Dissertation Abstracts

An Ethnography of Gratitude Money: The Doctor-Patient Relationship in Post-Socialist Hungary

Author: Fernezelyi, Bori , febori@gmail.com
Department: Sociology, Social Anthropology
University: Central European University, Hungary
Supervisor: Prem Kumar Rajaram
Year of completion: In progress
Language of dissertation: English

Keywords: informal payment , doctor-patient , ethnography , policy
Areas of Research: Health , Political Sociology , Institutional Ethnography


Informal payment between doctors and patients follows more than 50 per cent of the medical encounters in the Public Health Care system of Hungary. In some specializations (like surgery and obstetrics) only 25 to 35 per cent of a doctor’s earnings is made up of his/her official income, whereas the remaining comes from informal payment. There are different forms of informal payment. Sometimes it is negotiated and paid before the medical intervention, but most often, it is handed over after the treatment in a plain envelop, or wrapped together with a small present.
Informal payment in the health sector is not confined to Hungary. It is widespread in other Eastern European counties (Delcheva et al. 1997, Stan 2007) and in some parts of Asia (Lewis 2000). It is not a post-communist peculiarity, but in Hungary it dates back to the state socialist period (Ádám 1986). Informal payment in other sectors of the socialist and post-socialist societies have been widespread (Neef 2002, Patico 2002); furthermore certain forms of gift giving practices in doctor-patient, healer–patient relationship in other, contemporary Western (Nadelson 2002), or traditional societies (Bierlich 1999) have been documented. My dissertation deals with the peculiarities of informal payment in the health care system of Hungary, and its effect on the doctor-patient relationship.
The expression ‘gratitude payment’ or ‘gratitude money’, as the literal translation of the Hungarian word ‘HÁLAPÉNZ,’ accurately exposes the complexity of the phenomenon. On the one hand, gratitude payment is a money exchange. On the other hand, however, it is much more than a simple payment for a service, or a form of corruption. Studying gratitude payment, one has contend with a blurrier exchange relationship.
Gratitude payment has existed in the Hungarian health care system for at least 60 years, and has been a hobby-horse of policy makers and politicians since 1989. There have been countless discussions adn even fewer policy initiatives about what is wrong with the system and how it can be addressed. Still, the system remained practically unchanged until present day. What makes the system so unshakable?
In order to answer this question I studied gratitude payment on two levels: on the macro level of policy formulation and on the micro level of doctor-patient relationships. I will demonstrate how these two levels are profoundly intertwined.
The research studied all three kinds of actors responsible for the existence of the informal payment: patients, health care providers, and decision makers. This comprehensive approach required the use of multiple methods, including (1.) secondary analysis of surveys from 1994-2012, (2.) qualitative interviews of patients, doctors, policy actors and (3.) ethnographic observations of the informal payment relationship.

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