide range of travel choices. Extreme sports became popular and adventure travel came into vogue. Seemingly the EU healthcare card (called the E-111 formula at the time) covered medical expenses abroad. But these cards had shortcomings for travellers, not covering the fees of certain private physicians and did not cover the costs of repatriations. The Hungarian Association of Assurance (Insurance) Physicians found the cards to be inadequate and determined that the ideal solution would be travel insurance offered by private companies. But the Assurance Physicians realised (1) that the private insurance companies had no experience with travellers and (2) that most Hungarian travellers were poorly informed about the medical aspects of travel. The physicians therefore decided to establish a forum that could solve the problems - the beginnings of travel medicine. The entity of Hungarian Travel Medicine was introduced in Lisbon, at the 10th Congress of the International Travel Medicine Society.
The Hungarian way of travel medicine
Travel medicine as an entity was unknown in Hungary before 1990. And as a new medical science with a unique infrastructure, it had to fit into the existing structure of the local health care system. Therefore travel medicine in Hungary is organized differently than elsewhere; it had to be organized from the ground up. Although physicians were well informed about some travel-related issues - traveller's diarrhoea and deep vein thrombosis, for example - there was no forum for exchanging information. On the other hand, contagious disease prevention was already well established by the state run healthcare network.
From the onset travel medicine was considered an independent interdisciplinary specialty among the medical sciences, a part of assurance medicine.
Travel medicine is a multidisciplinary speciality with four main topics:
Fig.1 The segments of travel medicine and its medical backgrounds
A. Prevention. Reducing the incidence of infectious diseases (by vaccinations, routine examinations, and monitoring refugees and immigrants), and providing travel advice. These issues become important when Hungary joined the EU and became the EU's eastern border.
B. Assistance medicine. In Hungary travel medicine plays an important role in assistance medicine: treating and organizing the repatriation of foreign travellers in Hungary and Hungarian travellers abroad. Insurance companies often ask doctors for fitness-to-fly certificates. But due to the doctor's inexperience in this area, many doctors are not competent to make good judgements from the repatriation point of view.
C. Wilderness medicine. Hungary is a small country, with no coastline or high mountains. Adventure travellers and extreme sports fans must travel abroad, even for skiing. Yet the country has 40,000 licensed SCUBA divers, and more than 200,000 skiers. This presents a challenge for Hungarian doctors who must educate such travellers of the hazards of such activities.
D. Insurance policy medicine. Just as clinical medicine is necessary to help define and evaluate life insurance issues, travel medicine is essential for assistance insurance. New, EU-conforming travel insurance policies are more flexible and more customer-friendly. Moreover, these new forms encourage travel. This helps the travel industry. For example, appropriate statistical risk assessment shows that new and safer management of extreme sports makes them less dangerous and risky than believed; bungee-jumping is in fact less risky than skiing. Thus, some extreme sports previously specifically excluded in many policies can be covered by specially formulated insurance policies.
Development of travel medicine in Hungary
The travel medicine and travel insurance section of the Hungarian Society of Life Assurance Medicine was founded in 2005. (The first president is the author of this article.) But already a year earlier, in 2004, the first lecture in travel medicine was given, at a postgraduate course at the Medical University of Szeged. And the lectures were repeated in 2005 and 2006. The first textbook of travel medicine was issued in 2006.
In Hungary, the main aims of travel medicine are:
1. Establishing an appropriate infrastructure to both serve the public and to maintain a scientific centre for the continuing education of travel medicine practitioners. Presently, vaccination of travellers occurs in vaccination centres, which are mostly state run, and belong to the National Health Authority. These centres are not travel medicine offices, because they only vaccinate. They give no advice, an important segment of travel medicine. And although general practitioner offices play an important role in the giving of travel advice, their offices are overcrowded with social insurance patients. Moreover, the present financial structure makes it difficult for GPs to give regular pre-travel advice to patients. What is needed is a well functioning, nationwide network of travel medicine offices.
2. To instruct doctors in the basic principles of travel medicine and related topics. Obviously, our first target audience is physicians involved in tourism, assurance doctors, and private doctors who maintain offices exclusively for foreigners. Also, GPs and occupational medicine physicians should know basic principles of travel medicine.
3. To better prepare Hungarian travellers. Many are poorly informed regarding basic travel medicine concepts - the interaction of long flights with certain chronic diseases and pregnancy, for example. As travel is the most popular holiday activity for families and retirees, the mortality of these travellers has risen. We must emphasise the necessity of pre-travel advice, the importance of vaccination, and the avoidance of dangers. Unfortunately, even in well-developed countries many travellers neglect vaccinations, but in Hungary the situation is generally worse than elsewhere.
4. To help Hungarian insurance companies establish and clarify professional and financial protocols for travel medicine occurrences. Presently, there are no clear protocols for cost-effective treatment and repatriation of patients. Such protocols would avoid conflicts over costs of treatments between the company and the patient. After joining the EU, Hungary became a gateway to Eastern European and surrounding non-EU countries. Hungary with its advantageous geographical position appears to be an excellent stopover for any medical evacuation from Eastern Europe and countries beyond.
Obviously, travel medicine, as a newly founded medical speciality in Hungary, needs help in building a scientific base and an infrastructure. Help from abroad is essential to achieve these aims. With such help Hungarian Travel Medicine will fulfil its mission within the EU.
Dr. Felkai is medical director and chairman of the travel medicine section of MEBOT, the Hungarian Society of Life Assurance Medicine.
