Discussion Papers 1988.
Spatial Organization and Regional Development 180-206. p.
180
Eva OROSZ
REGIONAL STRUCTURE AND MAJOR SPATIAL PROCESSES
OF PUBLIC HEALTH CARE IN HUNGARY
The first part of the paper deals with the
regional structure of public health care in Hungary
in comparison to the prevailing tendencies of re-
gional structure of health care in the developed
countries and to basic principles and theoretical
models of regionalization of health systems. The
second part of the paper analyzes major processes
underlying regional inequalities in public health
care, giving priority to the mismatch existing be-
tween the state of health and the supply of health
services; as well as to contradictions between
meeting new social needs and the formation of re-
gional differences.
Introduction
Since the early 1960s, a new discipline cal-
led the 'geography of health care systems' has been
developing intensively in addition to the tradi-
tional branch of medical geography, the 'geography
of diseases' /Mayer 1982; Howe - Phillips 1983;
Pyle 1976, 1979, 1983/. This new branch of medical
geography aims primarily at investigating the re-
gional distribution of health manpower, facilities,
and financial resources; socio-spatial features and
inequalities of accessibility to health care; and
at exploring contradictions between the spatial
processes of health systems and the needs of the
population.

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
1 8 1
My research belongs to this new branch of
medical geography /Orosz
1985/. In my paper, I
shall first describe the spatial structure of pub-
lic health care in Hungary, emphasizing the defi-
nite contradiction that exists in the separation
of the regional structure of public health func-
tions from the regional structure of planning and
financing of public health care. In the second
part of the paper, I shall discuss the most im-
portant spatial processes of public health care
in Hungary that occurred between 1960 and 1985.
My approach differs from that of health policy
and of more traditional statistical investigations
that have dealt with regional differences.
1. Regional Structure of Public Health
Regional systems - efforts made to achieve
a comomise between concentration and
accessibility
During the last two or three decades, rapid
development of health technology had huge impacts
on the operation, professional, and regional struc-
ture of the health care system. Health technology
used by hospitals is becoming more and more comlex
and expensive,which has led to a concentration in
hospital care. Some of this new technology is worth
placing only in central hospitals having vast
catchment areas /partly because of the relatively
small number of patients requiring special cure/.
On the other hand, an important concept of the
philosophy of health care systems is the acces-
sibility of public health care to everyone. In
meeting the contradictory requirements of effici-
ency and accessibility, the regionalization of
health care systems has evolved as a compromise

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
182
/Roemer, 1977, 1979/.
In a broader sence, by regionalization is
meant a comprehensive management-organizational-
operational strategy encompassing the entire
health system, which includes primary health care.
In both the narrow and practical sense, regionali-
zation in most countries exists only within the
system of hospitals. Consequently, further on I
shall discuss regionalization in the narrow sense.
Inam ideal model, the institutions /hospi-
tals of various functions/ in a health /hospital/
region provide 1 or 2 million inhabitants. Within
a region, the hierarchy of hospitals is of three
interdependent levels:
a/ regional hospitals treating special
diseases of low frequency and requiring highly ex-
pensive technology and high-level professional
knowledge; regional hospitals are expected to fulfil
the task of education and research as well /in a
theoretical model these hospitals have 500-1,000
hospital beds/;
b/ county /province/ hospitals concentrating
medical professions of medium level /in a theore-
tical model these hospitals have 100-300 hospital
beds/;
c/ local, general hospitals of 50-100 hospi-
tal beds with relatively small catchment areas
/10,000-50,000 inhabitants/; they are expected to
cure the most general and frequent aliments.
The catchment area of a regional hospital is com-
prised of catchment areas of several county hospi-
tals, and, similarly, the catchment area of a
county hospital covers that of several local level
hospitals. Among hospitals on these three levels,

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
183
appropriately organized linkages should function
in the interests of patients to get proper health
care.
To sum up, by regionalization is meant a
strategy of organization and functioning of a
health system /primarily of hospital care/ in-
volving a larger hierarchy and coordination of
health services within an extended region. The
strategy of regionalization involves double-direc-
tion flows of patients between the periphery /local
level hospitals/ and regional centre, as well as
diffusion of professional knowledge from the centre
towards the periphery. Certain indications of the
regionalization principles mentioned above can be
noticed in the present hospital structure of all
developed countries. Deviations, however, are at
least as important, being expressed partly in hos-
pital structure and in the connections among hospi-
tals assuring more or less 'flows' of patients;
moreover in financing mechanisms and infrastruc-
tural facilities that strongly influence these
peculiarities.
Centralized and incomplete spatial structure
of the hospital network in Hungary
The reasons for establishing a regional
structure of hospital care and the basic principles
of the system are similar to the model described
earlier. The administrative organization and finan-
cing of public health are two factors influencing
practical execution; the unfavourable situation of
these elements, however, has a rather restricting,
deforming effect on the implementation of objectives
of the regional system.

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
184
Before detailed description, first let's examine
the main characteristics of the spatial structure
of hospitals.
In Hungary, health regions were established
in 1980, delegating tasks to  4  medical universities
and  3  county hospitals thereby allowing the delimi-
tation of catchment areas /Ajkai
et al. 1981/.
There are manifold differences among regions as
regards number of population and size of territory
/Fig. 1/.
For example, the territory of the Szeged-
centered region in the Southern Great Plain is
higher by 3.8 times and its population number is
larger by 2.5 times than the Gy6r-centered region
in Northern Transdanubia. These differences are
the consequences of circumscribing regions--which
represent professional-hospitalization regions--
along county borders even though medical considera-
tions would have required totally different re-
gionalization /e.g., in case of accessibility to
emergency care/.
Another characteristic feature of hospital
structure is centralization, manifest in the pre-
dominance of large hospitals with the deformation
of low level hospital structure. Of all the hospi-
tals, 45 percent /including maternity homes with
20-30 beds/ have more than 500 hospital beds; 23
percent have as many as 800 beds, and only 17 per-
cent have fewerthan 200 beds. As regards  general
hospitals, the average capacity at the regional
level amounts to 1,690 beds, in county hospitals
1,095 beds, while in local hospitals 407 beds in
1984. Evidently, the capacity of hospitals of both
medium and local level is much higher than pre-
dicted by the theoretical model. Nevertheless, it
exceeds by several times the size of general hos-

▪
Orosz, Éva: Regional structure and major spatial
•
processes of  ▪
public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
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Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
186
pitals of developed countries. For example, in the
early 1980s, in Belgium the average hospital bed
number in general hospitalsx was 187; in Finland:
136; in the Netherlands: 225; in Denmark: 289;
while in Hungary: 562. Table 1 illustrates in de-
tail the differences among hospital structures in
Hungary and Finland, highlighting the low level
hospital structure in Hungary.
In Finland, local level small hospitals
play a very important role in health care, especial-
ly for the aged. Not only are they situated near to
the residence and family of old patients, they are
rather efficient hospitals because the supply of
patients requiring simple health care costs much
less than the maintenance of expensive hospital
beds for acute diseases.
Deformation /lack/ of low level hospital
structure in Hungary shows significant regional
differences /Fig. 2/.
In Northern Transdanubia,
besides large hospitals a relatively dense network
of medium-sized and small hospitals has been estab-
lished. For example, on the territory of 9,600 kne
of Komarom, Gyor-Sopron, and Vas Counties, 14 set-
tlements have hospitals. An absolutely diverse
hospital structure is characteristic of the Great
Plain, where small hospitals are extremely rare.
Despite the territory of 11,800 kne of Bekes and
Hajdu-Bihar Counties, there are only 5 settlements
that have hospitals. In such a way, the extent of
Besides general hospitals, there are special hos-
pitals as well, e.g., mental hospitals and T. B.
sanatoriums. These hospitals and mental beds of
general hospitals were not considered in calcula-
tions to allow comparison.

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
1 88
the catchment areas of a number of hospitals in
the Great Plain is larger by 2-3 times both in
size and in population number than that of minor
hospitals in Transdanubia.
These differences, following largely from
inadequate transport and communication facilities,
influence significantly accessibility to primary
health care. These differences have deep historical
roots, reflecting the characteristics of regional
distribution of public hospitals in pre-war Hungary.
Indeed, between the two world wars even larger set-
tlements could not establish hospitals as a con-
sequence of their undeveloped economy and the back-
ward approach of municipalities. Since peasants
were excluded from health insurance, there was a
lower level of demand than in the other, more in-
dustrialized regions. Besides the public hospital
network, private hospitals also functioned to
'compensate' somewhat for these regional differen-
ces /for the rich only/ as private hospitals have
functioned in a significantly greater number in
the Great Plain than in Transdanubia. This part
of the hospital structure was abolished after World
War
Low level autonomy of health care administra-
tion
In most countries, regional management of
public health is closely connected to regional
organization of state administration. This de-
pendence, however, exhibits great variety. The
point is that there should exist a relative separa-
tion /autonomy/ of health care administration:
1. in connection to public administrative

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
1 89
bodies;
2. in planning-financing mechanisms;
3. in the relationship of board of councils
that represent residents.
At present, health administration is strong-
ly subject to council administration; the separa-
tion and local social control can be realized to
such a minor extent that it is almost impossible
for public health to make plans for coordinated
development of a region considering both compre-
hensive professional aspects and the connections
between settlements. The subordination of public
health administration is well-featured in the dis-
integration between regional systems of health
planning and financing and regional systems of pub-
lic health functioning. The regional units of the
latter are formed by the catchment areas of town
hospitals /i.e., a given town plus rural settlements
designated on a hospital referral order/. These
catchment areas do not appear in health planning-
financing or informational-statistical systems of
public health as regional units. Health administra-
tion, and consequently planning and financing,
follow the council hierarchy, which in turn is
linked to the regional distribution of state admin-
istration.
The separation of these two regional systems
can be better illustrated through examples. Plans
and expenditure of public health in rural settle-
ments are coordinated and supervised by the council
of a designated centre in state administration. It
frequently happens /e.g., in a lack of a hospital
in a town/ that the professional management of
primary health care in a village is performed by

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
1 9 0
the hospital of another town. Evidently, neither
the town hospital nor the town council can under-
take the task of becoming 'host' in public health
care of a catchment area. Another contradiction
is that general practitioners in villages are em-
ployed by local councils, while at the same time
they are professionally supervised by a chief
medical officer of a hospital respectively. A
town hospital is expected to provide patients of
the catchment area, too; but in reality it is just
the 'hospital of the town' because rural settlements
do not contribute to the maintenance and development
of town hospitals; nor are their interests repre-
sented in decision making for town hospitals.
Data from County Statistical Yearbooks prove
explicitly the consequences of disregarding actual
regional units because when determining the index
of 'hospital beds per 10,000 inhabitants', the
number of hospital beds is divided by population
number of the town only. If we calculate the en-
tire population of a catchment area of a hospital
/including the inhabitants of villages/, the in-
dices and sequences for health care would be en-
tirely different. As an example: in Kalocsa /1980/
the number of hospital beds per 10,000 inhabitants
amounted to 206; while is Kiskunhalas: 234 /Data
of Statistical Yearbooks of Counties/. If making
calculations by the real catchment area, the num-
bers would be 88 in Kalocsa and 56 in Kiskunhalas.
The realization of the purpose of regionali-
zation is limited by financing, which appears in
two ways. On the one hand, in the distribution
mechanisms of regional development resources, pub-
lic health does not have the separation required

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
191
either on the county or local level, which is a
consequence of the above mentioned administration
dependence. This partly explains why public health
is unable to represent the interests of either the
whole public health or of particular fields, like
primary health care, hospital care, and prevention.
On the other hand, scarcity of financial means
necessitates that in many cases diseases are cured
on the regional level instead of the county /medium/
level and, similarly, county level provides tasks
that could be solved in local hospitals. It would
naturally require appropriate health technology in
the local hospitals, too.
Self—government of health administration
could possibly be realized by establishing an organi—
zation system of independent local /and county/
health offices that would belong to councils of
settlements /and county councils/ only while having
coordinated relations with council administration.
2. Major processes of regional inequalities in
public health care
The main components of multidimensional re—
gional inequalities of public health are as follows:
1. Regional differences in the state of
health, rate of mortality of the population;
2. Regional inequalities of health facility
supply /supply of doctors, hospitals, etc./;
3. Regional differences of utilization of,
and accessibility to, health care.

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
192
State of health and health supply
Traditionally, health planning and statis-
tical analyzes examine regional differences in the
supply of doctors and hospitals by comparing data
of the individual counties with the national
average. This approach seems less and less suitable
to reveal basic tensions in regional differences.
A cardinal aspect of evaluating the regional distri-
bution of doctors, hospitals, and health services
should be the regional structure of needs. The state
of health of the population is not yet widely known.
An approximative, "rough" index of this could be the
rate of standardized mortality, which is much de-
bated but used widely in the international litera-
ture /Haynes 1985/.
When comparing the state of health and re-
gional differencesx of supply of health services,
certain parts of counties show a better state of
health and better supply of doctors and hospitals
than the national average; these advantages can
strengthen each other. In other counties--e.g.,
in Bacs-Kiskun, Szabolcs-Szatmar, Pest--the state
of health is below the national mean value, ac-
companied by unfavourable supply resulting in ac-
cumulating disadvantages.
Fig. 3
demonstrates the state of health by using
rate of standardized mortality, supply of health
institutions, and indices of number of doctors
and hospital beds per 10,000 inhabitants. The
order of counties is based on rate of standardized
mortality. As the lowest value for rate of mortal-
ity is the most favourable, reciprocals of actual
values were applied in the representation. Thus,
for all three indices, values over 100 percent
are favourable. These data show relative values
against the national mean.

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
194
For proper interpretation of Figure  3,  it should
be stressed that inadequate health supply consti-
tutes only one, even a secondary, reason for the
unfavourable state of the health of the popula-
tion, priority being given to socio-economic cir-
cumstances. Undoubtedly, regions having an un-
favourable state of health of the population should
be afforded a larger proportion of resources during
distribution of financial resources of public
health. By such a strategy of health policy, the
effects of other, non-health factors could at least
partly be compensated for. Figure  3  calls attention
mainly to the fact that inadequate financial means
and inefficient mechanisms of health policy in ef-
fect over the last decades could be an obstacle to
realizing the desired distribution.
In the health-sociological literature, by
'inverse care law' is meant a phenomenon whereby
lower social strata having unfavourable states of
health use health care to a much lesser extent than
upper social strata having better states of health
/Hart  1975;  Stacey  1977/.  My calculations presented
earlier can prove that the 'inverse care law' is
also valid for regional processes in Hungary.
Diversified development of backward regions
In 1960, considering the supply of doctors,
hospital beds, as well as health expenditure per
capita of counties, two backward regions could be
distinguished in Hungary: one of them was situated
in the south-western part of Hungary including
three counties /Zala, Somogy, Tolna/; the other
was in the middle and eastern part of the country
involving five counties /Bacs-Kiskun,  B4k4s, Pest,

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
195
Szabolcs-SzatmAr, Szolnok/ /Fig. 4/.
By 1980, only
the counties of the south-western region could
achieve the national average; while the eastern
region was able to improve its relative position
only to a small extent and retains its worst status.
This backwardness was maintained in spite of a cer-
tain leveling of differences between 1960-1980 con-
cerning on the one hand the national average and,
on the other, values of counties having the best
supply /especially in the case of hospital beds
per 10,000 inhabitants/.
Meeting new demands and regional differences
My investigations of the health supply of
counties under most unfavourable circumstances aimed
first of all at whether this leveling process--
which can be characterized by complex indices of
supply--served to meet new demands. The structure
of social needs for health supply was undergoing
significant transformation during the last decades.
/E.g., there is a radical change in the structure
of diseases, an increase in the rate of cardiovas-
cular, mental, and those diseases occurring in old
age./
x .
Data in Table 2 Illustrate that the struc-
ture of health care infrastructure of counties of
most unfavourable characteristics was less able to
In Table 2, this 'leveling' process is charac-
terized by complex indices such as the number of
working hours of polyclinics per 10,000 inhabi-
tants plus the number of hospital beds per 10,000
inhabitants. In these terms, the values of rela-
tive indices of backward counties are much higher
than in the case of meeting new demands.

•
Orosz, Éva: Regional structure and major spatial processes of public health care in
-
Hungary. In: Spatial Organization  •
and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
19 6
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Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
1 97
meet changing needs than that of counties having
a more favourable supply though still below na-
tional mean values. To put it in another way:
during the last decades, the leveling processes
that acted to diminish the extent of backwardness
existing in previous periods were unable to meet
new demands to the extent necessary. It means that
meeting new demands is accompanied by significant
regional inequalities at the expense of counties
having more unfavourable supply.
Uneven decrease of regional differences in
the supply of doctors and hospitals
During the last few decades, the number of
doctors increased to a much greater extent than
that of hospital beds. /Between 1960 and 1982, the
number of doctors increased by 72 %, while that of
hospital beds grew just by 28 % per 10,000 inhabi-
tants./ Despite the enormous increase in the number
of doctors, regional differences in the supply of
doctors diminished to a lesser extent than was
possible and necessary. Even a contrary tendency
can be noticed in the formation of regional dif-
ferences: there was a much smaller decrease in re-
gional differences in the supply of doctors than
hospital beds /Table 3/. One reason can be seen in
the deficiency of the means of central health
managementAfter development resources were cen-
tralized, constructing hospitals in undeveloped
regions of low level health services was a relati-
vely easier task; however, central health authori,-
ties did not have effective incentives to influ-
ence the decision making of doctors in selecting
settlements in the long run.

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
198
The data presented in Table 3 show that the
most critical point of regional differences are
the inequalities in the supply of specialists. If
the special fields of medicine are examined, there
are manifold differences in the supply of doctors
and hospital beds alike. E.g., in 1984 in Heves
County, which can be regarded as the best supplied
vith emergency treatment, the number of beds was
5.2 times higher per 10,000 inhabitants than in
Bekes and Szabolcs-SzatmAr Counties, which have
relatively the least emergency treatment beds.
Accessibility to health services in Bacs-
Kiskun County serving as an example
Among the main components of health inequali-
ties, the third one is meant by regional differences
of utilization of and accessibility to health ser-
vices. Accessibility is a complex phenomenon com-
prised of distances between settlements, costs of
services and travel, information services, con-
nections of doctors and patients, tradition of
doctor use, etc. To evaluate regional inequalities
of accessibility requires empirical examinations
to be made at the settlement level by different
health services. There is no comprehensive informa-
tion on regional differences in accessibility to
health care for the whole country. Information-
statistical systems of public health do not pro-
vide the required data to carry out such investiga-
tions; on the other hand, health policy and plan-
ning does not demand examinations of such a nature.
In the investigations in health care of
rural settlements of Bacs-Kiskun County, the tran-
sport and settlement characteristics of accessibi-

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
199
lity to out-patient clinics were examined /Fig. 5/.
As a result of examinations for distances between
rural settlements and seats of polyclinics, it can
be stated that out of 105 villages 49 were situat-
ed within a distance of 20 kms to a polyclinic.
These settlements contain 53 % of the rural popu-
lation of the county. In numerous instances, even
longer distances, up to 60 kms, must be overcome.
Population in 23 rural settlements /17.4 % of the
rural population/ have difficulties in accessing
polyclinics not only because of long distances
but also because of the low-frequency of transport.
In my paper, efforts were made to present
briefly the characteristics of the regional struc-
ture of public health in Hungary, as well as in
delineating four main processes of changing region-
al differences concerning the following:
- state of health and contrasted regional
distribution of health manpower and facilities;
- diversified development of backward coun-
ties in the leveling process;
- contradictions between meeting new social
needs and the formation of regional differences;
_ finally, the uneven decrease of regional
differences in the supply of doctors and hospitals,

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
200
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1. rural settlements without easy access and having
indirect means of transport;
2: rural settlements laying in long distances  and  ha-
ving  lowfrequency of transport;
3. rural settlements without easy access;
4. rural settlements having indirect means of transport;
5. rural settlements having low frequency of transport;
6. out-patiemt clinics;
7. boundary of catchment areas of out-patient clinics
FIGURE 5 Rural settlements having unfavourable
transport facilities in terms of accessi-
bility to out-patient clinics in BAcs-Kiskun
County, 1983

Orosz, Éva: Regional structure and major spatial processes of public health care in Hungary. In: Spatial Organization and Regional Development.
Pécs: Centre for Regional Studies, 1988. 180–206. p. Discussion Papers, Spatial Organization and Regional Development
201
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▪
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