Pussy Politics I: Gratuity, or the regulation of the trade in good will

“The Carpathian basin will belong to those who can fill it with their offspring,” once said Nicolae Ceausescu [Secretary General of the Romanian Communist Party between 1965-1989], the previous “Genius of the Carpathians.” More recently, Szilárd Németh [an MP from the ruling party Fidesz] made a similar statement, adding that he is willing to do anything for 300,000 new children to be born by 2030. I have previously written for Kettős Mérce about why this attitude is indefensible nonsense, and what should be done instead to increase fertility rates. Next to the scarcity of kindergarten places, lack of proper state financial aid for families, and income inequality, the state of Hungarian obstetric care is of equal significance: the highly hierarchical character of obstetrics is a strong deterrent for mothers to have children. As we will see, this is often not only the fault of the doctors.

Girls, what are you paying for?

Gratuity is the alpha and omega of Hungarian obstetrics, its basic principle of power: a system within the system. Despite its innocent name, we don’t give it out of gratefulness. Patients have a very reasonable motivation to pay: the universally acknowledged poor conditions of Hungarian obstetric care. These can be measured quantitatively, and the statistics are tragic.

Hungary has one of the highest rates of C-sections among OECD states: compared to the 5-15% recommended by the WHO, in 2014 we had 35,7%, which is more than double the recommended number – and the rate has been rising ever since.

The rate of episiotomies is equally bad. This procedure is normally done to avoid perineal rupture – which, in fact, is most commonly caused by the lithotomic, horizontally lying position. This position is difficult to defend, as in most cases it makes labour harder, increases pain, disturbs circulation, and puts more pressure on all of the organs involved in birth, most of all the perineum, which separates the vagina from the rectum. The WHO considers a rate of up to 10% acceptable – in Hungary however, the latest available figures show it applies to 61,96% of all births, and more than 80% among first births.

Internet fora on childrearing have developed a whole separate genre of delivery horror stories.

Even more important than the statistics, are the multitude of bitter experiences felt by a whole generation of parents. Internet fora on childrearing have developed a whole separate genre of delivery horror stories, which leave the readers in no doubt that if you don’t prepare for your birth very carefully, you will be treated badly.

Women know this. Young adults have already learned how many tens or hundreds of thousands of forints [10 thousand HUF is around €30] they should pay for a birth, and that for prenatal care they should go to a private doctor.

Gratuity payments are such an integral part of the system, that many hospitals and clinics sell small envelopes in their cafes.

At the core of gratuity is the patients’ complete defencelessness. It’s a grey zone, where the paying party has no rights, cannot hold the doctor accountable for their promises and promises are often left unsaid: by handing over the envelope we offer ourselves into the graces of the authority. The exchange is unbalanced, because the patient’s only option is to pay or not. That is, if they even have the option, since many can’t afford it to begin with. The provider – in this case, the doctor who maintains exclusive control and full authority – on the other hand, can decide for themselves what services they will offer in return.

Entire departments of doctors and nurses are emigrating abroad.

The hierarchical system of such ‘envelope-medicine’ is well illustrated by the vastly different sums other doctors connected to the delivery receive, regardless of their expertise and involvement. According to current legislation, if asked for or prescribed, gratuity is illegal – but if offered voluntarily, although taxable, it is legal. This differentiation, however, is problematic and even unrealistic, considering the months-long waiting lists, borrowed doctors [doctors from other hospitals or clinics who are hired by the parents to conduct the delivery in another hospital], and that entire departments of doctors and nurses are emigrating abroad. Not to mention that the practice is deeply culturally embedded.

How Many Doctors are Missing from the Hungarian Health Care System?

Compulsory social insurance as we know it now first emerged in 1891, but its legal harmonisation only occurred 40 years later. In 1950, insurance companies were nationalised, and healthcare became a civil right in 1952 – however, since the state had no funds to maintain it, upon party decree, it became a “tipped profession.” Since 1989, the medical profession can’t keep up with other prestigious professions and although many promises to raise wages have been made, few have been realised – and the hierarchical order is restored.

Although it is customary to justify gratuity due to the severe lack of funds in Hungarian healthcare, the actual paid sums are in relation to the employees’ means or to their involvement with the patient – quite the opposite. Employees with a lower income, such as the midwives, surgical assistants, physiotherapists, nurses, and doctors in training, get little to nothing from the envelope.

Naturally, even less is said about the patients’ financial means, as if we were talking about a folk tradition based on benevolence and kindness. In this argument, gratuity is referred to as some sort of voluntary contribution for a charity campaign to alleviate the problems of the healthcare system.

Instead of paying gratuity to low earning doctors, we could be campaigning for progressive taxes.

Following this line of thought, however, it would make more sense to collect money in a transparent manner, and for the workers to be paid from the funds collectively and proportionally. The money should be taxed and accounted for. Instead of paying gratuity to low earning doctors, we could be campaigning for progressive taxes – especially because the ability to pay is closely linked to one’s social status: the more money a patient has, the more gratuity they will pay to higher earning doctors in better equipped hospitals for better treatment. The same or even a smaller amount of money could be collected and systematically redistributed if taxation was progressive and if the more wealthy contributed more proportionally to fund a more stable healthcare system.

Peacock dance: the ritual of choosing a doctor

The practice itself is not illegal, even though its legal justification is very hypocritical, since nobody takes taxes seriously. It is a classic grey area: in a highly publicised case in 2015, the Curia [the name of the Supreme Court since 2012] reinforced the gratuity system. In several instances, employees of the Military Hospital in Budapest instructed mothers in labour to give money to all medical personnel involved in the delivery and sometimes declared the sum to be paid upfront. The rather harsh first degree sentence was considerably softened at the second degree, and finally the Supreme Court decided that accepting gratuity was not an undue advantage, and explained that it was a widespread custom, and thus it could not be sanctioned.

Choosing and hiring a doctor is a subtle and complex ritual, which has to be executed precisely in order to avoid the resistance or even wrath of medical personnel. The peacock dance begins with going to a private doctor for prenatal care. This happens either with a direct referral from the gynaecologist, or because the patient had already been going there before; and it is also common for women to find doctors based on friends’ recommendations. If you try to find a doctor after half-time (i.e. the 20th week of pregnancy), things can get complicated, as the doctors with good reputations are already busy, and if they aren’t, they can take offence at being contacted so late, as for them, this amounts to a considerable financial loss.

According to popular maths, the doctor receives ten times the fee of an individual appointment for the delivery.

According to popular maths, the doctor receives ten times the fee of an individual prenatal appointment for the delivery. In exchange, they don’t have to promise anything, or if they accidentally do, nobody can hold them accountable. The expectation is that the chosen doctor will be present at the client’s delivery, as requested by the client, because they don’t trust public obstetric care. Since the agreements are vague and unaccountable – not actually legal, but so widespread that everyone considers them to be – it is completely unpredictable what treatment the patient will receive, regardless of any attempts to ensure it and their efforts to purchase good will. Whether the doctor will be present or not, whether they will rush the labour because their shift is over or because they want to get it over with, or how other personnel working at the hospital will treat the patient, is a matter of sheer luck.

In several hospitals it is also customary to hire a midwife – my chosen doctor, for example, claimed they will not do it otherwise. In this case, the midwife also receives an envelope.

The practice of choosing your own doctor, however, is bad for both the doctor and the midwife: the expectation to be available and to leave their desks and beds even after finishing their shift in the middle of the night if they have a birth to attend is especially demanding considering the average salaries in healthcare. To keep this practice up, merely on basic salaries, is not only emotionally and logistically unsustainable, but also physically and psychologically highly taxing. The main reason for this state of affairs is the permanent and severe under capacity of medical institutions, which keeps the employees under constant strain and pressure, robs them of numerous possibilities, and crams midwifes’ schedules, all of which is detrimental to the quality of obstetric care and to the relationships between all involved.

Hospital cleaners in a failing health care system

At the same time, it is worth considering why there are no coordinated political responses to this practice, which works against everyone’s interests. Gratuity is normalised and maintained by customers. Beyond the tradition, paying bribes to public servants instead of working on a systematic solution cannot be justified in economic or ethical terms, nor from the point of view of public health – an issue which, in fact, concerns all citizens.

Class traitor

By refusing to deprive them of their ability to advocate for their interests, Geréb gave women agency.

Refusing gratuity was one of Ágnes Geréb’s original sins even during her clinical practice, which created very strong competition with other obstetricians [Geréb is a prominent proponent of extra-institutional deliveries in Hungary. Due to complications at an unplanned home birth, she was arrested in 2011, when these were still illegal. She is disbarred from practicing to this day]. The mere thought that practicing medicine was possible without accepting gratuity shook the structure to the core. Furthermore, by refusing to deprive them of their ability to advocate for their interests, Geréb gave women agency – even though this is a fundamental principle of contemporary medicine based on modern science, even more so during Geréb’s active years than now. Her entire practice foreshadowed a paradigm shift in obstetric care, whereby the regime created to control obedient bodies and to guard their fertility, should transform into a philanthropic endeavour. This meant a radical attack on the hierarchical practice of medicine. Furthermore, Geréb also paid attention to class differences and created the possibility of allowing the poor to also have good births.

Home deliveries have become to be considered a whim of the wealthy. This is not at all surprising, as the stigma was present throughout the women’s movement. Contrary to popular belief, however, Geréb’s team worked for very little money. At the time of her arrest in 2010, they only took on home deliveries when the customer completed a week-long intensive childbirth training scheme. The price for the training was a voluntary payment of between 0–50 thousand forints [around €160], emphasising that the customer pays as much as they seem fit. In other words, some participants paid nothing or only a couple thousand forints, thereby declaring their wish to give birth with Geréb. The participants received a receipt of this payment, and could decide whether they want to support Geréb’s foundation with a voluntary additional amount, either anonymously or not. According to Geréb, some of her former clients regularly support her team to this day.

Geréb’s practice meant a huge market advantage compared to the “chosen doctors” working in private practice and for gratuity, but all the while the team’s wages, tools and insurance was not covered by social security. With way less money they practiced significantly more woman-friendly obstetric care.
Not that the money was enough. According to Geréb, they never earned enough to have proper contracts with their team members. They tried in vain to supplement their budget with grants or through the work of volunteers. It is likely that it was precisely their lack of funds which isolated them, drawing the criticism of many experts and activists of extra-institutional delivery.

Class differences set in law

There had been several attempts to regulate extra-institutional obstetric care, but the Hungarian Medical Chamber was rather intractable on the issue, and some say even Geréb herself was stubborn. According to a representative of the Chamber, it was in fact Geréb’s PR which obstructed the process, and called her a “martyrly persona.”

Although even the European Court of Human Rights had reprimanded Hungary for the lack of regulation, the regulating process stagnated for 20 years before Geréb’s arrest in 2010 – which, being an encouragement for the proponents of conventional obstetrics, gave the process another kick.

With great efforts, the new law came into effect in 2011, even though Geréb’s supporters’ critique of the preliminary draft pointed out the very high standards of technological requirements and insurance, into which the majority of independent midwifes do not have sufficient capital to invest; while exempting them from social security coverage. In other words, extra-institutional births were allowed, but without state insurance, and with high production costs.

Now only those who can afford it are able to give birth at home. Thus the order has been restored: the legalisation of extra-institutional deliveries reinstituted them as the whim for the wealthy that their opponents had always considered them to be, by only allowing affluent women to indulge in it. For everyone else, there are the rigid hospital deliveries, and thus the upholding of the gratuity system.

 

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Translation by Anna Azarova.

This text was created as part of the Network 4 Debate project, supported by the International Visegrad Fund.