HEALTH EQUITY -2020 PROJECT REDUCING HEALTH …€¦ · Szinapszis Kft. 15.11.2015 This document arises from the project HEALTH EQUITY -2020 which has received funding from the European

RESULTS OF NEEDS ASSESSMENT AND ACTION PLAN & THE ÉSZAK-ALFÖLD REGIONAL HEALTH INDUSTRY STRATEGY

ÉSZAK-ALFÖLD, HUNGARY

Authors: University of Debrecen

Szinapszis Kft.

15.11.2015

This document arises from the project HEALTH EQUITY-2020 which has received funding from the

European Union, in the framework of the Health Programme.

HEALTH EQUITY-2020 PROJECT

REDUCING HEALTH INEQUALITIES

PREPARATION FOR REGIONAL ACTION PLANS

[North Great Plain, Hungary]

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Content

Overview ................................................................................................................... 3

PART 1 WHAT DOES THE EVIDENCE for your region SAY? ............................. 4

Introduction to Part 1 ......................................................................................................... 4

Phase 1 Carrying out the NEEDS ASSESSMENT ............................................................. 5

1.1 Introduction ............................................................................................................. 5

1.2 Regional profile ....................................................................................................... 5

1.3 Socioeconomic inequalities in health ...................................................................... 6

1.4 Socioeconomic inequalities in health determinants ................................................. 7

Phase 2 Conducting a CAPACITY ASSESSMENT.......................................................... 13

Phase 3 Setting the potential ENTRY POINTS for action ................................................ 19

1.5 Setting priorities .................................................................................................... 19

1.6 Choosing actions .................................................................................................. 20

1.7 Translating actions into regional action plans ........................................................ 21

Phase 4 The IMPACT ASSESSMENT ............................................................................. 22

1.8 Any other information related information to building your evidence-base ............. 23

PART 2 Action plan to TACKLE HEALTH INEQUALITIES ................................ 24

Introduction to Part 2 ....................................................................................................... 24

Translating HE2020 actions into regional action plans ..................................................... 24

2.1 Main questions to answer by an action plan .......................................................... 24

2.2 Recommended key steps...................................................................................... 25

2.3 Integrated planning ............................................................................................... 26

2.4 Monitoring and evaluation of the implementation of the Action Plan ...................... 26

2.5 Financial appraisal ................................................................................................ 26

Action Plan ...................................................................................................................... 27

2.6 General context .................................................................................................... 27

2.7 List of partner organisations .................................................................................. 27

2.8 List of supporting documents ................................................................................ 28

2.9 Action Plan table ................................................................................................... 29

2.10 Additional support ................................................................................................. 32

PART 3 DEVELOPING THE ACTION PLAN: the process .................................. 33

Introduction to Part 3 ....................................................................................................... 33

3.1 General overview of the process ........................................................................... 33

3.2 Using an evidence-based approach ......................................................................... 34

3.3 A community & intersectoral approach .................................................................. 34

3.4 Building Support ................................................................................................... 35

3.5 Typology of the region .......................................................................................... 35

3.6 Challenges ............................................................................................................ 36

3.7 Validating the regional Action Plan – Integrated planning...................................... 36

3.8 Financing the Action Plan ..................................................................................... 36

3.9 Benefits for the region, lessons learnt, good practices .......................................... 38

3.10 Cascade learning into other regions ...................................................................... 38

3.11 Annex – Information on the Regional Action Group............................................... 39


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Overview

This report is summarizing the work of the regions in the framework of the Action Learning

and Capacity Building programmes of the HealthEquity-2020 project. This document

consists of 3 interrelated parts:

Part 1: Developing the regional action plan. What does the evidence say?

Part 1 summarises the work that has been done in relation to testing the HE2020

Toolkit. The regions went through on different phases to collect the necessary

evidence providing step-by-step guidance in designing evidence-based action plans:

(i) conducting a needs assessment, (ii) a capacity assessment, (iii) selecting entry

points, (iv) carrying out an impact assessment. Based on the Toolkit this template

helps the regions summarize the data and information collected during the process

of assessing and addressing socioeconomic health inequalities.

Part 2: Regional Action Plan to tackle health inequalities

Part 2 is the main output of the work of the regions. The key activity of the HE2020

project is that participating regions prepare region-specific action plans that are

evidence-based and are integrated with regional development plans & that have

appraised financial options including ESIF. The provided information and template

help develop the regional Action Plan.

Part 3: Developing the regional Action Pan: The process

The HE2020 Action Learning and Capacity building programmes put a strong

emphasis on the process of learning, developing, and sharing. Part 3 helps thinking

through the action planning process in the project and documenting it. It summarises

the context in which the regional team works, the used approach, what has been

achieved and how, as well as the opportunities and challenges encountered.


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PART 1 WHAT DOES THE EVIDENCE for your region SAY?

Introduction to Part 1

The aim of the HealthEquity-2020 project was to assist regions in Europe in drawing up

evidence-based action plans to address socioeconomic health inequalities. Having an

evidence-based approach is important as it provides a rational, rigorous, and systematic

approach to: setting up interventions, designing policies, programmes, and projects. The

rationale is that well-informed decisions will produce better outcomes.

A key product of the project is the HE2020 Toolkit providing step-by-step guidance in

designing evidence based action plans: (i) conducting a needs assessment, (ii) a capacity

assessment, (iii) selecting entry points, (iv) carrying an impact assessment. Following the

Toolkit structure this template helps regions document the data and information collected

during the course of the process of assessing and addressing socioeconomic health

inequalities.

Regions are advised to fill in this template as much as possible with the information

gathered and assessments made along the development of the project by testing the

Toolkit. What is important is providing the best available evidence that can: (i) explain the

health gaps between people and the corresponding socio-economic determinants leading to

the inequalities; (ii) assess the capacities (existing/missing) to implement actions to address

inequalities; (iii) show how the entry points for actions/policies or interventions were

chosen; and (iv) assess the policy impact of the interventions chosen.

In practice this summary can serve as an annex to a regional Action Plan or any wider

strategy. It can also be used by regions to (i) draw policy makers` attention to a policy issue;

(ii) monitor policy implementation; and (iii) evaluate the outcomes of the interventions.

The full HE2020Toolkit is available at this link:

https://survey.erasmusmc.nl/he2020/

Additional support for the completion of this template can be found at:

http://wiki.euregio3.eu/display/HE2020EU10/Home


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Phase 1 Carrying out the NEEDS ASSESSMENT

Assessing the magnitude and determinants of socioeconomic health inequalities

1.1 Introduction

[Insert here a short introduction on why a needs assessment was undertaken. Please

describe the overall process: what methods and sources you used to obtain the data, how

the data was edited or analysed, was there any action undertaken to improve data

availability through conducting additional surveys or improving monitoring of data.]

Needs assessment was undertaken to measure the magnitude and determinants of

socioeconomic health inequalities in Észak-Alföld region, Hungary. Different sources were

used in this process, mainly Hungarian and international databases, such as Eurostat and

OECD Health Data sources.

Different publications from Hungarian public health researchers and annual reports of the

Budgetary and Financial Department of the Hungarian Health Insurance Fund were also used

during the Needs assessment.

1.2 Regional profile

[Please provide a short description of the region. You can refer to aspects such as: population

size and density, distribution of the population by age and gender, distribution of indicators

of socioeconomic position, degree and distribution of urbanity.]

The Észak-Alföld region is located in the East of Hungary and includes three counties: Hajdu-

Bihar, Jasz-Nagykun-Szolnok and Szabolcs-Szatmar-Bereg. 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). The Észak-Alföld Region is Hungary’s second largest region in terms of population

and area, but population density is below the EU average. It also has a younger-than-

average population compared to Hungarian standards.

The Észak-Alföld region is among the poorest in the EU, with per capita GDP of 40% of the

EU 27 average. 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.


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Socioeconomic inequalities in health

Mortality and life-expectancy

[Describe here the socioeconomic inequalities in mortality or life expectancy.]

The average life expectancy at birth is 74 years, it lags behind the indicators of the EU

Member States in 2009. The region has the country’s second lowest life expectancy rate for

both men (68.4 years) and women (77.3 years).

Hungary still ranks among the lowest in Europe with regard to life expectancy at birth,

trailing the EU27 average by 5.1 years and the EU15 average by 6.3 years in 2009.

Hungary - compared to Western European countries - has very high regional and social

differences in mortality. There is multifaceted and complex relationship between the

development of sub-regions and demographic characteristics of regions.

SOURCES:

Guide to Health Gains from Structural Funds, http://www.healthgain.eu/casestudy/north-

great-plain-hungary

Health during life

[Also during life, health inequalities can exist. Describe them for a few of the main indicators

such as disabilities, prevalence of certain chronic diseases and self-reported health.]

Aside from Hungary lagging behind the EU averages for many health indicators, the

persisting geographical and social inequalities in health within Hungary itself are also a

matter of concern. For instance, the gap between regions with the highest and lowest

healthy life years was 8.1 years for men and 7.7 years for women in 2008. Unfortunately,

reliable morbidity and mortality data are not available to describe the health status of the

Roma minority but it can be assumed that their health status is considerably worse than the

population average (Ádány, 2008). A recent survey comparing the health of people living in

Roma settlements to that of the general population found that the self-reported health

status of the former group was substantially worse than that of the latter. Moreover, the

share of people who indicated that they felt they could do much to promote their own health

was 13% to 15% lower among individuals living in Roma settlements than in the general

population, also smoking and unhealthy eating habits were 1.5 to 3 times more prevalent

than in the lowest income quartile of the general population (Kósa et al., 2007). The highest

concentration of Roma in Hungary can be found in the region Northern Great Plain.

Unemployment is much higher among this group than among ethnic Hungarians, and many

live in slum conditions without running water or sewerage (Kósa, Daragó & Ádány, 2009).

Infant mortality rates among the Roma are thought to be high, and life expectancy at birth is

presumably far lower than for the rest of the population (Ádány, 2008).

RESOURCES:


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Hungary - Health system review (Péter Gaál , Szabolcs Szigeti, Márton Csere, Matthew

Gaskins, Dimitra Panteli) Health Systems in Transition Vol. 13 No. 5 2011

Ádány R (2008). A magyar lakosság egészségi állapota, különös tekintettel az ezredforduló

utáni időszakra [The health status of the Hungarian population, with special reference

to period after the turn of the millennium]. Népegészségügy [Public Health], 86(2):5–20.

Kósa Z et al. (2007). A comparative health survey of the inhabitants of Roma settlements

in Hungary. American Journal of Public Health, 97(5):853–859.

Kósa K, Daragó L, Ádány R (2009). Environmental survey of segregated habitats of Roma in

Hungary: a way to be empowering and reliable in minority research. European Journal

of Public Health, 21(4):463–468.

1.3 Socioeconomic inequalities in health determinants

Health behaviours

[Describe the socioeconomic inequalities in health behaviours like: smoking, physical

inactivity, alcohol consumption or diet.]

Communicable diseases play a subordinate role in Hungary, with the incidence and mortality

rates for most childhood infectious diseases continuing to be lower than the EU12 average

(WHO Regional Office for Europe, 2010) and the mortality rates for viral hepatitis and HIV

remaining lower than the EU15 average (European Commission, 2011). Lifestyle factors –

especially the traditionally unhealthy Hungarian diet, alcohol consumption and smoking –

still play a very important role in shaping the overall health of the population. According to

the European Health Interview Survey (EHIS) conducted in 2009, 21.5% of male respondents

and 18.9% of female respondents reported that they were obese (BMI ≥30) and 39.4% and

31.1%, respectively, reported that they were overweight (BMI ≥25 and <30)

(HCSO, 2010e). With a 12.5 litre per-capita consumption rate for pure alcohol in 2005 among

individuals over the age of 15, Hungary ranked among the countries with the highest rate in

the entire EU27. This statistic is backed up by the findings of the 2009 EHIS, in which 4.6% of

those who completed the survey – 8.3% of all male and 1% of all female respondents –

reported being heavy drinkers (HCSO, 2010e). The consumption of illegally distilled

homemade spirits represents an additional risk factor for the development of alcohol-

induced cirrhosis and may contribute to the high level of cirrhosis mortality in Hungary

(Szucs et al., 2005).

In 2009, an estimated 31.4% of the population in Hungary aged 15 years and above were

regular daily smokers. Between 2000 and 2009, the share of daily smokers among both men

and women decreased in all age groups except for people ≥65 years of age in the total

population and for women aged 35 to 64 years. Importantly, the share of the heavy smokers

(defined as someone who smokes 20 or more cigarettes per day) reportedly decreased from


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66% to 46% among men, and from 43% to 24% among women between 1994 and 2009 in

those aged 15 to 64 years (HCSO, 2010e).

In 2009 the death rate from causes related to alcohol and smoking was almost twice as high

as the EU27 average and substantially higher than the EU12 average (WHO Regional Office

for Europe, 2010).

RESOURCES:

WHO Regional Office for Europe (2010). European Health for All database (HFA-DB).

Copenhagen, WHO Regional Office for Europe (http://www.euro.who.

int/hfadb)

HCSO (2010e). Statisztikai tükör [Statistical mirror], 27 April, 4(50)



Szucs S et al. (2005). Could the high level of cirrhosis in central and eastern Europe be due

partly to the quality of alcohol consumed? An exploratory investigation. Addiction,

100(4):536–542.

Working & living conditions

[Present inequalities in social conditions, such as social support and demand-control

imbalance, as well as physical conditions, such as housing quality, traffic safety, and

exposure to noise.]

We are convinced, that physical conditions, such as noise, traffic possibilities, safety, and

housing conditions has a significant impact on health of persons. Health can be influenced

also a wide range of housing factors. In Észak-Alföld region, most vulnerable and

disadvantaged population are the Roma population. Considerable evidence supports the

notion that adequate housing is related to health and that low quality of housing is

associated with higher environmental risks and worse health status. The majority of Roma

people in Észak-Alföld region have been experiencing great difficulties – among others – in

terms of adequate housing due to the high costs of housing relative to their income and the

low availability of social support of housing that results in considerably worse living

conditions of Roma compared to the average for the country. Improve the quality of housing,

traffic and safety should be the first marks on the long road to empower disadvantaged

people to improve their health.

The European Statistics of Income and Living Condition (EU-SILC) survey regularly assesses

the self-reported health status of the population in the EU. In 2008, 19.2% of respondents in


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Hungary reported that their health status was “bad” or “very bad”, compared to 9.5% in the

EU27 as a whole. Conversely, the share of respondents reporting that their health status was

“good” or “very good” was 55.2% in Hungary versus 68% in the EU27. There was a marked

difference in self-reported health status between men and women in Hungary with 58.9% of

men compared to 52% of women reporting that their health status was “good” or “very

good” and 17% of men compared to 20.1% of women reporting that their health status was

“bad” or “very bad” (European Commission, 2011).

RESOURCES:

Health impact assessment of Roma housing policies in Central and Eastern Europe: A

comparative analysis (Ágnes Molnár, Balázs Ádám, Temenujka Antova, Lubos Bosak, Plamen

Dimitrov, Hristina Mileva, Jarmila Pekarcikova, Ingrida Zurlyte, Gabriel Gulis, Róza Ádány,

Karolina Kósa) Environmental Impact Assessment Review 33 (2012) 7–14

European Commission (2011). Eurostat, Luxembourg, European

Commission (http://epp.eurostat.ec.europa.eu/portal/page/portal/eurostat/home)



Access and use of health services

[Describe inequalities in access to and use of health care and preventive services such as

general practitioners, medical specialists, hospitals, dental care, screening, vaccination

programs, and maternal and prenatal care. Consider both the geographical access as well as

the financial barriers.]

The basic theoretical principles of the Hungarian healthcare system include accessibility,

equality, full care, and ensuring gratuity.

It is well known that the expenses of healthcare systems in developed countries grow faster

and to a greater extent than the GDP of the particular country. The reasons for this include

the dynamic improvement in technology, aging society and the increase in customer

awareness and needs of the population. As a result, the sustainability of the healthcare

system (while simultaneously ensuring the above principles) represents a significant issue in

all countries.

Thus, besides the publicly-funded care system, the role of publicly-financed care increases

significantly everywhere. The financing of private care can take place in two ways: in all

developed countries it appears either as a direct private expense or a savings account in the

form of insurance or savings fund scheme. As in Hungary direct private financing dominates,

one of the long-term objectives of this study is to assess the long-term opportunities for the

development of private insurance in Hungary.


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The Hungarian healthcare system, which is primarily financed (although to a decreasing

degree) by public central taxes and targeted contributions, is built on the principle of

progressive healthcare. The objective of this is to provide care for the patients at the lowest

possible level, where the conditions are already available for the needs of the patients based

on their situation.

This structure has its roots in the 70’s and its principles have remained unchanged in many

respects. The healthcare system itself is based on the system of general practitioners which,

depending on the size of the settlement, can be separated into primary care for adults and

children. On this level the GP system is complemented by the district nurse system and

primary dental care, occupational healthcare and in certain cases with special home care.

These elements together make up the Hungarian primary care system and at the same time

the first level of the healthcare system.

The second level of healthcare is occupied by specialized care, with two different parts,

outpatient and inpatient care. The specialized care of outpatients takes place in outpatient

clinics, those patients are treated here whose care is not possible due to the lack of

professional or technical criteria in primary care. The places for special care are the

specialized patient care units operating in the hospitals. The treatment of inpatients takes

place within the hospital system in such cases when the condition of patients does not make

it possible to treat them as outpatients and/or if the type of care itself requires staying in

hospital.

The care for inpatients, and to a certain degree that of outpatients as well, can be divided

into four levels depending on the level of progressivity: national, regional, county and basic

level.

On the national level only those special treatments are performed for which specialists,

instrumentation and support services should be maintained only at a few places in the

country, e.g.: transplantations, rare operations. On the regional level such rare diseases are

treated or such rare or other treatments are provided where due to the limitation of

professional skills and instrumentation, they are expedient to be installed only in case of the

full utilization of instruments; e.g.: neurosurgery, oncology. The county level is a more

complex place including almost all special areas, where they are capable of treating almost

the full range of diseases. On the basic level¸ i.e. the level of city hospitals, they provide such

treatments that are simpler but still require hospital care and which typically affect a lot of

patients. On this level typically only a few basic professions are present, such as internal

medicine and obstetrics.

This organizational principle, of course, is affected by numerous factors, the strongest of

which is the issue of financing.

As the financing of primary care occurs mostly in the form of a capitation system based on

population numbers, those working in primary care do not have an interest in providing final

care on the given level. Thus the rate of consultations with specialists and forwarding of

patients is really high resulting in the overloading of the middle level, i.e. outpatient care.

(specialized outpatient care – very high patient numbers, German example – activity-based

financing).


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Inpatient care has Diagnosis Related Group (DRG) based performance financing, which

categorizes the same types of diseases into the same group and assigns one value, amount

to them. Due to the fact that the budget is closed from the top, this DRG/HUF value is

redistributed in the ratio of overall performance.

The review of this system was ended and by now the real cost of certain medical procedures

does not cover the level of expenses, while there can be such groups as well where due to the

decrease of costs the particular treatment can be performed profitably (of course, there are

very few of these).

An additional basic feature of outpatient care is the performance volume limit. This specifies

for a given institution how much the insurer will finance from a particular type of medical

procedure. Thus it can happen that there are waiting lists at an institution as over X number

of such procedures the insurer does not receive compensation. Thus it does not have an

interest in the unlimited care of patients turning to it not even if there are available free

capacities.

Developed countries specify the structure and tasks of their healthcare systems through

legislation. In Hungary, at the time of political transition, the use of healthcare services

became subject to insurance coverage based on the obligation of paying contributions.

Certain social groups were excluded and there were layers that were simply not included in

terms of this obligation. In Hungary Act CLIV of 1997 on Health (Health Act) and Act LXXXIII

of 1997 on Mandatory Health Insurance (Health Insurance Act) that fulfil this expectation

supplemented and amended by numerous pieces of legislation (government and ministerial

decrees).

Economic consequences of health inequalities

Labour related indicators

[Describe here labour related consequences of health inequalities (ill health), such as labour

participation, sickness leave, and labour productivity.]

In Észak-Alföld region there are several labour-productivity and standard-of-living measures

that can be affected by improvements in the health of the labour force (like output per hour

worked, output per paid labour hour, output per worker, output per labour force

participant).

Traditionally, human capital has been interpreted as education and skills. Nowadays,

increasing attention has been given to health as a form of human capital.

There are a growing awareness that interventions such as promoting healthy lifestyles and

reducing stress can result reduced sickness-related absence and health-care costs.

Ill health was related to poor economic outcomes, including reduced labour participation,

lower hourly wages, and receipt of more social benefits. Our estimates suggest that the

economic impact of socioeconomic inequalities in health is likely to be substantial. While the


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estimates of inequalities-related losses to health as a ‘capital good’ seem to be modest in

relative terms, they are large in absolute terms.

Just like an adequate level of education, a good health status enables people to engage in

formal and informal labour activities and to be productive, and will, through its effects on

the production of goods and services, indirectly contribute to people’s happiness or

satisfaction.

SOURCE:

Economic implications of socio-economic inequalities in health in the European Union (Prof.

Dr. Johan (J.P.) Mackenbach, Dr. Willem Jan (W.J.) Meerding, Dr Anton (A.E.) Kunst) Health

and Consumer Protection Directorate-General

Direct costs related indicators

[Describe here costs of health inequalities (ill health), such as healthcare costs and costs of

social security benefits.]

The framework of the financing of the Hungarian healthcare system is well reflected by the

composition and cumulative figures of the Health Insurance Fund’s total revenues and

expenses.

In 2014 the total revenue of the Health Insurance Fund was HUF 1,907,078,423,000 (EUR

6,356,928,077). The total expenses of the Health Insurance Fund for 2014 were HUF

1,907,078,423,000 (EUR 6,356,928,077). Although in the last few years the expenses of the

Health Insurance Fund grew in absolute terms, Hungarian healthcare is underfinanced in

both absolute and relative terms. The tendency prevalent within the fifteen years between

1993 and 2008 indicates that even in the case of countries with more moderate economic

potentials the annual average of growth of healthcare/public healthcare expenses exceeds

the average rate of annual growth of GDP in percentage, meaning that the share of

healthcare from the GDP continuously increases. Among OECD countries it is only in Hungary

that the extent of healthcare expenses falls short of the scale of GDP which indicates the

relative decrease in financing (OECD Health Data, OECD Publishing, Paris, 2010a). In

Hungary the National Health Insurance Fund provides financing for the running expenses of

healthcare providers which, however, does not cover amortization. In the case of healthcare

providers, capital expenditure is covered by the owners. The financing of inpatient

specialized care is also performance-based, built on the classification system of Diagnosis

Related Groups (DRGs).


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Phase 2 Conducting a CAPACITY ASSESSMENT

Introduction

[Please describe the overall process of conducting the capacity audit in your region (what

data was used, did you conduct interviews, during what period of time?]

Different sources were used in this process, mainly Hungarian and international databases,

such as Eurostat and OECD Health Data sources.

Annual reports of the Budgetary and Financial Department of the Hungarian Health

Insurance Fund were also used in creating Capacity assessment.

Findings

[What are the findings with regards to the main domains of the capacity audit? Please refer

to weaknesses as well as strengths and opportunities for development.]

The triple helix of the region is of indispensable importance, regarding both the

entrepreneurial side and the role in employment, but the educational demand and the

entrepreneurial supply should be better synchronized. The helix is build up from the

cooperation of industrial, academic and state members. In the industrial field, there is the

Pharmapolis Innovative Pharmaceutical Cluster, Pharmapolis Innovative Functional Food

Cluster, Thermal Cluster, Silicon Field regional IT Cluster, and LENERG Building-Energy

Cluster. In the academic part, the University of Debrecen plays a very significant role, and

there is also the Institute of Nuclear Research of the Hungarian Academy of Sciences, the

College of Nyíregyháza and the College of Szolnok. Regarding the state representatives, the

Municipality of Debrecen, the Regional Development Agency, the Chamber of Industry and

Commerce and the Regional Innovation Agency are crucial. Non-scientific stakeholders

related to the biotech sector as a whole belong to several groups in accordance with the

following: state organizations, government offices, local governments and local

governmental institutes, professional associations, chambers, bridging organizations, grant

intermediating organizations (including authorities involved in strategic planning). Among

the non-governmental organizations the most important players are the large collective

forum of state organizations and other undertakings, the chambers. These organizations

form groups voluntarily, however in many cases the membership is compulsory and the

advantages of this are primarily in the admission to closed communities and the

acquaintance with the best practices as well as the application thereof in everyday practice.

There are chambers for each profession in healthcare. Although commercial and industrial

chambers are not considered as professional organizations, they coordinate a group of

entrepreneurs (such as enterprises producing medical prostheses and surgical appliances,

manufacturers integrating their research findings into their products). In recent years, in

Hungary one of the major tools of national economic policy appeared, these are the

corporate groups called clusters. With the cooperation of the University of Debrecen and

Richter Gedeon Plc., the Pharmapolis Debrecen Innovative Pharmaceutical Cluster was


14

founded in 2008. This cluster has more than 26 members, including SMEs, spin off and start-

up companies. The companies participating in the Pharmapolis Cluster perform their

research and development activities in cooperation with the University of Debrecen and

other research institutes and endeavor to establish a long-term strategic partnership. Other

non-scientific organizations include investment supporting organizations, insurance

companies, banks, and financial institutes. Identified, non-scientific stakeholders are

JEREMIE fund managers, other venture capital companies and business angels. Small,

dedicated biotech firms play an important role in almost all fields of biotech applications,

especially in healthcare biotech. These small firms are mostly responsible for research and

innovation, even though they often depend on external funding. In fact, as firms expand in

size, typically they experience a decreasing number of discoveries. For large companies,

many discoveries usually represent slight adaptations of existing products rather than the

development of brand new ones. In contrast, usually truly inspirational ideas come from

smaller dedicated firms located in the clusters. Consequently, it can be concluded that big

industry is mostly dependent on small firms. Academic spin-offs are a particularly important

type of new companies in the biotechnology sector and that these companies serve as the

main vehicles for exploiting biotechnological research. The distribution of employees across

different categories is an important criterion, especially when evaluating the total number of

employees dedicated to R&D. Since SMEs are mostly involved in R&D and are responsible for

the new jobs created, their role in economic development is pivotal. The Észak-Alföld Biotech

Cluster was established in 2011 based on the initiative of small and medium-sized

enterprises. The Cluster intends to provide better business conditions and opportunities for

the SMEs operating in the biotech sector which is one of the main regional economic sectors.

Organizational development [You can talk about: organizational structures, policies and procedures/strategic directions, management support, recognition and reward systems, information systems, quality improvement systems, informal culture.] Hungary has a great heritage in the health industry (thermal baths, education, pharma

industry), although in the past few years tackling the emerging challenges has been in the

centre. Traditionally, the Hungarian Health System is social insurance and solidarity based,

even if there are some kind of shared responsibilities and functions of the local governments,

the state system and the National Health Insurance Fund. However, the reorganization of the

health system is happening nowadays, which builds on greater public engagement and the

health industry in focus. For today, in Hungary almost all policies are carried out on a national

level. Health services are organized on a regional basis. The ultimate goal is to make the

regional work effectively enough so that patients could obtain the required level and quality

of care and to give greater attention to the health industry, which has of strategic importance

for the economic factors. Regions are also statistical regions and were originally established

to coordinate developments better within the European Union. Észak-Alföld has great

experience based on its research potential and its university in the biotech sector as a whole.


15

Biotechnology is essentially relevant to pharmaceutical research and the manufacturing

phase. In recent years, in Hungary one of the major tools of national economic policy included

the appearance of corporate groups called clusters. The Pharmapolis Debrecen Innovative

Pharmaceutical Cluster was established in 2008 with the cooperation of the University of

Debrecen and Richter Gedeon Plc. This cluster has over 20 founding members including spin-

of enterprises that settled down in the environment of the University.

Resource allocation [You can talk about: financial and human resources, time, access to information, specialist advice, decision making tools and models, administrative support, physical resources.]

There is a need for strengthening the established health and social care system, the

development and extension of services available on the local level. These developments aim

at the modernization of the services and infrastructural conditions of the institutions as well

as the reduction of inequalities of access. The development of primary healthcare is crucial

because this level of care must be capable to perform the basic health screenings and health

checks and of effectively contributing to the strengthening of the health consciousness of the

population. The infrastructural developments in healthcare can contribute to the increase of

the number of healthy years of the population, restoration of the ability to work as soon as

possible, and with the concentration of resources, to the improvement of the cost efficiency

and quality of services.

The primary health care of the population is provided by the General Practitioners in all

settlements of the county. In the smaller villages primary care is provided on the basis of care

contracts or, for example, night or weekend duty is performed by private businesses based on

task performance contracts or it is provided simultaneously at several settlements through

institutional management associations or district notaries. In 2010 there was some kind of

outpatient care in 32 settlements of the county operating with regional task performance

obligations. About 81% of the county’s total population could use these services at their own

settlement, while in the past decade centralization characterized this area as well.

In the period up to 2020 we have to prepare also for the challenges of the aging society, with

the development of the related social and healthcare infrastructure as well as the services

intertwined to healthcare and with that of primary care.

Workforce development [You can talk about: workforce learning, external courses, professional development opportunities, undergraduate/graduate degrees, professional support and supervision, performance management systems.]

The case of human resource in Hungarian healthcare is in deep crisis and the current system

supports change only to a small extent. The human resource supply in the system is in a

verifiably bad position. According to data published annually by the Migration and

Monitoring Department of the Health Licensing Office1 the number of physicians emigrating

1 www.eekh.hu


16

increased continuously until 2011, since then a slow decrease can be seen. With regard to

emigration among the other healthcare professionals (dentists, nurses, and pharmacists) the

growth did not stop. In 2013 1,850 healthcare professionals left the country, half of them

were physicians and one quarter were nurses2. If we consider that in Hungary only

approximately 1,000 people get a medical degree annually then the negative trend is clearly

visible.

The aging society is also a growing problem all over Europe, including Hungary. Technological

development can compensate the quantitative problems of human resources but only if the

new professionals are appropriately trained with regard to the use of the new technologies.

Although the smaller human resource originated by technological development can itself be

questioned, for example, in case of imaging diagnostics, there has been exponential growth in

the last years, still there is a need for the same number of radiologists as before.

The decreased or missing motivation due to the overburdened, expensive and wasteful

system is also a disadvantage. The role of clinics and hospitals has become stronger in this

respect as local initiatives can turn this worrying trend more positive. The health faculties and

clinics of the University of Debrecen have introduced personalized healthcare HR

management several years ago. The system is capable to motivate the employees and can

also maintain this level. It creates a career plan for everyone for the purposes of

predictability; it is cost effective and pays attention to appropriate working conditions.

Moreover it guarantees legal protection as well in the case of possible malpractice lawsuits.

Leadership [You can talk about: interpersonal skills, technical skills, personal qualities, strategic visioning, systems thinking, visioning of the future, organizational management.]

Several local and international studies have been published which clearly shed light to threats

that can influence the building of successful companies from new enterprises in health

industry, where the manager must be competent in several professions. Several programs

provide qualifications in economics and finances as well as spread the innovation and

management approach in Debrecen. There are two possible ways leading to the training of

biomanagers: the financial (further) training of students and researchers interested in the

business approach from the fields of medical and health sciences, life sciences, agricultural

sciences, or the other way around, the health science education of people with qualifications

in economics, finance. The former approach is generally accepted and can be realized more

easily, it can be adapted successfully even with minor changes in the system. The knowledge

of business should be integrated systematically in the above mentioned health industry-

related study programs and all such self-motivated forms of education should be supported

that aim to strengthen the business knowledge of the population. It was the need for the

training of healthcare managers and their supply that resulted in the creation of the

2 http://www.vg.hu/vallalatok/egeszsegugy/itt-vannak-a-legfrissebb-migracios-adatok-420038


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Department of Health Systems Management and Quality Management for Healthcare at the

Faculty of Public Health at the University of Debrecen in 20123. The aim of the training

programs offered by the Department is to help professionals participating in the program to

effectively meet the requirements they have to face in the public, business, governmental,

and non-profit sectors as well.

The health industry depends on all the actors in the triple or quadruple helix, thus from the

regulatory bodies as well. The aim of the local government is to support, educate, and

prioritize those managers in the organizational structure, who have management skills,

international experience, and knowledge of foreign languages.

It is the joint innovative education development program (supporting the development of the

economy) of the Municipality of Debrecen and the University of Debrecen to establish a

Healthcare Management Training Centre at the Faculty of Public Health and to provide the

necessary conditions for it. The University of Debrecen, as the Research University and

University of National Excellence of the Észak-Alföld region as well as that of the Észak-

Magyarország twin region, has a clear social and professional policy responsibility with

regard to providing future managers who are adequately qualified and have appropriate

management competencies. With the establishment of the manager training centre, the

framework is created for demand-based HR planning, system-level competence development,

managerial talent management, management brand development, while the continuous

expert support of managers and their further training also receives attention. The target

groups of the training programs offered by the centre are the civil servants, public employees

(healthcare, public and higher education) and the health industry sector. Besides this, the

centre, in cooperation with the multinational companies, SMEs of the region, also provides

internal training programs customized to the needs of the business sphere.

Together with the management, it could provide continuous support for the managers and

employees in the business/public sector with individual career planning and competence

development, and with the involvement of managers it facilitates the harmonization of

individual objectives with the organizational ones.

It supports the process of talent management as a partner either through finding talents from

the outside (recruiting) or with the identification and special training of hopeful talents within

the company with the appropriate methodology.

Besides all these, the Centre supports the definition of the company’s strategic objectives with

a methodology based on scientific research findings as well as the completion of the

processes related to management of changes in company culture necessary for the realization

of the strategic objectives.

The direct participation of TEVA Gyógyszeripari Zrt. in the educational program of the

University of Debrecen is also a good example for the importance of the proper training

among future professionals. There are two departments operating within the university with

the support of TEVA; these are the External Pharmaceutical Industry Department (Faculty of

Science) and the External Pharmaceutical Manufacturing Department (Department of

3 http://emmt.unideb.hu


18

Pharmacy). The experts of TEVA also participate in the educational work of these external

departments starting from elaborating the curriculum to teaching. Moreover, the practical

experience of students is also strengthened by the company with visits to the factory, the

modernization of the department’s infrastructure, and by providing summer internship

positions. Specialists of TEVA are also open to work with graduating students as advisors to

their theses. This relationship, however, has two sides: the specialists working at TEVA also

apply to the doctoral school of the university, who this way can acquire a doctoral degree

while contributing to the up-to-date range of programs of the doctoral schools with their

practical experience. Those students graduating from the external departments can find a job

more easily within the pharmaceutical industry, the majority is employed already before they

receive their diploma.

Partnerships [You can talk about: shared goals, relationships, planning, implementation, evaluation, sustained outcomes.]

The lack of an adequate financial background, information sharing and adequate practical

sector specific knowledge are the main obstacles of innovation, therefore the formation of an

effective and supportive environment is indispensable. There is also a lack of innovation

awareness, with a lack of cooperation. The sharing of innovation knowledge is not very

common, although there are some good examples for joint R&D programs and research

platforms. Involving an external advisor or mediator organization would help a lot in the

whole process. Relevant intellectual property and technology transfer activities are required

for the better exploitation of research results. Regional biotech companies do not really feel

the need for management consultancy services; they try to solve these issues within the

company. They rather need outside help in terms of patent issues. Those services which are to

help map and build up potential relationships also aroused their interest. They would

welcome opportunities which could take them to bigger partners. Therefore the development

of an innovation system is a key, interconnecting the supply and demand side of innovation

on the regional level, exploiting the potential local capacities. At present, the size of the

companies – besides the time and money shortage - is the biggest hindrance in the prosperity

of the companies (economies of scale) rather than the fact that they are not able to reach the

potential companies, customers. In some cases they cannot afford the needed services due to

financial limitations. Therefore, encouraging the involvement of venture capital and private

equity, co-financing methods are essential. Companies do not use external help because they

consider themselves too small to enter into it alone. They see several opportunities in the

clusters. The co-operation with the members of the sector, relationship building may help

getting into bigger projects or even participation in professional events can become easier. A

supporting organization would give a great opportunity to organize information coming from

different sources. The role of the University of Debrecen is prominent in the region’s

innovation (among external research services used by the companies), and also the

participation of the Hungarian Investment and Trade Agency, the Knowledge and Technology


19

Transfer Office of the University and the Regional Innovation Agency (INNOVA). They provide

information about different events and possibilities and give help in the realization of projects

and research. Common research groups, projects were formed between the University and

the companies, and this worked very well in providing help mutually. However, it is

sometimes difficult to find the appropriate partner in research services. Regarding

management consultancy services, companies try to solve these issues mainly themselves,

employing indoor specialists, meanwhile other companies think that different financial, sales

and HR tasks have to be handled within the company. Smaller companies think that outsiders

cannot get involved in the operation of the company to such extent that they would be able

to help. Contact building (possibilities, available services, and mediator organization) is

considered to be one of the main business issues. The role of clusters is also very important

(regarding common projects, cooperation, participation in conferences, representation), but

clusters do not operate the same way in Hungary as abroad, they are more heterogeneous

and have fewer members. Participating in an international biocluster would open up broader

perspectives to the members.

Phase 3 Setting the potential ENTRY POINTS for action

1.4 Setting priorities

[What are the health inequalities that raised concerns in your region? Why? How did you choose a/ between priorities? Explain it by taking into account factors like: impact, changeability, acceptability, resource feasibility. Talk about European regional priority setting! European Structural and Investment Funds are a potential source for funding actions but they also set up the political agenda in terms of developing priorities. Have you managed to relate your priorities set up for your region/country to the European level?]

In order to realize the sectoral and regional objectives included in the Hajdú-Bihar county Regional Development Concept, those priorities have been specified within which the particular measures (as developmental tools for the execution of the concept) will be implemented. Development priorities of Észak-Alföld region for 2014-2020: 1. Sustainable Environment 2. Complex Development of the County’s Agriculture 3. Competitive Economy 4. Improvement of Accessibility in Hajdú-Bihar County 5. Intelligent Society 6. Healthy and Caring Society 7. The Development of a Supportive Environment for Innovative Economy in Debrecen


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1.5 Choosing actions

[What are the actions you can take to address this health inequality? Talk about the mechanism chosen! (e.g. (a) reducing the inequalities in socioeconomic position itself (education, income, or wealth); (b) improving health determinants prevalent among lower socioeconomic groups (living and working conditions, health behaviours, accessibility to and quality of health care and preventive services) ; (c) reducing the negative social and economic effects of ill health (school drop-out, lost job opportunities and reduced income) Talk about the strategy chosen: e.g. (a) a targeted approach; (b) a whole population approach; (c) a life-course perspective; (d) tackling wider social determinants of health.

Have these interventions already been proved successful in reducing inequalities in other regions or studies?]

To address health inequalities we decided to improve health determinants prevalent among

lower socioeconomic groups (living and working conditions, health behaviours, accessibility

and quality of health care and preventive services). In order to achieve this, Faculty of Public

Health at the University of Debrecen promote awareness, political commitment and action

on the adverse social conditions (including poverty and social exclusion) that make certain

groups (such as Roma and other ethnic minorities) vulnerable to ill health.

Health status assessment among disadvantaged people is evaluated in a yearly basis. These

assessments are also analysed by specialists of University of Debrecen Faculty of Public

Health. According to these assessments, we are able to determine action that should be

taken in order to reduce socioeconomic health inequalities.

Another key weakness and focus area in the Észak-Alföld region occurs in the regulatory

framework. The biggest problem is the lack of capital in the diffusion of innovation. The

overly rigid and inflexible legal background makes the system also very complicated. The

regulatory framework and the business infrastructure can be characterized by the lack of

structural solutions for authorities to address regulatory market and financial risks raised by

new bio products, sometimes there are heavy administrative burdens too. The majority of

research and development is conducted at universities or institutes and collaboration with

the industry is limited. Therefore, the lack of entrepreneurial experience in public research

institutes and administration is also a great obstacle of development. Regarding the

financial background, it can be contested that the risk-sharing mechanism is not designed

for entrepreneurs. The process for funding applications is relatively uncoordinated. There is a

lack of business advice for start-ups. Venture capital investment is limited, there is only pre-

seed funding. There are no available local financial sources for biotech companies, only

national and international opportunities. Research is mainly related to higher education and

public funds. The reasons behind this – which have to be changed - are the risk-averse

culture in the financial and risk sharing structures, the lack of international culture and of

entrepreneurship recognition and the lack of communication on role model entrepreneurs

and on reward of their success. Therefore, knowledge and technology transfer platforms are

welcomed. The availability of professional and business advice is increasing, but remains


21

expensive for most of the SMEs. Forming a supportive development environment is essential,

where mediator organizations and adequate external advisors can play more explicit role.

The importance of the innovative approach has to be understood by the companies, the

public and the private sphere as well in practice, via workshops, good examples, municipal

and governmental incentives. In order to create better funding, it is indispensable to better

understand the needs of people. Development and service has to be offered for them,

because as for today, they have and they provide most of the sources. Customers, clients,

patients, we can call them in many different ways.

1.6 Translating actions into regional action plans

[For the actions chosen did you think about? (a) the reach of the action (the intended target

population)?, (b) effectiveness/ efficacy of the action (the desired effect of the action) ?; (c)

who will adopt the action?; (d) who should implement the action? (e) what type of

maintenance of the action was required?]

As part of the planning process we choose to define overall objectives and strategic

objectives. We identified three overall and three strategic area objectives:

Overall objective 1

Economic development based on the natural features, traditions and research potential of

Hajdú-Bihar county, which increases employment and strengthens the function of the county

as the innovation centre of Eastern Hungary

Overall objective 2

The strengthening of service and administrative functions for reducing poverty and social

exclusion and to increase the marketable skills of the working-age population

Overall objective 3

Effective water and energy management and the establishment and development of the

conditions for sustainable environmental management in order to reduce the negative

effects of climate change in the Northern-Great-Plain’s TransTisza region

Strategic area objective 1

Debrecen, the Vital City, as the capital of health and innovation in the Carpathian Basin


District centres and the district-level small towns as centres of cooperation for local

communities



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Small settlements as the scenes of livable rural communities

Phase 4 The IMPACT ASSESSMENT

Assessing the potential impact of actions on health and health inequalities

Screening

[Is the policy/ intervention likely to impact health/ determinants of health considerably? Which populations are currently relatively disadvantaged in the context of this policy or intervention? Does the policy enhance equity or increase inequity? What might be the unintended consequences?]

The intervention is likely to impact health determinants. We are able to determine action

that should be taken in order to reduce socioeconomic health inequalities between the most

vulnerable groups, like Roma population.

Scoping

[Which health outcomes or determinants of health outcomes does this impact assessment focus on? How was it carried out (literature reviews, quantitative modelling, qualitative analysis- expert consultations, interviews, focus groups)? What evidence was used to show how the health equity impact was identified?]

University of Debrecen Faculty of Public Health have been participating many research programs, resulting many publications in this field. We are able to draw up evidence-based action plans to address socioeconomic health inequalities. After identifying problems and evaluation of the situation the first step of the actions clearly is realignment of vulnerable groups.

Impact assessment

[Quantify or describe potential, important health and health equity impacts.]

With regard to the specific circumstances of the Észak-Alföld 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. In order to address these difficulties the region needs to

curb territorial imbalances and adjust health care services to local needs. Improving the

institutional framework for rehabilitation and developing outpatient care are crucial to

achieve these objectives.

Evidence-based action plan to address socioeconomic health inequalities is also based on

these main characteristics.

Decision making

[Provide recommendations to improve policy (evidence-based, practical, realistic and


23

achievable measures that would reduce the negative and enhance the positive health equity

impacts of the policy).]

Thanks to strong political support, the region is determined in focusing health inequality

problems.

For example during the design of operative programs regarding Hungary, Ministry of Human

Resources continuously consulting with Hajdú Bihar County concerning health issues. In

decision making process we tried to involve all actors which are able to influence and

improve policies.

Monitoring & evaluation

[Talk about: the process evaluation (Was the impact assessment carried out successfully?

Were there challenges or barriers?); the impact evaluation (will the recommendations of the

impact assessment be adopted/implemented?); the outcome evaluation (How will you know

if health inequities have been reduced in real life?)]

Impact assessment and evaluation was necessary in order to get appropriate feedback. We

experienced challenges in coordination and cooperation of all relevant actors.

1.7 Any other information related information to building your evidence-base

[If you had any difficulties with regards to the data collection and interpretation, please

describe it here.]

There were negligible number of difficulties regarding data collections and interpretation.


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PART 2 Action plan to TACKLE HEALTH INEQUALITIES


The key outputs of the Action Learning and Capacity Building programmes are the evidence-

based regional Action Plans to address socioeconomic health inequalities.

There are many different types of action plans in practice: from simple to more complex.

Ideally action plans are linked to a wider strategical plan and can be developed annually,

biannually.

The HealthEquity-2020 project did not plan to introduce a particular action plan format as

there are many factors in practice that can influence their particular design and content. The

regions themselves are also differing in their priorities and objectives they want to focus on

and achieve, their stakeholders and their institutional background, their political context,

the mandate or role to be played as a strategic document for the region.

Nonetheless, this document aims to present the key characteristics of an action plan and

provides some guidance on the most important elements that should be considered

together with providing a simple template.

The regions are kindly asked to fill in this template based on their work, or use any other

format that is also in line with the basic characteristics of an action plan and with the

characteristics of their own local/national policy planning/action planning processes.

Whichever way the region chooses, the main point is to build the Action Plan on the data

and knowledge gathered via the action learning process documented in Part 1.

Translating HE2020 actions into regional action plans

2.1 Main questions to answer by an action plan

An action plan is detailed plan related to a strategic document outlining:

1. What will be done (the steps or actions to be taken) and by whom (which organisation).

2. Time horizon: when will it be done (when the actions/steps will be done) 3. Resource allocation: what specific funds are available for specific activities.

In practice we can find various different kinds of documents that are called Action Plans

with elements like vision, mission, aims, objectives, goals built on each other, and actions

etc., but these documents are more likely should be considered as Strategies.

Within the HealthEquity-2020 project the idea was to look for (to develop) action plans to

be integrated into regional development plans, national reform programmes etc. These


25

Action Plans should be aligned to these existing strategical documents’ vision, mission,

objectives etc.

2.2 Recommended key steps

Considering the special context of the HE2020 project and the steps already taken as part of

the HE2020 Actin Learning programme, the following key steps are recommended to be

taken to finalize your regional Action Plan.

2.2.1 Bring together the different people/organizations/sectors to be involved in

developing the Action Plan to get various views in the planning work.

This group is ideally the Regional Action Group. While action planning can take place

within single departments, organizations and sectors, the HealthEquity-2020 project

encouraged cross-sectoral action planning.

2.2.2 Review your data and information that you have collected with the help of the

Toolkit.

Regions assessed the magnitude and determinants of health inequalities in their

region by conducting a needs assessment, assessed the capacities, formulated entry

points, and some of them have taken to the impact assessment phase.

Please review what you have learned about health inequalities, and what capacities

you have to tackle that. Examine again the selected priorities based on the data, and

the possible actions by which you can address the assessed inequalities. Critically

evaluate the chosen strategy to tackle the problem. If data exist evaluate the

potential impact of possible actions on health and health inequalities.

This information and careful analysis should provide the background and basis of

your action plan; it is going to be the so called evidence-base of the Action Plan.

2.2.3 Develop the action plan by

3.1 Presenting the general context under which the action plan was developed.

a) Explain why actions are needed, make a reference to the evidence

collected by briefly summarizing the results of the health inequality

assessment (key considerations, why these priorities/objectives have been

selected)

b) Briefly explain how this plan was developed

c) Explain how the action plan fits within or linked to a wider development

strategy or other document(s) (Operational Program/National

Reform/Health or Social Strategy etc.)


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3.2 Filling in the action plan table by identifying

a) the key actions of the priority area/identified objective (you can also chose

to prioritize actions if you want to bring focus on certain issues (essential;

high; medium; low)

b) the output/deliverable of the action

c) the responsible parties

d) other parties to involve

e) the timeline

f) key outcome indicators to measure success

g) financial resources.

3.3 Listing the partner organisations contributing to the development of the Action

Plan

3.4 Listing the supporting documents as annexes of the action plan (e.g. a more

detailed review of the determinants of socioeconomic health inequalities in your

region).

2.3 Integrated planning

A key element in the HealthEquity-2020 project is that the developed Action Plans should be

integrated into regional development plans. Please describe in the General context to which

regional or national strategical document your Action Plan can be linked to and how.

2.4 Monitoring and evaluation of the implementation of the Action Plan

Monitoring and evaluation is a key to demonstrate the results achieved to policy makers/

policy entrepreneurs/ decision makers/supporters/stakeholders and to generate financial or

political/institutional support further on during/after the implementation stages of the

action plan. However, building a monitoring and evaluation system requires special

expertise, thus here you can focus only on listing a few key indicators measuring outcomes.

2.5 Financial appraisal

Getting financed the action plan is crucial for implementation. HE2020 puts an emphasis on

the use of the European Structural and Investment Funds (ESIF) as an important source of

funding for actions related to the inequalities area.

Please make a financial appraisal. A few points for consideration:

- What are the funds available for your region?

- Consult the Operational Program(s) that cover your region. Can you make a match

with its priorities that can support the Action Plan? Are you eligible to apply for

funding?


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- Can you build synergies/partnerships with your stakeholders, officials, industry

representatives and NGOs from your Regional Action Group to increase your profile?

- When the Calls for Proposals are organized and how does that fit with the

implementation stages of the Action Plan?

- Funds are allocated to those projects that can demonstrate their ability to achieve

the results in a measurable way relevant to the priorities mentioned in the

Operational Programs. Can the evidence you collected in your assessments support

this approach?

- Other sources of funding might also be available at national/regional level or within

other frameworks (regional, national, or other international funds e.g. the

Norwegian Grant). Have you considered them?

Action Plan

2.6 General context

[Please (i) Explain why actions are needed, (ii) Make a reference to the evidence collected by

briefly summarizing the results of the health inequality assessment (key considerations, why

these priorities/objectives have been selected), (iii) Briefly explain how this plan was

developed, (iv) Explain how the Action Plan fits within or linked to a wider development

strategy or other document(s) (Operational Program/National Reform/Health or Social

Strategy etc.)]

Hajdú-Bihar county is to preserve its natural values by 2020 and building on the cooperation,

capabilities, and traditions of local communities, it will be a liveable, sustainable, balanced,

rural environment with quality life available for its population and utilizing the beneficial

effects of the position of Debrecen as the health centre of the Carpathian Basin and the

competitive centre for innovation on the economy and jobs.

2.7 List of partner organisations

[Please list the partner organisations contributing to the development of the Action Plan.]

Pharmaceutical Industry

SMEs in medical devices, medical appliances and (including eHealth, mHealth)

Healthcare service providers (Clinical Centre of the University of Debrecen, Kenézy Gyula

Hospital and Outpatient Clinic)

Medical Tourism providers

Biotech companies

Functional and healthy food companies

Bioinformatics companies


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2.8 List of supporting documents

[Please list the supporting documents as annexes of the action plan (e.g. a more detailed

review of the determinants of socioeconomic health inequalities in your region).]

Health Industry strategy for 2014-2020, Debrecen


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2.9 Action Plan table

Actions Output/ Deliverables

Responsible party

Others to involve to complete action

Timeline Indicators Financial resources

Priority area/Objective

Overall objective 1 Economic development based on the natural features, traditions and research potential of Hajdú-Bihar county, which increases employment and strengthens the function of the county as the innovation centre of Eastern Hungary

growing employment rate

municipalities, educational centers

university 2020 numbers of re-employed citizens reduction of unemployement rate (relative and absolute)

government resources, EU funds,

Overall objective 2 The strengthening of service and administrative functions for reducing poverty and social exclusion and to increase the marketable skills of the working-age population

organizing trainings

educational centers

university 2020 numbers of education, vocational trainings, number of participants

government resources, EU funds


30

Overall objective 3 Effective water and energy management and the establishment and development of the conditions for sustainable environmental management in order to reduce the negative effects of climate change in the Northern-Great-Plain region

water and energy management feasibility report

municipalities infrastructural providers

2020 water and energy management feasibility report

government resources, EU funds

Strategic area objective 1 Debrecen, the Vital City, as the capital of health and innovation in the Carpathian Basin

capital of health and innovation report

municipalities university 2020 capital of health and innovation report

government resources, local tenders

Strategic area objective 2 District centres and the district-level small towns as centres of cooperation for local communities

specific needs assessment among the citizens

municipalities, research organizations

university 2020 local survey results

government resources


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Actions Output/ Deliverables

Responsible party

Others to involve to complete action

Timeline Indicators Financial resources

Priority area/Objective

Strategic area objective 3 Small settlements as the scenes of liveable rural communities

liveable rural communities report, surveys

municipalities 2020 liveable rural communities report

government resources, local tenders

Please add further rows as necessary.


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2.10 Additional support

Additional support for different types and models of action plans can be found on the

HE2020 Wiki Page under the section “Action Plans Examples”. These documents can be used

as a source of inspiration and adapted according to the needs of the regions.

http://wiki.euregio3.eu/display/HE2020EU10/Action+Plans+Examples

Regions can also consult other sources or documentation on action planning like:

http://ctb.ku.edu/en/table-of-contents/structure/strategic-planning

https://www.hitpages.com/doc/6289108800372736/1

http://www.open.edu/openlearnworks/mod/oucontent/view.php?id=53774&section=1.4 ]

For further information you can also consult:

The HE2020 Policy Matrix link at HE2020 wiki

The Regional Development Agency in your region:

http://ec.europa.eu/regional_policy/index.cfm/en/atlas/managing-authorities

A large database with successful projects available for review for the past period that can serve as inspiration: http://ec.europa.eu/regional_policy/projects/stories/index_en.cfm

Other potentially relevant websites:

http://ec.europa.eu/regional_policy/en/checklist/ http://ec.europa.eu/regional_policy/en/atlas/ http://ec.europa.eu/health/health_structural_funds/used_for_health/index_en.htm http://www.esifforhealth.eu/ http://fundsforhealth.eu/

[Észak-Alföld, Hungary]

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PART 3 DEVELOPING THE ACTION PLAN: the process


Regions have different starting points in the action planning process and they also have

region-specific development scenarios depending on their organizational background,

institutional, political, and cultural context. The regions differ in their policy making

processes, problem perceptions, and problem solving practices, as well as they work with

various stakeholders.

This template helps thinking through the action planning process in the project and helps

documenting it. It summarises the context in which the regional team works, the used

approach, what has been achieved and how, as well as the opportunities and challenges

encountered.

3.1 General overview of the process

[Please describe the overall process of developing the action plan throughout the HE2020

project. Please define the context.

How the process has started? Have you had dealt with the topic of health equity before

within your region/country (in a direct or indirect way)? Have you built your work in the

project on any earlier regional work/developments related to the inequities field? Have

health/health equity/social determinants of health issues had been on the discussion table of

policy makers before? How did this have an effect on the general process of developing the

Action Plan as part of the project?]

University of Debrecen Faculty of Public Health together with the Municipality of Debrecen

are very enthusiastic in reducing socioeconomic health inequalities, regarding the city of

Debrecen as well as the Észak-Alföld region. Special program of Faculty of Public Health aims

at catching up underprivileged citizens (e.g. Roma population) regarding health status

assessments and health conditions. In 2012 WHO has designated the Department of

Preventive Medicine in the Faculty of Public Health, at the University of Debrecen, Hungary,

as a WHO Collaborating Centre on Vulnerability and Health.

Life expectancy among marginalized Roma communities is considerably lower than the

average for the WHO European Region. The Centre will promote awareness, political

commitment and action on the adverse social conditions (including poverty and social

exclusion) that make certain groups (such as Roma and other ethnic minorities) vulnerable to

ill health.

Health status assessment among disadvantaged people is evaluated in a yearly basis. These

assessments are also analysed by a specialist of University of Debrecen Faculty of Public

Health. According to these assessments, we are able to determine action that should be

taken in order to reduce socioeconomic health inequalities.


34

Faculty of Public Health have been participating many research programs according to these

evaluations, resulting many publications in this field.

We are able to draw up evidence-based action plans to address socioeconomic health

inequalities. After identifying problems and evaluation of the situation the first step of the

actions clearly is realignment of vulnerable groups.

3.2 Using an evidence-based approach

[How much does evidence usually matter in decision making? Are strategies usually

evidence-based in your region? Were there enough available (regional) data on health

status, social determinants of health to conduct the necessary needs assessments for

designing this action plan?

Have you managed to build your Action Plan on the collected evidence? To what extent did

the evidence gathered influenced: setting the priorities; choosing actions and interventions?]

According to the assessments mentioned in previous section, we are able to determine

action that should be taken in order to reduce socioeconomic health inequalities. Evidence-

based researches have been conducted like “A comparative health survey of the inhabitants

of Roma settlements in Hungary” by Karolina Kósa, “Studying vulnerable populations:

lessons from the Roma minority” by Karolina Kósa and Róza Ádány.

City of Debrecen is engaged in reducing health inequalities among underprivileged people.

Revision of previous health status assessment reports is currently in progress.

3.3 A community & intersectoral approach

[Health inequalities is a cross-cutting issue. In dealing with health inequalities, it is important

to implement a community/intersectoral approach to develop action. For this reason regions

were encouraged to set up a Regional Action Group with stakeholders from various

sectors/organizations who either directly or indirectly are dealing with the inequity problem.

Please describe how you managed to set up the Regional Action Group. Please list the

member organisations of your RAG in the Annex of this part of the document. Have you had

already used an intersectoral approach before? Is this something that is part of your

institutional/working culture or quite the opposite? If it was not possible to set up a Regional

Action Group, please explain why not (e.g. no interest or support, reluctance in sharing

information or competencies).]

Regional Health Council has been working, but their work is discontinued. There is no other

organization which is able to take over its role and activities.

HealthEquity 2020 project drew attention to the need of the reorganization of such

institution.


35

European Union grants allocation is interpreted locally, that means there are different

operative programs. In Észak Alföld region regional development operative program is

coordinated by Hajdú-Bihar County. The region is determined in focusing health inequality

problems.

3.4 Building Support

[How would you describe the political/institutional support that you have received during

your pursuit of developing an action plan to tackle health equity (either in the framework of

a RAG discussed above or in any other forms)? Have key decision-making bodies

(municipalities, local/regional governments, Ministry of Health, other professional bodies at

the health and social field, European Structural and Investment Funds Managing Authorities,

etc.) been involved in drafting/adopting/implementing the action plan? Have they been

supportive?]

As mentioned in previous section European Union grants allocation is interpreted locally.

Regional development operative program is coordinated by Hajdú-Bihar County. Thanks to

strong political support, the region is engaged focusing on health inequality problems.

During the design of operative programs regarding Hungary, Ministry of Human Resources

continuously consulting with Hajdú-Bihar County concerning health issues (e.g. which

operative problems should focus on inpatient and outpatient care).

Regional organizations are constantly consulting with Ministry of Human Resources and

Medical Chambers and managing authorities. Solutions for health conditions problems are

made locally. Regional cooperation between these institutions is necessary in order to get

funding from operative programs.

3.5 Typology of the region

[The characteristics of a region can have a strong influence on the process of developing an

action plan at the local level. Is your region only an administrative/statistical reporting unit

or an autonomous region with higher competences in designing policies at local level? What

are the opportunities usually to develop actions for health/health equity at a regional level? ]

The Észak-Alföld regional development operative program is coordinated by Hajdú-Bihar

County. By comparing regions in Hungary Észak-Alföld is the least developed region and has

the worst indicators in health issues. The region has a better competence in realizing

problems concerning health inequalities. Thanks to strong political support, the region is

engaged focusing on health inequality problems.


36

3.6 Challenges

[Describe the major challenges you encountered in the process of attaining your goals during

the course of the action learning process (e.g. changes within the institutional context, lack

of support from higher level authorities, weak collaboration or partnership with others

sectors/stakeholders, lack of data to make the case of health inequalities, lack of financing

or capacities to take forward actions)?]

There might be two major challenges in the process of attaining our regions’ goal.

Challenge 1: Regional Health Council is abolished. There is a need for a same organization in

order to coordinate cooperation between the actors of the region and the country.

Challenge 2: Vulnerable groups, disadvantaged people are hard to reach therefore it is

complicated to ensure their participation. This results many inadequate assessments.

3.7 Validating the regional Action Plan – Integrated planning

[One guarantee of successful implementation of actions is taking an integrated approach by

incorporating specific, health inequality focused action plans into wider regional and/or

national development plans in order to promote and ensure synergies in decision making

and funding. This means that higher-level decision-making processes can validate regional

plans. However, getting those priorities integrated into a regional or even a national

planning cycle is one of the biggest challenges in this work. What preparations have you

made through your RAG or any other way to have the Action Plan join a more powerful

process (regional planning, regional masterplan, national reform programme, etc.) or what

opportunities exist for this?]

Partners participating in the implementation of our action plan should be involved in

planning processes, commentaries, and research. University of Debrecen Faculty of Public

Health is ready to participate in these activities and to disseminate outcomes in local,

regional and national level.

3.8 Financing the Action Plan

[Do you think you (your region) have enough knowledge about using European Structural

and Investment Funds (ESIF) in your own country? How do you get the information? If no,

why?

What investment opportunities have been identified for your region under ESIF? Are

health/health equity issues compatible with them? Or are any of them health related?

Have your region had any opportunities to influence the drafting of the Operational

Programs or the overall programming process?


37

What about your stakeholders? Do you have the possibility/competences/know-

how/resources to access this type of funding?

If you think about the financial aspect of the developed action pan, what future actions are

you planning to take to finance it? What resources do you have available for implementing

the Action Plan? What resources do you think will be available in the future? Is there an

opportunity to fund the Action Plan from ESIF? Please add into details that are not explained

in the Action Plan.]

Észak-Alföld region has access to knowledge about using European Structural and

Investment Funds. There are several regional development agencies that help the

appropriate use of funds.

Recently formed organization of the Municipality of Debrecen is named EDC Debrecen Urban

and Economic Development Centre. The centre’s aim is to help the region in using European

Structural and Investment Funds. The EDC also designs comments and influences the

drafting for Operational Programs.

Municipality of Debrecen is the centre of the region. The city designed a Health Industry

Strategy for 2014-2020, determining actions and financing opportunities for actions. These

actions have also a huge regional impact.


38

3.9 Benefits for the region, lessons learnt, good practices

[What do you think are the major achievements of your planning process? What main

lessons your team learned during the course of developing/adopting the action plan? What

are the main influencing factors and drivers for your success? What good practices or

recommendations would you like to share with other regions? What helped you overcome

some of your challenges, problems?]

While developing the action plan made the chance to realize HealthEquity 2020 project was

a great opportunity to examine our region potential. We also had the chance to get an

insight to other European regions planning processes. We discovered that there is a room for

improvement. In order to achieve our goals we need to make policy makers and universities

cooperate, because problems just can be identified and solved together.

3.10 Cascade learning into other regions

[On of the objectives of HE2020 project is to cascade learning from HE2020 project into other

regions. Have you managed to share your learning and experiences from the project with

other regions (in your own country or with any other regions in the EU)? How important do

you think for your region is to build working relationships nationally or internationally with

other regions in order to exchange experiences and learn from each other?]

Due to the HealthEquity 2020 project we had the chance to participate in a work based on

knowledge-sharing. We are ready to participate in similar project in the future as partner

instiution.

We experienced there is professional expertise by HealthEquity 2020 partners in different

health related fields that we understand as a good practice we could use and apply.


39

3.11 Annex – Information on the Regional Action Group

Official name of the group:

List of member organisations of the Regional Action Group

1. Municipality of Debrecen

2. Clinical Centre of University of Debrecen

3. University of Debrecen

[Any other information concerning the work of the RAG (e.g. working method, who is

coordinating the group, responsibilities etc.)]

Clinical Centre of University of Debrecen is responsible for coordinating the group.

Észak-Alföld

Regional Health

Industry Strategy Created by the University of Debrecen and Szinapszis Kft.

2015

1

TABLE OF CONTENTS

1. Executive Summary ......................................................................................................................................... 3

2. Methodology ................................................................................................................................................... 5

3. Hungarian Health Care System ....................................................................................................................... 6

3.1. Brief introduction to the financing structure os the healthcare system and its effects ........................ 6

3.2. Levels of Healthcare in Hungary .......................................................................................................... 10

3.2.1. Primary Healthcare.......................................................................................................................... 10

3.2.2. Outpatient Specialized Care ............................................................................................................ 11

3.2.3. Inpatient Specialized Care ............................................................................................................... 13

3.2.4. Progressive Healthcare .................................................................................................................... 15

3.2.5. Financing of Healthcare Services ..................................................................................................... 16

3.3. Managed Patient Care ......................................................................................................................... 23

3.4. Healthcare Quality Management System ............................................................................................ 23

4. Regional State of Play report ........................................................................................................................ 24

4.1. Regional macro analysis ...................................................................................................................... 24

4.1.1. Relevant National Data for the Health Sector ................................................................................. 24

4.1.2. Portrait of the Region ...................................................................................................................... 26

4.1.3. Main health sub-sectors today ........................................................................................................ 28

4.1.4. Ecosystem for Health Innovation .................................................................................................... 30

4.1.5. Regional Stakeholders ..................................................................................................................... 31

4.1.6. Human Capital: Education and Entrepreneurship ........................................................................... 32

4.2. Hajdú-Bihar County ............................................................................................................................. 34

4.2.1. Priority no. 1: Sustainable Environment ......................................................................................... 36

4.2.2. Priority no. 2: Complex Development of the County�s Agriculture ................................................. 37

4.2.3. Priority no. 3: Competitive Economy .............................................................................................. 38

4.2.4. Priority no. 4: Improvement of Accessibility in Hajdú-Bihar County ............................................... 40

4.2.5. Priority no. 5: Intelligent Society ..................................................................................................... 42

4.2.6. Priority no. 6: Healthy and Caring Society ....................................................................................... 43

4.2.7. Priority no. 7: The Development of a Supportive Environment for an Innovative Economy in

Debrecen ....................................................................................................................................................... 44

4.3. Jász-Nagykun-Szolnok county .............................................................................................................. 47

4.3.1. Overall Objective no. 1: A Strong Link With the Development Axes of the Macroeconomy .......... 52

4.3.2. Overall Objective no. 2: Dynamic Balance of Diverse Cultural Landscapes .................................... 53

4.3.3. Overall Objective no. 3: Healthy, Well-Educated Population, Cooperative Society........................ 55

4.3.4. Overall Objective no. 4: The Regional-Structural Framework and Relations of Regional

Development in the County .......................................................................................................................... 57

4.4. Szabolcs-Szatmár-Bereg county .......................................................................................................... 58

4.4.1. The County�s Set of Objectives ........................................................................................................ 60

4.4.2. Overall Objective no.1: The Active County ...................................................................................... 62

4.4.3. Overall Objective no. 2: the County Showing Solidarity.................................................................. 63

4.4.4. Overall Objective no. 3: The Attractive County ............................................................................... 63

4.4.5. Strategic Objective no. 1: Competitive Food Industry .................................................................... 64

4.4.6. Strategic Objective no. 2: Green County ......................................................................................... 65

4.4.7. Strategic Objective no. 3: Proactive County .................................................................................... 65

4.4.8. Strategic Objective no. 4: Well-Educated County ........................................................................... 66

4.4.9. Strategic Objective no. 5: Developed Center .................................................................................. 67

4.4.10. Strategic Objective no. 6: Dynamic Centers and Service-Providing District Centers .................. 68

4.4.11. Strategic Objective no. 7: LIvable Countryside and Converging External Peripheries ................ 69

5. Stakeholders in Debrecen ............................................................................................................................. 71

2

5.1. Regional Business Map ........................................................................................................................ 71

5.2. Pharmaceutical Industry ...................................................................................................................... 74

5.3. Medical Devices, Medical Appliances and Diagnostics (including eHealth, mHealth) ........................ 75

5.4. HEalthcare Services, Privately-Financed Patient Care ......................................................................... 79

5.5. Medical Tourism .................................................................................................................................. 83

5.6. Functional Omics ................................................................................................................................. 84

5.7. Functional, Healthy Food ..................................................................................................................... 86

5.8. Health and Bioinformatics ................................................................................................................... 89

6. Human resources .......................................................................................................................................... 92

6.1. The Human Resource Background (Doctors, Dentists, Nurses) ........................................................... 92

6.2. The Need for New Competencies ........................................................................................................ 92

7. SWOT analysis ............................................................................................................................................... 95

8. Bibliogrpahy .................................................................................................................................................. 98

9. Tables and Figures ......................................................................................................................................... 98

3

1. EXECUTIVE SUMMARY

Regions are key players in the EU�s R&D strategy. Észak-Alföld is the innovative region of health

industry, agro-industry and IT, where the priority areas of innovation include the already significant

agricultural and thermal research potential, the strengthening of life science research bases and their

interconnections with IT developments, moving towards the appreciated sectors of the global

economy (pharmaceuticals, medical technologies and devices, genomics, diagnostics, nanotechnology,

functional food, healthcare ICT, eHealth/mHealth). Both fields include big multinational companies,

suitable for the role of multiplicator, as well as regional SMEs and companies formed for the utilisation

of the economic results (spin off and start-up companies). In the knowledge centres of the Észak-Alföld

Region, in a unique manner in the country, joint R&D programs have been launched in a number of

areas both in the health industry and the development of innovative functional food and renewable

energy. A significant network of relations between industrial companies has been created in the region

within these joint programs. It is also very important that the knowledge and commercial basis with

Debrecen-Nyíregyháza as its centre has a good chance of becoming one of centers of the entire

Central-Eastern European region in these traditionally developed Hungarian fields of industry. Regional

strategic planning (S3) is very important, not only from the aspect of gaining local competitive

advantage, but also appointing the ways and methods of cooperation, not forgetting the growth factor

and job-creating effects. The existing infrastructure throughout the region is not enough; innovative

workforce development is also indispensable. Intellectual capacity is one of the prerequisites, which

can be connected to infrastructural development. Innovation is based on knowledge, companies need

to recognize that they can benefit and have a competitive edge - get better use of R&D potential -

when investing in knowledge and innovation. Collaborative innovation and dissemination of innovative

projects are essential. Involvement of professional investors, private equity and venture capital are of

priority importance in solving the capital shortage problem. Within innovation, sectors where the

companies of the region have a good chance in competition on the global market are the health

industry including genomics, nanotechnology, diagnostics, the manufacturing of medical instruments,

and the development of pharmaceuticals. In the field of agriculture, the headway made by renewable

energy applications, as well as by functional and healthy food has opened new prospects. A major

competitive advantage can be achieved by linking the individual partial areas to one another, as well

as by developing a third area, IT. The top 100 companies of the region include a high number of IT

enterprises. The majority of research and development projects are conducted at universities or

institutes and collaboration with the industry is limited. The availability of professional and business

advice is increasing, but it is still expensive for most of the SMEs. The regional biotech sector is made

up of small companies. Therefore, the size � besides the money and time shortage � is the biggest

4

hindrance of the prosperity of the companies (economies of scale) or rather the fact that they are not

able to reach the potential companies, customers. In some cases they cannot afford the needed

services due to financial limitations or they do not use external help because they consider themselves

too small to enter into it alone. Clusters and other forms of cooperation seem to be good possibilities

for them, since one main obstacle of innovation is the real practical cooperation of companies,

research centres, and the public and private sphere. The main aims of the region are to increase

competitiveness, to demonstrate, promote, apply regional research results on the domestic and

international scenes more and more, and to make better use (more fully and effectively) of the

intellectual property available here.

Debrecen, the Vital City

Debrecen is the most significant city of the Észak-Alföld region and it is also the centre for actors of

industry providing close to half of the GDP. In the strategy, therefore, the survey of the city�s health

industry received special attention as it has a direct effect on the competitiveness of the entire region.

Debrecen, by means of the �Vital City� complex program, aims to become an innovation centre locally

as well as in the Euro-region, building on the development of the economic structure that would

strengthen the interrelatedness of local knowledge-intensive sectors and the cooperation of local

players. The objective of the present health industry strategy is to explore the strengths of the sector

(by selecting it from among the key sectors and analyzing the local health industry based on factual

data) and building on this to specify those objectives and related action with which such developments

can be realized in our city that bring measurable benefits economically and socially as well.

The concept of internationalisation is discernible throughout the strategy: including the international

positioning of the city as a health industry centre, helping the more dynamic entry of businesses into

the international market, and the positioning of research globally. For the successful realization of the

set objectives, the entire region has to cooperate for international competitiveness. We can realize

this goal only together.

With the broader interpretation of the health industry, all relevant sectors present in the region have

been analyzed in the following groups: pharmaceutical industry, medical device and diagnostics

(including eHealth/mHealth), healthcare (including privately-financed patient care), medical tourism,

functional omics (e.g.: genomics) and bioinformatics as well as functional food. It should be

emphasized that although this strategy focuses on the health industry, due to its nature the planned

developments may and should be linked successfully with the other local key sectors.

5

2. METHODOLOGY

This chapter introduces the methodological framework of the study that can contribute to the better

understanding of the material and may facilitate the utilization of its findings, while also reflecting the

professional methodology and implementation.

In the process of drawing up the Regional Health Industry Strategy, we first analysed the national

health care system. It is crucial to understand the Hungarian operating environment, and health care

especially, as several branches of industry become interested parties through this and the situation of

health care plays a central role in national, regional, and local decision making also. Therefore, the

Healthcare Quality Management System is discussed in a separate chapter.

After the national overview, we completed a regional macroeconomic analysis. The analysis was built

on secondary databases, with the continuously updated and maintained database of the Hungarian

Central Statistical Office (Központi Statisztikai Hivatal) providing an excellent resource. We also used

other studies analysing the region based on macroeconomic data.

The main section of the publication is made up by the county analyses. The creation of the counties�

Integrated Urban Development Strategies (IUDS) within the Smart Specialization Strategy (S3) took

place simultaneously with the current project. The methodology of the county development strategies

is the same as that of the current study. The reason for the use of the uniform methodology is to avoid

wasting resources also available on the county level and allocated for utilization. Therefore, as part of

the IUDS such materials have been created that can be used by the present study and project also as

they were not prepared in parallel with each other but jointly.

The chapters of the study presenting the county analyses include the action plans separately with the

necessary actions detailed within them. Necessary interventions, needed challenges and barriers have

also been listed. County authorities are responsible for carrying out these actions thus their planning

was related to the specification of strategic objectives and priorities.

Debrecen, a city with county rights, is a key strategic centre not only in the region but also nationally.

Due to such key significance, the city as well as the region were analysed separately. We also built on

primary research made in 2014 for the Health Industry Strategy of Debrecen; this way it could provide

new data for the present strategy also. The Human Resources chapter is another important section as

part of which we conducted direct interviews with the most significant actor in the region, the

University of Debrecen.

6

3. HUNGARIAN HEALTH CARE SYSTEM

3.1. BRIEF INTRODUCTION TO THE FINANCING STRUCTURE OS THE HEALTHCARE

SYSTEM AND ITS EFFECTS

The basic theoretical principles of the Hungarian healthcare system include accessibility, equality, full

care, and ensuring gratuity.

It is well known that the expenses of healthcare systems in developed countries grow faster and to a

greater extent than the GDP of the particular country. The reasons for this include the great

improvement in technology, aging society, and the increase in customer awareness and needs of the

population. As a result, the sustainability of the healthcare system (while simultaneously ensuring the

above principles) represents a significant issue in all countries.

Thus, besides the publicly-funded care system, the role of publicly-financed care increases significantly

everywhere. The financing of private care can take place in two ways: in all developed countries it

appears either as a direct private expense or a savings account in the form of an insurance or savings

fund scheme. As in Hungary direct private financing dominates, one of the long-term objectives of this

study is to assess the long-term opportunities for the development of private insurance in Hungary.

The Hungarian healthcare system, which is primarily financed (although to a decreasing degree) by

public central taxes and targeted contributions, is built on the principle of progressive healthcare. The

objective of this is to provide care for the patients at the lowest possible level, where the conditions

are already available for the needs of the patients based on their situation.

This structure has its roots in the 70s and its principles have remained unchanged in many respects.

The healthcare system itself is based on the system of general practitioners which, depending on the

size of the settlement, can be separated into primary care for adults and children. On this level the GP

system is complemented by the district nurse system and primary dental care, occupational healthcare

and in certain cases with special home care. These elements together make up the Hungarian primary

care system and at the same time the first level of the healthcare system.

The second level of healthcare is occupied by specialized care, with two different parts, outpatient and

inpatient care. The specialized care of outpatients takes place in outpatient clinics, those patients are

treated here whose care is not possible due to the lack of professional or technical criteria in primary

care. The places for special care are the specialized patient care units operating in the hospitals. The

treatment of inpatients takes place within the hospital system in such cases when the condition of

7

patients does not make it possible to treat them as outpatients and/or if the type of care itself requires

staying in hospital.

The care for inpatients, and to a certain degree that of outpatients as well, can be divided into four

levels depending on the level of progressivity: national, regional, county and basic level.

On the national level only those special treatments are performed for which specialists,

instrumentation and support services should be maintained only at a few places in the country, e.g.:

transplantations, rare operations. On the regional level such rare diseases are treated or such rare or

other treatments are provided where due to the limitation of professional skills and instrumentation,

they are expedient to be installed only in case of the full utilization of instruments; e.g.: neurosurgery,

oncology. The county level is a more complex place including almost all special areas, where they are

capable of treating almost the full range of diseases. On the basic level¸ i.e. the level of city hospitals,

they provide such treatments that are simpler but still require hospital care and which typically affect

a lot of patients. On this level typically only a few basic professions are present, such as internal

medicine and obstetrics.

This organizational principle, of course, is affected by numerous factors, the strongest of which is the

issue of financing.

As the financing of primary care occurs mostly in the form of a capitation system based on population

numbers, those working in primary care do not have an interest in providing final care on the given

level. Thus the rate of consultations with specialists and forwarding of patients is really high resulting

in the overloading of the middle level, i.e. outpatient care. (specialized outpatient care � very high

patient numbers, German example � activity-based financing).

Inpatient care has Diagnosis Related Group (DRG) based performance financing, which categorizes the

same types of diseases into the same group and assigns one value, amount to them. Due to the fact

that the budget is closed from the top, this DRG/HUF value is redistributed in the ratio of overall

performance.

The review of this system was ended and by now the real cost of certain medical procedures does not

cover the level of expenses, while there can be such groups as well where due to the decrease of costs

the particular treatment can be performed profitably (of course, there are very few of these).

An additional basic feature of outpatient care is the performance volume limit. This specifies for a given

institution how much the insurer will finance from a particular type of medical procedure. Thus it can

happen that there are waiting lists at an institution as over X number of such procedures the insurer

8

does not receive compensation. Thus it does not have an interest in the unlimited care of patients

turning to it not even if there are available free capacities.

Developed countries specify the structure and tasks of their healthcare systems through legislation. In

Hungary, at the time of political transition, the use of healthcare services became subject to insurance

coverage based on the obligation of paying contributions. Certain social groups were excepted and

there were layers that were simply not included in terms of this obligation. In Hungary Act CLIV of 1997

on Health (Health Act) and Act LXXXIII of 1997 on Mandatory Health Insurance (Health Insurance Act)

that fulfill this expectation supplemented and amended by numerous pieces of legislation

(government and ministerial decrees).

The healthcare system, its organizational units, management and thus its different levels in Hungary

can be derived from the Hungarian Health Act:

Section 6. Each patient shall have the right to receive, in an emergency, life-saving care, care to prevent

serious or permanent impairment to health, as well as to have their pain controlled and suffering

relieved.

Section 7 (1) Each patient shall have the right, within the frameworks provided for by law, to

appropriate and continuously accessible healthcare justified by their health condition, without any

discrimination.

Section 75 (1) The healthcare system makes it possible to provide healthcare services in a manner

coordinated with the implementation of public health objectives.

(2) The objectives of healthcare services are to contribute to the maintenance of individual health, to

restoration of health to the extent possible, to reducing the deterioration of health, and to promote

the integration of persons with altered health into work and into the community.

(3) The healthcare system is built upon a system of institutions that is intended to provide

differentiated care to persons in differing states of health and is based on the principle of division of

labor and progression, in which the combination of all specific features that make up the state of health

of an individual shall determine the level of care necessary (hereinafter: progressive healthcare).

(4) Within the healthcare system, available resources shall be used efficiently to improve the overall

state of public health.

Section 76 (1) The principle of progressive healthcare shall be valid for all levels of healthcare.

9

(2) The personnel and objective conditions necessary to provide the various healthcare services within

progressive healthcare shall be defined under separate statute.

Section 87 (1) The healthcare delivery system shall provide healthcare to patients on an outpatient

basis, within an inpatient facility, and in their homes.

(2) The healthcare delivery system shall operate in keeping with needs assessed in the course of public

health activity.

(3) Expansion of the healthcare delivery system and improvement of its standards shall take place in

coordination with socio-economic resources

In Hungary, the financing of healthcare primarily rests on the health insurance contributions paid by

employers and employees and the healthcare contribution paid by employees, as public funds, while

private healthcare spending is not estimated at more than 20-30%. With the division of the Social

Insurance Fund, the Health Insurance Fund was created, supervised by the Government, while with

the division of the Directorate of the National Social Insurance Fund the National Health Insurance

Fund (NHIF) was created, its management supervised by the government through the Minister of

Health (state secretary for health). In accordance with Act CLVI of 2011, since 1 January 2013

employers shall pay a 27% Social Contribution Tax after the gross salary paid to the employee,

however, there are certain special cases when this amount is lower; e.g., in the case of employees over

55 or under 25 years of age it is 12.5%; i.e. the employer receives a reduction of 14.5 %. This stipulation,

however, is valid only for the business sector. The employee shall pay a 10% pension contribution, 7%

health insurance contribution (4% in kind, 3 % financial), and 1.5 % labor market contribution (18.5%

in total). There has been no fixed healthcare contribution after salaries for 3 years. The cap of

contribution payments was terminated on 31 December 2012. The rate of contributions is stipulated

by Act LXXX of 1997.

10

1. Figure: The Financing Environment (Dózsa Cs. 2007) Egészségbiztosítási Reform 2007-2009. [Health

insurance reform, 2007-2009] http://www.eum.hu/archivum/hirek-esemenyek/egeszsegbiztositasi-090921

3.2. LEVELS OF HEALTHCARE IN HUNGARY

Today emergency care and programmed, pre-arranged (non-emergency) care are becoming sharply

distinct on all levels of healthcare.

3.2.1. PRIMARY HEALTHCARE

Section 88 (1) All patients shall be assured continuous long-term healthcare based on a freely chosen

personal relationship, in or near their places of residence, irrespective of gender, age or the nature of

their illness.

General Practitioners

In 1992 the previous district physician system was reorganized into a GP (family doctor) service which

created the basis for the free choice of doctors in Hungary. The general practitioner who is easily

accessible by the public is a key figure in all European healthcare systems. There is a wide variety of

expectations towards these doctors who provide fast and direct help, decide on ambulance service or

patient transport, direct patients to specialists or hospitals, treat patients with less serious diseases as

outpatients or in their home, and also provide advice on lifestyle. Their role ranges from the support

of the family to being the gatekeepers to medical insurance while the development of science (e.g.,

Parliament Annual budget

Ministry of Human

Capacities Professional rules

Government Financing techniques

NHIF Financing

- monitoring - controlling

Medical profession Code

Professional protocols

11

one can hardly work without modern diagnostics and consultation nowadays) and the transformation

of society (e.g., urbanization, aging) require constant adaptation from their part as well. They are

affected by healthcare reforms as well, receiving performance-based financing (adjusted capitation

payment) but in several countries they can account specific healing performance as well. In 2000

practice right was introduced among doctors performing individual medical practice with regional

service obligation, on the basis of which medical activities can be pursued by the doctor only personally

and one doctor can have only one practice right; however, the successors are entitled to it if they meet

all requirements.

In Hungary their management in the last decade can be criticized, although they count on doctors in

all health reforms. Their tasks require further specification, their workload adequate proportioning,

on-call duties a radical solution and a part of their income needs whitening, more transparency.

Family pediatricians

A form of care available in Hungarian cities, a transition between primary healthcare and outpatient

specialized care with a strong caring profile. It is not well organized in scarcely populated regions of

the countryside, thus a difference in quality cannot be denied between the care of children and adults

in certain areas.

Dentists

They used to play a strong part in primary healthcare. Reforms of the past decade relaxed their role

and decreased support (later a part of these were corrected). A significant section of the population

does not use dentistry services with the necessary regularity and this is visible � among others � in the

number of deaths related to oral cancer in Hungary. Probably a regulation and interest similar to that

of general practitioners would bring significant public health results in terms of the oral hygiene of the

population.

3.2.2. OUTPATIENT SPECIALIZED CARE

Section 89 (1) General outpatient specialized care shall be understood as one-off or occasional

healthcare provided on a referral from the physician regularly attending and caring for a patient, or on

the self-referral of the patient, or continuous specialist care when the patient has a chronic condition

not necessitating inpatient care. General outpatient specialized care shall be provided at a venue

accessible by means of public transport without endangering the health of the patient (hereinafter:

close to where the patient lives).

12

In the course of the development of social insurance and state healthcare services, during the two

world wars an increasing number of patients had to be cared for, and while primary care was not

sufficient for them they did not need expensive hospital care either. At first, outpatient clinics with

multiple specializations emerged primarily in cities. Conceptual uncertainties have been visible from

the very beginning and have lasted for more than 80 years now. It is a basic question which approach

is more adequate: to build it together with a hospital and operate it in an integrated manner or to

bring it even closer to the population independently, as a patient care �factory�. The latter markedly

appeared in the �Semashko (Soviet) model� that was dominant in Eastern Europe for decades. To

provide another example: German specialist doctors in the �Hartmann alliance� were successful in

achieving that programmed outpatient specialist care could be provided only by �settled specialist

doctors� for decades, only emergency care and consultations could be given at the hospitals. In

Hungary, however, outpatient care is increasingly connected to inpatient specialist care, meaning

outpatient specialist visits are mostly operated by hospitals. The financing of outpatient specialist care

takes place based on performance financing expressed in scores associated with activities and taken

over from the German healthcare system (even in the case of high-value imaging diagnostics � CT,

MRI). In the process, a score is established for the particular types of examinations and procedures

which reflect the cost ratios between the specific activities.

2. Figure: Outpatient specialist care in Hungary (Kincses Gy. 2007) Egyenl!tlenségek a magyar

egészségügyben [Inequalities in Hungarian healthcare]

http://www.eski.hu/new3/publ/eloadasok/2007/egyenlotlensegek%20%202007%20NET%20r_elemei/fram

e.html

13

3.2.3. INPATIENT SPECIALIZED CARE

Section 91 (1) General inpatient specialized care shall be understood as healthcare provided in an

inpatient facility close to where the patient lives. The patient shall access said facility, as set forth under

separate statute, through a referral by the physician providing the patient with regular care, by an

attending physician or other authorized person, or by the self-referral of the patient himself.

(2) Care, as set forth under Subsection (1) may consist of

a) diagnosis, treatment, rehabilitation or nursing, provided to a patient who has been admitted as an

inpatient, including long-term care,

b) care, with the objective set forth in Paragraph a), provided at specified times of day,

c) singular interventions or a course of treatment which requires subsequent monitoring for a specific

period of time, and which guarantees further immediate healthcare, if necessary, during the

monitoring period.

Section 92 (1) In addition to the level of care set forth under Section 91, enhanced inpatient specialized

care with enhanced diagnostic and therapeutic backup and the ability to resolve medically complex

tasks shall be provided for a predefined number of population as determined under separate statute

by the incidence of diseases.

A special form of specialist care is hospital care where diagnostic and therapeutic services are provided

in a hotel environment. The needs of the population (patients), the development of medical sciences

and technology can be measured in the improvement and transformation of hospitals as well. Before

the discovery of antibiotics, pavilion system hospitals were established practically on a one profession,

one building basis. In the last fifty years, the development of hospitals took place with the

consideration of the findings of modern business organization (widespread use of information

technology, business management efficiency, logistics systems, quality assurance-quality control). In

terms of architecture, the block hospital can provide the most appropriate structure for effective care

but within it we find well separated functional units: emergency admissions, diagnostics, intensive

care, operating system, nursing units.

Until the middle of the 20th century, one of the largest problems was the accessibility of hospitals (the

transportation of patients), thus, in developed countries (in relatively heavily populated areas)

hospitals were built every 20-30 km. The development of motorization and communication (up until

helicopter rescue and patient transport) greatly influenced this practice. Professional and economic

efficiency is a priority requirement also from a financial perspective. Only the sufficient number of

14

patients can justify the maintenance of a hospital and an organizational unit (e.g. department) within

it and this requirement is further strengthened by the now general performance-based financing.

Today the hospital structure in Hungary shows the following characteristics:

- Urban hospitals: care provided close to a population of 50-150 thousand people, in the

area of some �basic� professions (typically internal medicine, surgery, obstetrics and

gynecology, pediatrics). Due to morbidity conditions and demographical changes, pediatric

care was terminated at many urban hospitals (there aren�t enough children to be treated

in hospital). Today some of the gynecology departments witness a similar fate and

professional discussion has already been started whether programmed surgical care (e.g.

breast cancer operations) can be performed if the annual case number is low (and thus

medical practice is insufficient) and the medical environmental conditions (histological

diagnosis, chemotherapy, radiation therapy) are incomplete. It is a further problem for

small hospitals that for their normal continuous operation a bigger staff would be

necessary than what they are capable of supporting. Nowadays the program for the

transformation of urban hospitals is taking shape, instead of active care, the care,

rehabilitation and nursing of chronic patients comes to the center of their activities.

- County hospitals: these are capable of providing definitive and emergency care for a larger

number of patients in several fields. Their service area covers 150-500 thousand people.

- Regional centers � healthcare providers also performing higher educational activities

(medical science centers): they provide complete specialist care including cardiac surgery,

neurosurgery, burn surgery, pediatric surgery, transplantation and complex oncological

care, as well as the diagnosis and therapy of rare diseases. The regional centers also

perform county and urban hospital functions in their area.

- Specialist hospitals, national institutes: established for the treatment of certain diseases

which are crucial from the perspective of public health and for addressing organizational-

methodological issues (in the areas of TBC, cardiology, rehabilitation, cardiovascular

disease, oncology, traumatology, etc.). Their long-term role cannot be predicted yet in the

healthcare system under transformation.

Long-term nursing services today are provided mostly at hospital units or in a home nursing form. Fast

improvement is expected in this area, the establishment of nursing institutes can be predicted which

become markedly detached from active patient care; these will be capable of realizing partial (part-

time, non-residential) and episodic forms of nursing as well in their areas.

15

In the past decades, the Hungarian hospital structure did not precisely reflect the above didactic

description but it corresponded to it in its main points.

Before 1990, the limited financial opportunities, the clientele system, and political voluntarism

prevented the development of a system enabling regionally fair care. Later the governments changing

every four years and the resource needs of economic transition typically had a negative effect on

healthcare in Hungary.

3.2.4. PROGRESSIVE HEALTHCARE

Its definition is seemingly straightforward: the patients have to be cared for at the place, level

appropriate for their condition (needs). It has two aspects, emergency and programmed care. These

often �overlap�, after examination a case that seems to require emergency care can be classified as

programmable, while a programmable patient (illness) may become acute (see, for example, the

emergence of indicated coronary symptoms as sudden heart attack, etc.). The general practitioner

directly observing the patients and the emergency service (which can today be an on-call medical

health service or ambulance service, while the most advantageous would be the combination of the

two that already operates in several parts of the country) are in a key position.

It is relatively easy to find the appropriate level of progressive healthcare for acute patients as, besides

all its problems, we have a working, uniform ambulance service which gets the patient to the on-duty

emergency system at the hospital (receiving body) operating under the supervision of ÁNTSZ (National

Public Health and Medical Officer Service) through the institutional owner ÁEEK (State Healthcare

Centre) or EMMI (Ministry of Human Capacities). Meanwhile it can perform professional life-saving

activities if required. If a higher level of progressive care is needed for the definitive care of the

patients, then they can be transported to the appropriate caring institution under precisely planned

professional conditions after the stabilization of their life functions. This system, based on the capacity

of response units and emergency ambulance at the ambulance service, is perfectly complemented by

the MICU (mobile intensive care unit) and the network of high-performance rescue helicopters.

In the case of patients with chronic or stable conditions, the general practitioner has to specify on

which level the patient care should be continued, corresponding to the condition (illness) of the

patient. This might require the use of diagnostics (laboratory, imaging) and the specialist doctor

(institution) at the outpatient or inpatient care has to be contacted in the form of consultation in the

case of issues exceeding the competence of the GP.

16

The notion of subsidiarity is little known and used in Hungary even though it is necessary for the

specification of the use of healthcare. It means that the kind of care most suitable and necessary for

the condition of the patient should be provided at the closest and the necessarily and sufficiently

lowest level. The principle of subsidiarity is especially important in such systems where the costs are

not born by the patient but are financed by public funds (social insurance, budget). For example,

because of a simple illness that could be treated on an outpatient basis a patient should not be

hospitalized. However, the performance-based financing introduced recently significantly superseded

the principle of subsidiarity as the pressure from local financial interests (the accounting of the

particular case in the Diagnosis Related Groups) was stronger than professional arguments and public

interest this causing a significant distortion in the healthcare system.

The key question in the modernization of the Hungarian healthcare structure will involve the re-

regulation of the service system and its adequate development.

3.2.5. FINANCING OF HEALTHCARE SERVICES

The operation and financing of healthcare shows significant differences in Europe.

17

3. Figure: The types of healthcare systems according to dominant funding body in EU member countries

(Borbás I - Kincses Gy 2007) Egészségügyi rendszerek az Európai Unió régi tagállamaiban [Healthcare systems

in the old member countries of the EU] http://www.eski.hu/new3/kiadv/zip_doc/Nyugat_Europa.pdf

The framework of the financing of the Hungarian healthcare system is well reflected by the

composition and cumulative figures of the Health Insurance Fund�s total revenues and expenses.

In 2014 the total revenue of the Health Insurance Fund was HUF 1,907,078,423,000 (EUR

6,356,928,077) consisting of the following sources:

1. Revenues and contributions

1.1. Share of social contribution tax due to the Health Insurance Fund and employers� health

insurance contributions

1.2. Contributions by the insured

1.3. Other charges and contributions

1.3.1. Healthcare service contribution

1.3.2. Contribution paid according to agreement

1.3.3. Employer�s contribution to sick-pay

- Healthcare system with multiple

health insurers

- Healthcare system with a single

insurer

- State healthcare system

- Tax-based healthcare connected

to regional government system

- Mixed healthcare system,

primarily financed by state budget

and to a smaller extent social

insurance

18

1.3.4. Rates and taxes for simplified employment

1.3.5. Reimbursement by National Employment Fund (terminating as of 2015)

1.4. Healthcare contribution

1.5. Charge for overdue payments, fine

2. Contributions by the budget

2.1. Budgetary contribution to expenses connected to handling health tasks

2.2. Funds received as contribution paid by the budget

2.3. Received funds for partial coverage of disability, rehabilitation benefits

2.4. Contribution connected to the Workplace Protection Action Plan to Health Insurance Fund

(terminating as of 2015)

2.5. Intended receipt of funds

3. Other revenues connected to health insurance activities

3.1. Private charge for abortion

3.2. Accident and other damage compensation

3.3. Reimbursement of payments, other revenues

3.4. Payments by pharmaceutical producers and distributors

3.5. Reimbursement of benefits based on international agreements

3.6. Repayments of healthcare providers

3.7. Accident tax

3.8. Public health product tax

3.9. Health contribution by tobacco businesses (new item from 2015)

4. Revenues from asset management

5. Revenues used for operation

The total expenses of the Health Insurance Fund for 2014 were HUF 1,907,078,423,000 (EUR

6,356,928,077) consisting of the following:

1.1. Benefits in cash of health insurance

1.2. Infant-care fee, pregnancy and confinement benefit

1.3. Sick-pay

1.3.1. Sick-pay

1.3.2. Child-nursing sick-pay

1.3.3. Accident sick-pay

19

1.4. Sickness benefits

1.4.1. One-time benefit

1.5. Compensation rent

1.6. Accident rent

1.7. Child-care fee

1.8. Disability, rehabilitation care

2. Benefits in kind, other expenses of health insurance

2.1. Curative-preventive health care

2.1.1. General Practitioners� service, GP on-duty service

2.1.2. District nurse services, maternal, child, youth protection

2.1.3. Dental care

2.1.4. Patient transportation and transportation of the deceased as prescribed by physician

2.1.5. Dialysis

2.1.6. Home special nursing

2.1.7. Operating expense advances

2.1.8. Targeted appropriations

2.1.9. Ambulance service

2.1.10. Laboratory care

2.1.11. Combined specialized care (as of 2015 the budgets of outpatient and inpatient care were

combined)

2.1.12. Provision for curative-preventive care

2.1.13. 1st stage of the reform of the GP care system (new item from 2015)

2.2. Subsidy on spa and other medical treatment

2.3. Breast milk supply

2.4. Subsidy on medicaments

2.4.1. Expenses of subsidies on medicaments

2.4.2. Medicament expenses with special procurement

2.4.3. Medicament subsidy advances

2.4.4. Provisions for medicament subsidies

2.5. Subsidy on medical devices

2.5.1. Bandage subsidy

2.5.2. Subsidy on renting medical devices

2.5.3. Subsidy on other medical devices

2.6. Refund of travel expenses

2.7. Expenses resulting from international agreements and treatment provided abroad

20

2.7.1. Emergency care within EEA, Switzerland

2.7.2. Emergency care outside the EEA

2.7.3. Reimbursement of healthcare services planned abroad

2.7.4. Special healthcare services provided abroad

2.7.5. Use of healthcare services abroad which are not available in Hungary

2.8. Provisions for benefits in kind

3. Other expenses of health insurance

3.1. Reimbursement for disbursement agencies

3.2. Postage

3.3. Other expenses

3.4. Compensation of pharmaceutical manufacturers, settlement of accounting differences

3.5. Pharmacy benefits

3.6. Service fee of pharmacies

4. Expenses of asset management

5. Operational expenses

In the last three years the balance of the Health Insurance Fund developed in accordance with the

following:

4. Figure: Development of Yearly Balance of the Health Insurance Fund (2012, 2013, 2014) Source: Table

prepared based on the annual reports of the Budgetary and Financial Department of the Hungarian Health

Insurance Fund.

Year

2014 2013 2012

Revenue of Health

Insurance Fund (HUF)

1 907 078 423 000 1 848 132 586 000 1 744 580 383 000

Revenue of Health

Insurance Fund (EUR)

6 356 928 077 6 160 441 953 5 815 267 943

Expenses of Health


1 907 078 423 000 1 848 645 439 000 1 791 503 635 000

Expenses of Health


6 356 928 077 6 162 151 463 5 971 678 783

Balance of Health


0 - 512 853 000 - 46 923 252 000

Balance of Health


0 - 1 709 510 - 156 410 840

Based on the annual

report of the Budgetary

and Financial Department

of the Hungarian Health

Insurance Fund

21

Although in the last few years the expenses of the Health Insurance Fund grew in absolute

terms, Hungarian healthcare is underfinanced in both absolute and relative terms. The tendency

prevalent within the fifteen years between 1993 and 2008 indicates that even in the case of countries

with more moderate economic potentials the annual average of growth of healthcare/public

healthcare expenses exceeds the average rate of annual growth of GDP in percentage, meaning that

the share of healthcare from the GDP continuously increases. Among OECD countries it is only in

Hungary that the extent of healthcare expenses falls short of the scale of GDP which indicates the

relative decrease in financing (OECD Health Data, OECD Publishing, Paris, 2010a).

5. Figure. The relationship between healthcare expenses and the annual average growth of GDP (%) in OECD

countries, 1993 � 2008 (OECD Health Data, OECD Publishing, Paris, 2010a)

In Hungary the National Health Insurance Fund provides financing for the running expenses of

healthcare providers which, however, does not cover amortization. In the case of healthcare providers,

capital expenditure is covered by the owners. The financing of inpatient specialized care is also

performance-based, built on the classification system of Diagnosis Related Groups (DRGs).

The rules for the accounting of performance-based financing have been modified multiple times since

their introduction in 1993. The most significant change in recent years was the introduction of the

performance volume limit (PVL) in 2004 which besides active inpatient care also affected outpatient

care. According to the PVL, 98% of the converted performance accounted in active inpatient weighting

factor (in the case of outpatient care in scores) for 2003 was accounted with full (100%) national base

fee. The performance reported and accountable above the PVL was accounted in a band system at a

AUS

AUT

BEL

CAN

CHL

CZE

DNK

FIN

FRA

DEU

GRC

HUNISL

IRL

ISR*

ITA

JPN

KOR

MEX

NLD

NZL

NOR

POL

PRT SVN

ESP

SWE

CHE

TUR

GBR

USA

0,0

1,5

3,0

4,5

6,0

7,5

9,0

0,0 1,5 3,0 4,5 6,0 7,5 9,0

Real annual growth in per capita GDP, 1993-2008 (%)

Re

al a

nn

ua

l gro

wth

in p

er

cap

ita

he

alt

h s

pe

nd

ing

, 1

99

3-

20

08

(%

)

22

60% HUF value up to 5%, at 30% between 5 to 10 %, and at 10% HUF value over 10%. The NHIF used

this technique in the case of the 2005 accounting as well, the basis was still provided by the natural

performance converted in accordance with the 2003 classification rules effective from 1 January 2004

and modified by other amendments (other modifications included, for example, further changes in

classification rules, changes in weighting factors related to certain activities or in scores, consideration

of capacity changes during the year).

Another significant change in the accounting of patient care performance came from the second half

of 2006 when band-based financing was ended. The performance volume limit was 95 % of the

weighting factor (score in the case of outpatient care) providing the basis of performance fee paid in

100% in 2005. The performance exceeding this was not accounted. From the second quarter of 2009,

another significant change occurred in the financing of both inpatient and outpatient specialized care.

The rule according to which the service providers cannot receive funding above a specified

performance volume was eliminated.

Part of the performance is reimbursed via an increased base fee called preannounced performance

base fee (PPBF). The amount of PPBF was 70% of the 2008 performance. The performance above the

PPBF is financed with a floating base fee specified by the available pro-rata (monthly) budgetary

sources and the nationally reported performance of the current month.

From 1 November 2009, the PVL returned again. The NHIF monthly accounted at most the

performance corresponding to the difference between PVL specified for the current period as

accounted until the current month, on the pro-rata basis according to monthly division and the PVL

used until the month preceding the current month at the HUF value corresponding to the performance

unit and it did not provide funding over 100%.

From 1 January 2011, the following change took place in performance accounting: in the case of

outpatient care, it was accounted at 30% HUF value up to 110%, at 20% between 110 and 120%, in the

case of inpatient care it accounted maximum 10% of the extra performance with 30% of the base fee.

From 1 January 2013, the performance accounting of outpatient care was modified in accordance with

the following: accounting at 20% HUF value up to 108%, in the case of inpatient care maximum 104%

extra performance with 25% of base fee.

From 1 January 2014 (1 November 2013, according to performance) in the case of outpatient care

accounted at 30% HUF value up to 110% and at 20% between 110 and 120% and in the case of inpatient

care there have been no changes so far, thus performance accounting takes place in accordance with

the percentage valid from 1 January 2013.

23

3.3. MANAGED PATIENT CARE

In a healthcare system with such a complicated structure operating more than fifty diagnostic and

therapeutic fields, continuous and supportive advising and management is of crucial importance for

the patients. In the case of emergency care, the emergency chain, if organized well, ensures this

without any special deliberation but programmed care has to be organized. The care of elderly patients

is very often more complex due to the complications of more than one disease or their underlying

disease. As a result, the specialized care (inpatient and outpatient) structure of developed countries is

designed in a way that those institutions are preferred that have a larger, multiple-profession, strong

diagnostic background where elderly patients who suffer from multiple diseases can also be healed

effectively and efficiently. Individual patient management has to be established, mainly and ideally in

primary care. To achieve this, a new approach, good regulations and financing (interest), professional

environment, and information technology support are necessary. There has been a special attempt at

this in Hungary as well (managed care system).

3.4. HEALTHCARE QUALITY MANAGEMENT SYSTEM

How can this extremely complicated and expensive system be operated in a balanced, effective and

efficient way as well as fairly and safely? This question has emerged many times in developed countries

for decades, together with the need to keep track of the development of medical science and

technology. The answer is provided by the quality control and development (today quality

management) systems which emerged from industrial quality assurance in countries with strong

consumer protection. These are capable of self-correction, the consideration of the opinion of patients

(satisfaction), the optimal organization of patient paths, the tracking of professional development, the

training of human resources and their efficient movement.

As the Hungarian healthcare system (similarly to all other countries) is in transition and under

development, it is necessary to consider the basic principles of the system and its practice so that the

system designed as new should be really effective, transparent and financeable in all aspects. This is

the expectation of the people who increasingly identify themselves as customers and partners as

opposed to being (passively suffering) patients.

24

4. REGIONAL STATE OF PLAY REPORT

4.1. REGIONAL MACRO ANALYSIS

4.1.1. RELEVANT NATIONAL DATA FOR THE HEALTH SECTOR

Hungary has a great heritage in the health industry (thermal baths, education, pharma industry),

although in the past few years tackling the emerging challenges has been in the center. Traditionally,

the Hungarian Health System is social insurance and solidarity based, even if there are some kind of

shared responsibilities and functions of the local governments, the state system and the National

Health Insurance Fund. However, the reorganization of the health system is happening nowadays,

which builds on greater public engagement and the health industry in focus. For today, in Hungary

almost all policies are carried out on a national level. Health services are organized on a regional basis.

The ultimate goal is to make the region work effectively enough so that patients could obtain the

required level and quality of care and to give greater attention to the health industry, which is of

strategic importance for the economic factors. Regions are also statistical regions and were originally

established to better coordinate developments within the European Union. Észak-Alföld has great

experience based on its research potential and its university in the biotech sector as a whole.

Biotechnology is essentially relevant to pharmaceutical research and the manufacturing phase. In

recent years, in Hungary one of the major tools of national economic policy included the appearance

of corporate groups called clusters. The Pharmapolis Debrecen Innovative Pharmaceutical Cluster was

established in 2008 with the cooperation of the University of Debrecen and Richter Gedeon Plc.,. This

cluster has over 20 founding members including spin-of enterprises that settled down in the

environment of the University.

The regulatory framework is in need of an overhaul. The legal background is sometimes over-rigid and

impenetrable, not prepared to address the new forms of cooperation. The flexibility of the supply

system has to be increased. Poor coordination, especially among levels of care and cross sectoral

coordination, and the lack of entrepreneurial experience in public research institutions and public

administration are obstacles, too. The authorities have to be prepared for structural solutions to

address regulatory issues. In the field of research services, the experience and willingness of

international cooperation of companies is significant, but sometimes they get stuck in the regulatory

difficulties. In the implementation of international management activities, the following factors have

been problematic especially for the smaller companies: choosing adequate advisors, contracting them

and building an international market entry strategy. There is also a lack of appropriate financial

background, e.g. there are no available local financial sources for biotech companies, only national and

25

international ones. Hungary has a risk-averse culture in the financial chain and risk sharing structures,

which has to be changed following the good practices. The inefficient resource allocation and the lack

of interfaces have led to the labor migration of doctors and health workers. Despite the difficulties,

innovation is really taking place in the Észak-Alföld region (cluster projects, science park investments,

cooperation research centers and research teams � in more details: 3 clusters, 8 research centers, 4

big pharma companies, 100 research groups, Molecular Medicinal Centre of Excellence, Bioincubator

Centre for start-up companies).

Table 1: Macroeconomic indicators of the Észak-Alföld region

MACROECONOMIC INDICATORS IN THE FIELD OF

HEALTH SECTOR

Available

at:

Indicator

value

Indicate

year

GDP p.c. EUROSTAT 66 2011

Employment rate EUROSTAT 60.7 2011

Economic growth EUROSTAT 1.6 2011

The proportion in GDP of health care expenditure by

provider (all providers)

EUROSTAT 7,28 2009

Pharmaceutical expenditure (% total expenditure on

health)

OECD 33,6 2010

Health personnel (per 100,000 inhabitants)

Practising physicians or doctors

Practising dentists

Practising pharmacists

Physiotherapists

Nursing and caring professionals (total)

EUROSTAT

286,9

52,6

58,2

30,4

866,7

2010

2010

2010

2010

2010

Final consumption expenditure of households by

consumption purpose - for health (percentage of total)

EUROSTAT 4,3 2011

Hospital beds by type of care - Available beds in

hospitals (per 100,000 inhabitants)

EUROSTAT 718,2 2010

SCIENCE AND TECHNOLOGY

Expenditure for finished and unfinished research works

in the field of health (in 1000 EUR)

NATIONAL

STATISTISC

- -

Number of doctorate holders in medical and health

services

NATIONAL

STATISTISC

34736 2011

Gross domestic expenditure on R&D (GERD) by source

of funds

(Percentage of total GERD)

Business enterprise sector

Government sector

Higher education sector

Private non-profit sector

Abroad

EUROSTAT

47,4

39,3

-

0,9

12,4

2010

2010

-

2010

2010

Turnover from innovation (% of total turnover) EUROSTAT

26

Industry

Services

22,3

6,1

2008

2008

Employment in knowledge-intensive service sectors

(Share of total employment; %)

EUROSTAT

28,73

2008

Patent applications to the European Patent Office

(Applications per million inhabitants)

EUROSTAT

-

-

Human resources in science and technology as a share

of the labor force (% of total)

EUROSTAT

34,6

2011

4.1.2. PORTRAIT OF THE REGION

The region has a considerable intellectual potential, there is a high proportion of doctorate and

academic degree holders, the research areas are varied, and there is a balanced age-structure among

the researchers. However, the inputs do not appear in the economic performance, the implementation

of innovative results is quite low due to the lack of cooperation, using intermediaries and innovation

strategies. GDP/capita is quite low, even though productivity indicators are a bit better. There is a high

share of employment in services, mainly in the state-funded sectors. The unemployment rate is also

high, even the quality parameters of it are bad regarding the prospects of recently graduated people.

Entrepreneurship is relatively low. The region has above-average endowments and production

experience in the fields of agriculture and food industry. From the point of view of industrial

development, the relatively high number of industrial parks plays a big role. Debrecen is of key

importance in education, research and development is highly related to higher education. In Hungary,

the University of Debrecen is pursuing doctoral (PhD studies) in most of the disciplines. R&D is one of

the strengths of the region; it takes the third place in R&D expenditure in GDP and value per capita, or

number of workers in the R&D sector with the dominance of Hajdú-Bihar county. The University of

Debrecen is the intellectual centre of the region, not only in education, but R&D as well. The activity

of SMEs is quite low, mainly because of financial constraints and the lack of networking structures.

Regarding healthcare indicators (hospital beds, number of patients per general practitioner), the

region is in an unfavorable position.

Legal/administrative status of region1 Hajdú-Bihar / Észak-alföld

NUTS level III. / II.

Size of region (in km²): 6210,56 / 17.729

1 For example: Podravje is an administrative region at the NUTS III level and according to the Regional

Development Act it is a development region.

27

Population (number) 541298( 2010) / 1.525.317(2007)

Region2 2007 2008 2009 2010 2011

SCIENCE AND TECHNOLOGY (NUTS 2 level)

Total intramural R&D expenditure

(GERD) by sectors of performance and

NUTS 2 regions (for all sectors in EUR

per inhabitant)

26,7 40,2 43,1 - -

Employment in high-tech sectors (high-

tech manufacturing and high-tech

knowledge-intensive services) by NUTS

2 region (Percentage of total

employment)

3,24 3,60 - - -

Researchers, all sectors by NUTS 2

regions

(Percentage of total employment)

0,28 0,29 0,34 - -

Human resources in science and

technology (HRST) by NUTS 2 region

(Percentage of economically active

population)

26,7 27,4 27,1 26,8 28,7

HEALTH INDICATORS (NUTS 2 level)

Available beds in hospitals by NUTS 2

regions

664,8 657,9 677,6 680,7 -

Health personnel by NUTS 2 regions 3,192 3,615 3,623 3,556 -

Physicians or doctors by NUTS 2 regions 209,3 238,8 241,1 238,3 -

Dentists by NUTS 2 regions 22,2 27,7 28,8 35,6 -

Available beds in hospitals by NUTS 2

regions (Per 100,000 inhabitants)

664,8 657,9 677,6 680,7 -

Long-term care beds in nursing and

residential care facilities by NUTS 2

regions

12,910 13,096 13,163 13,336 -

QUALITY OF CARE (NUTS 3 level)

Physicians (Per 10,000 population) 30,5 35,8 37,5 40,3 42,2

2 SOURCE OF DATA: EUROSTAT.

28

Nurses (with upper secondary and

tertiary education 1) (Per 10,000

population)

Dentists (Per 10,000 population) 3,69 3,69 3,69

Pharmacists (Per 10,000 population)

Hospital beds (Per 10,000 population) 69,0 69,2 69,4

Economic indicators (NUTS 3 level)

Gross domestic product (GDP) at current

market prices by NUTS 3 regions (EUR

per inhabitant)

7,052.1 7,470.2 6,702.1 - -

4.1.3. MAIN HEALTH SUB-SECTORS TODAY

Traditionally Debrecen is well known for its pharmaceutical and biotechnology industry. There are

great possibilities in manufacturing pharmaceuticals, proteins, biosimilars, isotopes, and also in

packaging, tableting and logistics. Regarding R&D as well, clinical trials and testing also offer great

possibilities in this sector, since Debrecen has got strong human capital, well-educated staff (University

and research centers, science parks). Genomics with an already existing strong service background is

also very important in this respect; the business model has to be found as part of business

development. Molecular medicines and nanotechnology are already in the focus, extending to

agricultural and industrial bio- and nanotechnology as well. Local production and logistics of functional

food are also a big opportunity, also including medicinal and herbal products and other health-related

foods such as mineral water. The supplementary health services industry will also gain an important

role in the near future, including yoga therapy, fitness, massage and also the role of insurance

companies and health funds in this area. Service management and related education is very important.

In the field of health informatics, healthcare software developers, distributors, bioinformatics

companies and related equipment (apparatus, application, interfaces) have a potentially bright future.

Health tourism is also a sector which is very much in focus, regarding the already existing traditions

and heritage (thermal spas, dental and gynecological tourism, beauty industry). As a result of all this,

the training and education of health care professionals (HCP and entrepreneurship education) are very

much needed. There is also potential in outpatient-care and related service companies (diagnostics,

lab, patient transport). In terms of application areas, health biotechnology is the dominant field, with

more than 40% of expenditure. The number of those employed by core biotech firms is approximately

900 (of which 500 is employed in R&D). If related areas are included, the number comes up to 4,000

(firms operate with a low employee headcount).

29

The regional biotech sector is made up of small companies. Therefore, the size � besides the money

and time shortage � is the biggest hindrance to the prosperity of the companies (economies of scale)

or rather the fact that they are not able to reach the potential companies, customers. Biotech

companies of the Észak-Alföld region cannot present themselves on the EU or other international

markets as effectively as companies belonging to other long-standing clusters. In some cases they

cannot afford the needed services due to financial constraints, or they do not use external help

because they consider themselves too small to enter into it alone. Clusters and other forms of

cooperation in the fields of technology and knowledge transformation seem to be good opportunities

for them, although at present the clusters do not operate the same way in Hungary as abroad; they

are more heterogeneous and have fewer members, therefore representation and bargaining is more

complicated. The availability of professional and business advice is increasing, but it is still expensive

for most of the SMEs. The majority of research and development activities are conducted at

universities or institutes and collaboration with the industry is limited. However, joint R&D programs

have been launched in a number of areas both in the field of health industry, and the development of

innovative functional food and renewable energy. A significant network of relations between industrial

companies has been created in the region along these joint programs. It is also very important that the

knowledge and commercial basis with Debrecen-Nyíregyháza as its centre has a good chance of

becoming one of centers of the entire Central-Eastern European region in these traditionally

developed Hungarian fields of industry.

Health Sub-sector2 Correlation to degree course

Pharmaceutical, biotechnology & related life

sciences

Pharmacist, Biotechnologist, Biochemist

Health care equipment & services Health Engineer

Health tourism Health tourism manager

Physiotherapist

Health informatics Informatics

Prevention, health management Healthcare manager

Innovation manager

There are 77 biotech companies in Hungary, 12 in Biotech Therapeutics, 55 in Biotech R&D services

and 10 other. Approximately one third of them (25) are located in the region of Észak-Alföld. The local

health industry employs around 10,000 people. The Pharmapolis Cluster, which mainly carries out

30

projects in the region, has 26 members, 22 of which are SMEs. There are 4 big pharmas (TEVA, Richter

Gedeon, Actavis and Sun Pharma) and there are 3,000 jobs in the pharmaceutical sector in Debrecen.

The focus areas are innovative therapy and molecular imaging, bioinformatics, genomics, molecular

medicine and diagnostics. TEVA, the leading generics manufacturer of the world, has its main European

manufacturing and R&D center in Debrecen. There are 31 industrial parks in the region. Debrecen

houses 4 industrial parks (2 are owned by the local government, one belongs to the University of

Debrecen, one is supervised by an association of private enterprises) and a 5th one is under

construction. The most prestigious one is the Regional and Innovative Industrial Park, which was

established in 1997. 60 % of the companies operating here are recently founded ones. In the region

there are 280 research and development units, 49 of which are commercial. In these R&D units 3,271

scientific research and development staff are working on approximately 2,000 research projects (70 %

of them are related to the University of Debrecen, high % of them are doctorate holders). In the clinics,

under the supervision of 70 world-famous professors of medicine, there are 91 internationally

acclaimed associate professors and 140 senior lecturers with nearly 1,000 doctors and 2,000

healthcare professionals contributing to the recovery of 15,0000 patients annually. Approximately 150

clinical trials are carried out a year. The total number of the students in the regional area is 48,000

(30,000 in Debrecen, at 15 faculties), of which 10,000 study life sciences (7,000 in Debrecen). There

are 8 doctoral schools (the highest number in Hungary), 35-50 new PhD degrees are awarded every

year.

4.1.4. ECOSYSTEM FOR HEALTH INNOVATION

Észak-Alföld is the innovative region of health industry, agro-industry and IT, where the priority areas

of innovation are the already significant agricultural and thermal research potential and the

strengthening of life science research bases and their interconnection with IT developments, moving

towards the appreciated sectors of the global economy (pharmaceuticals, genomics, diagnostics,

nanotechnology, functional food, renewable energy sources). Innovation and the importance of long-

term planning is well-marked in regional planning (the Észak-Alföld Regional Innovation Strategy and

Operational Program � EARIS was created in 2007 and was revised in 2010), where the main focus is

on the increasing and better targeting of R&D investment, the facilitation of innovation and

entrepreneurship-promotion, the information society and the improvement of accessibility in the field

of finances. The driving sectors of the EARIS are the pharmaceutical industry and biotechnology,

focusing especially on the generated added value and the role in employment. Program-development

is also essential for fundraising and enforcement of the interests. Innovation Agencies are formed in

the regions (the main tasks of INNOVA Észak-Alföld Regional Agency include the organization of

31

technology innovation networks and organizational framework for the provision of innovative

services). Institutional development, the creation of interfaces and broadening partnerships, and

enhancing collaboration are all necessary. The main aims of the regional innovation strategy are

increasing the capacity of innovation, encouraging long-term R&D&I contacts based on real market

needs, forming of a supportive environment for innovation and the development of an innovative

workforce. The region has a considerable intellectual potential, there is a high proportion of doctorate

and academic degree holders, the research areas are diverse, and there is a balanced age-structure

among researchers. However, the inputs do not appear in economic performance, the implementation

of innovative results is quite low, due to the lack of cooperation, using intermediaries and innovation

strategies. The researchers are mainly supported by public funding and are largely related to higher

education system. Regarding the health industry and the health sector, patient- and client-centricity is

getting more and more important. The reason behind this is related to the fact that the financing of

the healthcare system should be based more and more on peoples� expenditure. Therefore, a much

better understanding and also serving of the needs of the population is required, showing the value of

health which can be achieved. This is a great deficiency in the current system.

4.1.5. REGIONAL STAKEHOLDERS

The lack of an adequate financial background, sharing of information and adequate practical sector

specific knowledge are the main obstacles to innovation, therefore the formation of an effective and

supportive environment is indispensable. There is also a lack of innovation awareness, with a lack of

cooperation. The sharing of innovation knowledge is not very common, although there are some good

examples for joint R&D programs and research platforms. Involving an external advisor or mediator

organization would help a lot in the whole process. Relevant intellectual property and technology

transfer activities are required for the better exploitation of research results. Regional biotech

companies do not really feel the need for management consultancy services; they try to solve these

issues within the company. They rather need outside help in terms of patent issues. Those services

which are to help map and build up potential relationships also aroused their interest. They would

welcome opportunities which could take them to bigger partners. Therefore the development of an

innovation system is a key, interconnecting the supply and demand side of innovation on the regional

level, exploiting the potential local capacities. At present, the size of the companies � besides the time

and money shortage - is the biggest hindrance in the prosperity of the companies (economies of scale)

rather than the fact that they are not able to reach the potential companies, customers. In some cases

they cannot afford the needed services due to financial limitations. Therefore, encouraging the

involvement of venture capital and private equity, co-financing methods are essential. Companies do

32

not use external help because they consider themselves too small to enter into it alone. They see

several opportunities in the clusters. The co-operation with the members of the sector, relationship

building may help getting into bigger projects or even participation in professional events can become

easier. A supporting organization would give a great opportunity to organize information coming from

different sources. The role of the University of Debrecen is prominent in the region�s innovation

(among external research services used by the companies), and also the participation of the Hungarian

Investment and Trade Agency, the Knowledge and Technology Transfer Office of the University and

the Regional Innovation Agency (INNOVA). They provide information about different events and

possibilities and give help in the realization of projects and research. Common research groups,

projects were formed between the University and the companies, and this worked very well in

providing help mutually. However, it is sometimes difficult to find the appropriate partner in research

services. Regarding management consultancy services, companies try to solve these issues mainly

themselves, employing indoor specialists, meanwhile other companies think that different financial,

sales and HR tasks have to be handled within the company. Smaller companies think that outsiders

cannot get involved in the operation of the company to such extent that they would be able to help.

Contact building (possibilities, available services, and mediator organization) is considered to be one

of the main business issues. The role of clusters is also very important (regarding common projects,

cooperation, participation in conferences, representation), but clusters do not operate the same way

in Hungary as abroad, they are more heterogeneous and have fewer members. Participating in an

international biocluster would open up broader perspectives to the members.

4.1.6. HUMAN CAPITAL: EDUCATION AND ENTREPRENEURSHIP

The triple helix of the region is of indispensable importance, regarding both the entrepreneurial side

and the role in employment, but the educational demand and the entrepreneurial supply should be

better synchronized. The helix is build up from the cooperation of industrial, academic and state

members. In the industrial field, there is the Pharmapolis Innovative Pharmaceutical Cluster,

Pharmapolis Innovative Functional Food Cluster, Thermal Cluster, Silicon Field regional IT Cluster, and

LENERG Building-Energy Cluster. In the academic part, the University of Debrecen plays a very

significant role, and there is also the Institute of Nuclear Research of the Hungarian Academy of

Sciences, the College of Nyíregyháza and the College of Szolnok. Regarding the state representatives,

the Municipality of Debrecen, the Regional Development Agency, the Chamber of Industry and

Commerce and the Regional Innovation Agency are crucial. Non-scientific stakeholders related to the

biotech sector as a whole belong to several groups in accordance with the following: state

organizations, government offices, local governments and local governmental institutes, professional

33

associations, chambers, bridging organizations, grant intermediating organizations (including

authorities involved in strategic planning). Among the non-governmental organizations the most

important players are the large collective forum of state organizations and other undertakings, the

chambers. These organizations form groups voluntarily, however in many cases the membership is

compulsory and the advantages of this are primarily in the admission to closed communities and the

acquaintance with the best practices as well as the application thereof in everyday practice. There are

chambers for each profession in healthcare. Although commercial and industrial chambers are not

considered as professional organizations, they coordinate a group of entrepreneurs (such as

enterprises producing medical prostheses and surgical appliances, manufacturers integrating their

research findings into their products). In recent years, in Hungary one of the major tools of national

economic policy appeared, these are the corporate groups called clusters. With the cooperation of the

University of Debrecen and Richter Gedeon Plc., the Pharmapolis Debrecen Innovative Pharmaceutical

Cluster was founded in 2008. This cluster has more than 26 members, including SMEs, spin off and

start-up companies. The companies participating in the Pharmapolis Cluster perform their research

and development activities in cooperation with the University of Debrecen and other research

institutes and endeavor to establish a long-term strategic partnership. Other non-scientific

organizations include investment supporting organizations, insurance companies, banks, and financial

institutes. Identified, non-scientific stakeholders are JEREMIE fund managers, other venture capital

companies and business angels. Small, dedicated biotech firms play an important role in almost all

fields of biotech applications, especially in healthcare biotech. These small firms are mostly responsible

for research and innovation, even though they often depend on external funding. In fact, as firms

expand in size, typically they experience a decreasing number of discoveries. For large companies,

many discoveries usually represent slight adaptations of existing products rather than the

development of brand new ones. In contrast, usually truly inspirational ideas come from smaller

dedicated firms located in the clusters. Consequently, it can be concluded that big industry is mostly

dependent on small firms. Academic spin-offs are of a particularly important type of new companies

in the biotechnology sector, and that these companies serve as the main vehicles for exploiting

biotechnological research. The distribution of employees across different categories is an important

criterion, especially when evaluating the total number of employees dedicated to R&D. Since SMEs are

mostly involved in R&D and are responsible for the new jobs created, their role in economic

development is pivotal. The Észak-Alföld Biotech Cluster was established in 2011 based on the initiative

of small and medium-sized enterprises. The Cluster intends to provide better business conditions and

opportunities for the SMEs operating in the biotech sector which is one of the main regional economic

sectors.

34

4.2. HAJDÚ-BIHAR COUNTY

In order to realize the sectoral and regional objectives included in the Hajdú-Bihar county Regional

Development Concept, those priorities have been specified within which the particular measures (as

developmental tools for the execution of the concept) will be implemented.

Development priorities of Hajdú-Bihar county for 2014-2020

1. Sustainable Environment

2. Complex Development of the County�s Agriculture

3. Competitive Economy

4. Improvement of Accessibility in Hajdú-Bihar County

5. Intelligent Society

6. Healthy and Caring Society

7. The Development of a Supportive Environment for Innovative Economy

in Debrecen

8. Livable Countryside, Livable Settlements

The following chart illustrates the relationship between these priorities and the objectives specified in

the Hajdú-Bihar county Regional Development Concept.

Relationship between the objectives and priorities of the HB County regional development

strategy and the strength of the relationship

Priority

Objectives

C1 C2 C3 Á1 Á2 Á3 Á4 T1 T2 T3

1. Sustainable Environment + - ++ ++ - - - + + +

2. Complex Development of the County�s Agriculture ++ + ++ + ++ + + ++ ++ ++

3. Competitive Economy ++ - - - ++ ++ - ++ + +

4. Improvement of Accessibility in Hajdú-Bihar County ++ - - - ++ - + ++ + +

5. Intelligent Society ++ ++ - - ++ ++ + + + -

6. Healthy and Caring Society - ++ - - - - ++ ++ + +

7. The Development of a Supportive Environment for

Innovative Economy in Debrecen ++ + + - ++ ++ + ++ + -

8. Livable Countryside, Livable Settlements + ++ + - - - ++ - + +

++ strong relationship, + moderate relationship, - weak relationship/no relationship

The following figure illustrates the system of objectives for Hajdú-Bihar County for 2014-2020:

35

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36

4.2.1. PRIORITY NO. 1: SUSTAINABLE ENVIRONMENT

Hajdú-Bihar can be said to be poor in surface waters, its most significant watercourses are the Tisza,

Berettyó and Sebes-Körös, which conduct the watercourses of the area directly and indirectly. The

Hortobágy, Kösely and Kállók can be considered to be more modest watercourses. Hungary, and thus

the county as well, is rich in underground water. As a result of the hydrologic features of Hajdú-Bihar

county, flooding and inland water pose a serious threat to the area. The natural, landscape values of

the county are varied and diverse in many respects.

Currently in Hajdú-Bihar county, in line with the national average, about 60% of the collected domestic

solid and industrial waste is disposed of by means of landfills, without pretreatment, which is the least

developed method of the current waste management technologies; the transformation of this is

recommended on the long run. Besides the principle of environmental sustainability, it is also

necessary for the purposes of protecting the health and quality of life of the population to implement

complex waste management that is well-founded both economically and environmentally, including

separated waste collection, the recycling of solid waste, striving for reducing the quantity of waste.

There are ever-increasing requirements in connection with local-regional infrastructure investments

with regard to environmental damage prevention, damage control and remediation.

Numerous projects have been started in Hajdú-Bihar county for the modern utilization of renewable

energy and the increase of energy efficiency but the process is still at an initial phase. In accordance

with the EU 2020 Strategy�s Energy, Climate Change objective, energy efficiency has to be improved

with 20% and significant intervention is required also to achieve the 10% overall energy-saving

specified in the National Reform Program. With regard to sustainable energy use, the features of

Hajdú-Bihar county with regard to the utilization of renewable energy are very favorable. Based on

geothermal energy, we could also increase the value of agricultural production as the wide-ranging

use of geothermal energy is justified in Hajdú-Bihar (in terms of agriculture, building energetics, other

industrial use). Local energy generation and supply can be stimulated by energy crops grown in lower-

quality soil of agricultural and forestry areas or the growing of plants for use in energetics.

Connections to EU thematic objectives and/or investment priorities

The cleanliness and preservation of the environment, natural scenery, effective energy, water and

waste management are all key areas in the European Union, in accordance with these, the first

priority contributes to the following EU thematic objectives:

37

(4) supporting the shift towards a low-carbon economy in all sectors;

(5) promoting climate change adaptation, risk prevention and management;

(6) protecting the environment and promoting resource efficiency;

Interventions planned within the priority

Intervention no. 1: Complex water management

Intervention no. 2: Protection of the county�s natural, landscape values

Intervention no. 3: Complex waste management

Intervention no. 4: Environmental damage prevention, control and remediation

Intervention no. 5: Sustainable energy use and energy efficiency

4.2.2. PRIORITY NO. 2: COMPLEX DEVELOPMENT OF THE COUNTY�S AGRICULTURE

Although the agricultural sector in Hajdú-Bihar county, due to its regional structure, has favorable

natural features, farming traditions, and a significant agricultural potential, in order to increase the

income-generating ability of the sector the strengthening of activities representing higher added value

and steps leading to added value related to the production, processing, logistics and sales of

agricultural products are high priority areas. The structure of land use is adapted to the relatively

diverse landscape of the county. In the field of raw material production and food processing a

breakthrough could be the production of high added-value, high-quality products, exploiting the

opportunities provided by the materials with excellent nutritive value. Besides the excellent conditions

for intensive and large-scale agriculture, the opportunities are also favorable for the development of

organic farming as well as extensive livestock farming.

Hajdú�Bihar county is one of the leading agricultural producers of the country, where the production

of grain and industrial crops is dominant, together with animal husbandry built on a natural and arable

land fodder base. The degradation of processing capacities can be mentioned as a negative trend with

regard to the agricultural sector, which results in the production of lower local added value.

With regard to efficient energy use, the county has favorable features for the implementation of

complex developments built on agriculture. The excellent farmland, strong traditions with regard to

large-scale production, the extensive nature of previous and existing markets as well as the

organizations with significant traditions provide a suitable basis for the planned developments.

38


The complex development of agriculture contributes to several EU thematic objectives:

(1) strengthening research, technological development and innovation;

(3) enhancing the competitiveness of small and medium-sized enterprises, the agricultural sector

(for the EAFRD) and the fisheries and aquaculture sector (for the EMFF);



(8) promoting employment and supporting labor mobility;

(10) investing in education, skills and lifelong learning;


Intervention no. 1: Competitive agriculture

Intervention no. 2: Sustainable agriculture

Intervention no. 3: Knowledge transfer in agriculture

Intervention no. 4: Effective energy use

Intervention no. 5: Cooperation to strengthen the county�s agriculture

4.2.3. PRIORITY NO. 3: COMPETITIVE ECONOMY

The weight of Hajdú-Bihar county in the Gross Domestic Product of Hungary changed between 3.8 and

4.2% during the decade following the millennium. Also considering Budapest and Pest county, it is the

county with the fifth highest GDP. In 2010 there were 33.8 employees for 100 residents in Hajdú-Bihar

county, based on which it is the 17th in the ranking of counties and Budapest. The industry of Hajdú-

Bihar county shows a balanced structure, the dominant local presence of industries producing high-

added value is another positive feature. The following sectors are dominant in the economic structure

of the county: agriculture; food, drink- and tobacco production; chemical materials and products

manufacturing; machinery, equipment manufacturing; manufacture of electrical machinery and

equipment; electricity, gas, and water supply; transport, storage, post and telecommunications;

healthcare, social care.

The infrastructure supporting economic development has been extended greatly in the last years in

Hajdú-Bihar county, with significant industrial park and incubation capacities established and cluster

organizations founded. Hajdú-Bihar county is characterized by entrepreneurial activity permanently

below the national average and the relatively modest presence of foreign capital investment. The

industrialization of Hajdú-Bihar county, which is below the national average and (especially) the

39

average of the countryside is partly the result of inherited characteristics, and partly that of the

circumstance that after the loss of industrial jobs following the change of the political system these

have not been replaced by new industrial projects. This is closely related to the more modest presence

of foreign direct investment: the export-oriented nature of the county�s industry is still below the

national average.

The county�s outstanding research and development activity is remarkable, primarily resting on the

public institutional basis, which provides a suitable ground for strengthening the role of knowledge-

based, innovative activities in its economy. A serious structural weakness of the county�s R&D sector

is the underrepresented nature of the business sector. The research and development expenditure of

the county in proportion to the GDP is outstanding, with the county�s special economic structure being

in the background of this. An above the average education-healthcare sector share is connected to the

above mentioned GDP, with the educational segment especially having a close relationship to the R&D

sector as well.

The increase of employment horizontal objective can be met with the development of local businesses

and the arrival of businesses in the area. To achieve this, the infrastructural (e.g., road, rail) deficiencies

have to be ended besides the development of business infrastructure and services and the free and

discounted high-quality business and innovation supporting services have to be developed further.

Studying the figures of the first half of 2012, we can see that with regard to the number of tourist

nights spent in commercial accommodation Hajdú-Bihar county occupies the 6th position among the

counties, with a 2 percent point higher value than in the same period of 2011. 65% of the tourist nights

were realized in Hajdúszoboszló, indicating the outstanding significance of health tourism, especially

medical/spa tourism. The Hortobágy National Park featured on the UNESCO world heritage list is

partly located in the county; it is a significant nature conservation area and cultural landscape both

nationally and internationally, the utilization of the protected environment can be realized in this area

with landscape preservation, gene conservation and the environmentally-friendly transformation of

facilities.


The priority axis contributes to the following EU thematic objectives:


(2) enhancing access to, and use and quality of, information and communication technologies;



40

(8) promoting employment and supporting labour mobility;


INVESTMENT PRIORITY (Article 5, Section 8 of ERDF regulation)

promoting sustainable and quality employment and supporting labour mobility by:

b) supporting employment-friendly growth through the development of endogenous potential as part

of a territorial strategy for specific areas, including the conversion of declining industrial regions and

enhancement of accessibility to, and development of, specific natural and cultural resources;


Intervention no. 1: Development of a supportive business environment

Intervention no. 2: Business development

Intervention no. 3: Economic development of local interest

Intervention no. 4: Improvement of innovation and competitiveness

Intervention no. 5: Tourism built on the values of the county

4.2.4. PRIORITY NO. 4: IMPROVEMENT OF ACCESSIBILITY IN HAJDÚ-BIHAR COUNTY

The transport-geography position of Hajdú-Bihar county is favorable. The main national and

international transport routes of the Tiszántúl region cross the county, while with the railroad system

Debrecen is one of the best junctions in the country. However, the reconstruction of the road transit

routes crossing the county to provide higher throughput is incomplete, the capacities of the railroad

system and the airport are unused and numerous second and third class roads and the inner roads of

several settlements in the county require renovation. The most important and busiest international

airport in Eastern Hungary can also be found here, with the second largest traffic in Hungary after Liszt

Ferenc International Airport in Budapest. Besides Debrecen, which has been deemed suitable for the

role of a logistics center in earlier regional planning documents as well, primarily the logistic functions

of Polgár could be strengthened, due to its closeness to the junctions of the M3 and M35 motorways.

With regard to transportation, the location of the county along the border has a crucial effect;

together with the crossing points towards Romania open for international traffic, currently as the

Schengen border. The transportation infrastructure of Hajdú-Bihar county went through impressive

development recently, however, its disadvantage is still obvious compared to the national level,

especially with regard to the main and secondary roads as well as inner-city roads. The accessibility of

41

the county is greatly affected by the development of the Budapest-Szolnok-Debrecen-Záhony railroad

line to a high-speed rail line. A genuine bicycle route network has not developed in the county with

respect to the already built short sections that are not connected as a network.

One factor hindering economic growth in Europe is the insufficient use of information and

communication technologies (ICTs). One of the key priorities of Europe 2020 is intelligent growth, with

the idea of an economy based on knowledge and innovation. The establishment of information-

communication systems in the settlements of the county is favorable: the differences within the

county decreased significantly between 2005 and 2010 and the number of subscribers increased

considerably due to the developments realized in the period between 2007 and 2013.

Connections to EU thematic objectives and/or investment priority

The priority axis contributes to the following EU thematic objectives:


(7) promoting sustainable transport and removing bottlenecks in key network infrastructures;


The priority axis contributes to the following investment priorities:

Regulation on the Cohesion Fund, Article 3. point d) i): �supporting a multimodal Single European

Transport Area by investing in the TEN-T;�

Regulation on the Cohesion Fund Article 3. point ii) : developing and improving environmentally-

friendly (including low-noise) and low-carbon transport systems and the promotion of sustainable

regional and local mobility ��

Article 3. point iii): �developing and rehabilitating comprehensive, high quality and interoperable

railway systems, and promoting noise-reduction measures;�

Article 5, Section 7.b of ERDF regulation �enhancing regional mobility by connecting secondary and

tertiary nodes to TEN-T infrastructure, including multimodal nodes;�


Intervention no. 1: Development of international and national transport networks

Intervention no. 2: Development of county and local transport networks

Intervention no. 3: Development of community and environmentally-friendly transportation

Intervention no. 4: Developments in info-communication

42

4.2.5. PRIORITY NO. 5: INTELLIGENT SOCIETY

Hajdú-Bihar county has a dual image with regard to the situation of its human resources: on the one

hand, it concentrates a relatively high population and shows a population decline under the national

average, while on the other hand, it is characterized by considerable migration loss (the migration of

the skilled workforce posing a significant problem); nevertheless, the age structure of its population is

young. Slowing down migration and the preservation of existing human potential is the basic interest

of local communities.

In the area of providing human resources, one of the outstanding advantages of Hajdú-Bihar county is

represented by the University of Debrecen, which is one of the country�s largest institutions of higher

education, offering the widest selection of study programs (agriculture, arts and humanities, IT, law,

economics, engineering, medical and health sciences, pedagogy, natural sciences, music). Still, the

indicators for educational attainment of the county�s population are below the national average.

The relative overrepresentation of education in Hajdú-Bihar county is high, the role of Debrecen as a

higher educational, health, and research center is outstanding nationally. The network of institutions

providing secondary education and higher vocational training can be deemed satisfactory, although in

certain areas (e.g. in agriculture, tourism) the development of qualified workforce is essential. In the

process of the quality development of education, vocational training, and higher education primarily

economic considerations have to be taken into account; the involvement of businesses in study

programs has to be supported, an effective career orientation system has to be established. In the

county, the ratio of people with at least a high school diploma to the population over 18 was above

the national and countryside average only in the Debrecen micro region (50.3%), the other micro

regions were all below it. In the Hajdúhadház, Balmazújváros and Derecske-Létavértes micro region

the ratio of people with a high school diploma was under 20%. The ratio of people with multiple

disadvantages is higher than the national average similarly to the ratio of people with smaller income.


Due to the integrated nature of human resource development, the present priority axis contributes to

the realization of the following thematic objectives:


(9) promoting social inclusion and combating poverty;


INVESTMENT PRIORITY � ESF Regulation Article 3. section (1) a) i. Access to employment for job-

seekers and inactive people also through local employment initiatives and support for labour mobility;

43


Intervention no. 1: Development of public education and public educational institutions,

education in harmony with the needs of the market

Intervention no. 2: Development of cultural institutions

Intervention no. 3: Raising awareness

4.2.6. PRIORITY NO. 6: HEALTHY AND CARING SOCIETY

The development of the �Healthy and Caring� priority axis is justified by the low level of public services

in terms of quality and accessibility, the existing regional differences, as well as the numerous

deteriorating settlement parts that are becoming segregated and depopulated as characteristic in

Hajdú-Bihar county as well. In accordance with this, in the district centers high-quality, accessible

public services and public administration with equal opportunities for access have to be provided for

the settlements of the district, with special attention to the health, public health, and social services.

In line with this, the further strengthening of the established health and social care system, the

development and extension of services available on the local level are the objectives of the priority.

These developments aim at the modernization of the services and infrastructural conditions of the

institutions as well as the reduction of inequalities of access. The development of primary healthcare

is crucial because it is this level that is most capable of performing the basic health screenings and

health checks and of effectively contributing to the strengthening of the health consciousness of the

population. The infrastructural developments in healthcare contribute to the increase of the number

of healthy years of the population, restoration of the ability to work as soon as possible, and with the

concentration of resources, to the improvement of the cost efficiency and quality of services.

The primary health care of the population is provided by the General Practitioners in all settlements

of the county. In the smaller villages basic care is provided on the basis of care contracts or, for

example, night or weekend duty is performed by private businesses based on task performance

contracts or it is provided simultaneously at several settlements through institutional management

associations or district notaries. In 2010 there was some kind of outpatient care in 32 settlements of

the county operating with regional task performance obligations. About 81% of the county�s total

population could use these services at their own settlement, while in the past decade centralization

characterized this area as well.

44

In the period up to 2020 we have to prepare also for the challenges of the aging society, with the

development of the related social and healthcare infrastructure as well as the services connected to

healthcare and with that of primary care.


The priority axis primarily supports the realization of thematic objective (9) promoting social

inclusion and combating poverty;

INVESTMENT PRIORITY � ERDF Regulation Article 5

(a) investing in health and social infrastructure which contributes to national, regional and local

development, reducing inequalities in terms of health status, promoting social inclusion through

improved access to social, cultural and recreational services and the transition from institutional

to community-based services;


Intervention no. 1: Healthy county

Intervention no. 2: Caring county

4.2.7. PRIORITY NO. 7: THE DEVELOPMENT OF A SUPPORTIVE ENVIRONMENT FOR AN

INNOVATIVE ECONOMY IN DEBRECEN

The Municipality of Debrecen is a regional and knowledge center with a cross-border influence due to

its services and based on its geographical position, natural, economic, and human resources that can

be mobilized well and that are capable of renewal. It has an innovative economy that is competitive

both nationally and internationally. In this respect it relies on the following key sectors: agriculture,

food and pharmaceutical industry, machine manufacturing, electronics, information technology,

logistics, industries built on natural resources and renewable energy, and the service sector.

The logistic developments built at the airport are of crucial importance from the perspective of foreign

direct investments and supply networks. The central institutions of research and development

activities are the University of Debrecen, mint more than 32,000 students (among them 3,300

internationals), and 6,000 employees, and the Institute for Nuclear Research of the Hungarian

Academy of Sciences.

With regard to the economy of the city, the fact that it is built on more than one pillar has to be

mentioned as a positive characteristic, meaning that there is no such sector that would play a dominant

role in the life of the city and thus which decline would shatter the economy. With respect to the

45

sectors of the economy, one can find those sectors with long traditions (e.g., machine manufacturing,

printing, pharmaceutical industry), while, at the same time, new sectors have appeared that were

previously unknown in the life of Debrecen (e.g. production of electronic devices, SSC sector).

The foreign investors prefer greenfield investments, as a result of which usually one can see the

increase of R&D expenses and employee numbers. The innovation environment based on businesses

is strong in several sectors in the city, which can be developed with complex export incentives, the

support of businesses, and the arrival of new companies.

Debrecen is one of the most important transportation hubs of the Tiszántúl region, serving as the

starting point for numerous public roads and railroad lines. With respect to the city and its

agglomeration, labor mobility has to be facilitated by means of the improvement of suburban traffic,

connected to the needs of the county.

Debrecen has a significant tourist potential nationally and locally as well in the areas of built-cultural,

natural environment, medical and wellness tourism (health tourism), meetings, incentives,

conferences, exhibitions (MICE) and religious tourism, besides which one can also find offers related

to gastronomical and other touristic branches.

The modernization of properties, institutions owned by the local government can be continued in

Debrecen together with the quality and capacity improvement of infrastructure and community

spaces related to an active and healthy lifestyle, in which regard numerous developments have been

realized during the previous period, providing a sound basis for the planned new projects.

With regard to environmental protection, two significant problems can be highlighted in Debrecen;

the solution of these is considered to be a key task for the upcoming period. The effects of air and

noise pollution related to urban road transport especially along the main transport lines crossing the

city should be addressed.

Debrecen has a considerable healthcare and social care function in the region. The city itself can be

characterized by an aging social profile, and based on the current demographic tendencies the

healthcare system will have a growing role in the future. The development projects carried out in this

area will contribute to a more effective healthcare system that is competitive internationally as well.


The priority axis contributes to the realization of the following thematic objectives:


46

(2) enhancing access to, and use and quality of, information and communication technologies;






(9) promoting social inclusion and combating poverty;


The priority axis contributes to the following investment priorities:

ERDF Regulation Article 5

6(e): taking action to improve the urban environment, to revitalise cities, regenerate and

decontaminate brownfield sites (including conversion areas), reduce air pollution and promote noise-

reduction measures;

(8) promoting sustainable and quality employment and supporting labour mobility by: b) supporting

employment-friendly growth through the development of endogenous potential as part of a territorial

strategy for specific areas, including the conversion of declining industrial regions and enhancement

of accessibility to, and development of, specific natural and cultural resources;.

9 (a) investing in health and social infrastructure which contributes to national, regional and local

development, reducing inequalities in terms of health status, promoting social inclusion through

improved access to social, cultural and recreational services and the transition from institutional to

community-based services;


Intervention no. 1: Economic and innovation development

Intervention no. 2: Food-processing industry development

Intervention no. 3: Tourism development

Intervention no. 4: Transportation development

Intervention no. 5: Human-resources development

Intervention no. 6: Urban development

Intervention no. 7: Environmental development, CO2 reduction

47

4.3. JÁSZ-NAGYKUN-SZOLNOK COUNTY

The special location of Jász-Nagykun-Szolnok county within the Great Plain, its diverse system of

relations that is free of any privileged direction, the division of its area, and the markedly different

identity and developmental processes of its regions also specify the path for the future in different

directions. For the regions and areas with various features and with differentiated tools adjusted to

the characteristics of the population, different target conditions can be achieved. What is common at

the beginning of 2013: imbalance and deteriorating quality of life, despite the obvious results, the

gradual depletion of resources. The common goal for 2030 irrespective of the development paths

differing from one region to the other is the following: the creation of a new equilibrium that is more

resistant than the one today and which can adapt flexibly to the ever-more complex and unpredictable

challenges. The establishment of such equilibrium positions should be the aim through which the

economy, society, and environment of the county would be able to tackle prevailing external shocks

with minimal losses, concentrating its resources effectively and moving on in a strengthened status.

The basis for this lies in the unfolding of the inherent opportunities deriving from the geographical

position of the county.

DIVERSE EQUILIBRIUM ON DIFFERENT PATHS IN THE FORCE FIELD OF BUDAPEST AND THE EUROPEAN

DEVELOPMENT CORRIDOR, IN THE CENTER OF THE TISZA-VALLEY, CONNECTED TO SEVEN NEIGHBORING

COUNTIES

Due to the process leading to the emergence of a new equilibrium the quality of life of people living

in the county, their level of education, self-confidence, their confidence in each other and the future

will improve markedly by 2030. The number of people planning to leave the county decreases

significantly although inter-county migration is strong due to the still existing differences in

opportunities. The damage control and crisis management characterizing the first two decades of the

new millennium are replaced by the consolidation and building processes of the economy, society,

and the environment.

Certain regions of the county � Jászság, the Szolnok-Törökszentmiklós-Martf! region, Tiszazug � join

successfully and vigorously the national and international transportation development corridors

touching or crossing the county, serving as the basis for the strengthening of the economy. The

stronger connection to the macro-economic development axis strengthens the position of the county

but the internal regional differences decrease only on the longer run. The mitigation of regional

differences and the ripple effects of the improvement of the macro-economic position are realized by

means of the building-development based on the social, mental, and cultural characteristics.

48

According to demographic projections, the decrease of the county�s population will continue to be

significant, 60-70 thousand fewer people will live here around 2040. This shrinking affects the regions

and settlements of the county to a different degree: while in certain regions the ratio of the Roma

population increases significantly, in other regions aging will be more significant. The county has faced

this challenge: due to the institutions and various tools supporting social integration, inclusion, and

the realization of talent, abilities, and skills and the application of educational and employment

policies also inclusive of the Roma population, the decrease of the population and migration is much

lower than what was projected. The rate of employment rises above 65%: the number of people paying

taxes increases and the number of those requiring social benefits decreases. As a result of the effects

of programs aimed at social inclusion and equality of opportunities child poverty decreases, social

tension subsides. Regional cooperation and the division of work ensure the existence of an institutional

system that is significantly smaller than the one today but also differentiated and of much higher

quality. As a result of focused developments, the diversified production systems of the county achieve

outstanding results in the agricultural-food industry: the raw material production for and processing

of work-intensive products absorbs a significant workforce, while processing and cultivation-breeding

with high added value also develops to a significant degree. The increase and maintenance of forest

areas along the rivers, rational management also takes up considerable workforce. A new, dynamically

growing sector of the county�s economy is represented by fish farms, capable of showing significant

results on the national level as well within two decades already. As a result of the medium-term

development of the county�s significant touristic focus areas (the active tourism potential in river Tisza

and its tributaries, medicinal waters, Szolnok city tourism), the radiating effect of the sector is

especially true, tourism and connected services are capable of taking up free capacities at more and

more settlements of the county.

Along the river Tisza, in the less urbanized areas there is landscape preservation, development and

stabilization farming (land management) taking place that is highly organized, built on integrated

water management and adapted to the challenges posed by climate change. The diverse features of

the areas along the river Tisza make it possible to create such work cultures that result in the

production of high-added-value products on the one hand, and as part of long-term cooperation, they

offer the opportunity for significant groups of the Roma population as well for a choice of lifestyle and

construction of identity. Partly within its context it becomes possible to breed species that can bear

both periodic flooding and prolonged droughts, as well as to preserve, propagate or revive old resistant

plant varieties. Along the Tisza, on lower quality farming areas, there is significant afforestation,

landscape beautification taking place with extensive pastoral farming in the low-lying areas; this results

in a favorable condition in terms of adaptation to climate change, more complex water management,

49

and the development of mesoclimate. The region of the Tisza Lake represents an outstanding value

of the county, where as a result of the touristic structural transformations of almost two decades and

the cooperation of counties the profit-generating capacity of tourism started to increase on the

regional level. It has been shown that the attractiveness of the region increased, together with the

growth in the number of attractions and services attracting people with a higher income. Besides

these, the holiday opportunities of smaller-income families and the youth are also present in a

differentiated manner in terms of space. The creation of joint marketing and program packages with

the tourist destination of the foothills of the Bükk Mountains and Eger also contribute to the

attractiveness of the region while the health tourism developments enabling the extension of the

season also contribute to it, which can thus gain positions on the European tourism market. The water

and bicycle tourist infrastructure along the Tisza, Zagyva and Hármas-Körös creates an important link

among the touristic offerings of the regions taking different paths.

The county�s �greatly shrank� regions are the Tiszazug and Körös-mente open up in an East-West

direction with the new bridge in Csongrád and the good quality expressway (no. 44). The Bánát road

unfolding the Eastern side of the Tisza in a North-South direction becomes continuous in the long term,

from the Szolnok connection of the M4 motorway to the Törökbecse region in Vojvodina. The small

villages of the Tiszazug region join the Szentes horticultural cluster that meanwhile started to supply

the international market and at the same time, by joining the highly appreciated Cserkesz!l! medical

tourism offer they become holiday villages of the Tisza, where the four-season tourist destinations

and the special Tiszazug farming coordinated by the Tiszaföldvár regional center provide an excellent

living for the population. At the same time, the Kunszentmárton supplier and processing industry

strengthened due to the improving larger regional contacts provide growing employment

opportunities for the region (besides Kecskemét and the re-industrializing Martf!) together with the

Mez"túr labor market becoming available again. The latter is to expand impressively by 2030 with the

exploitation of the international freight traffic function increasing significantly following the

renovation of railroad no. 120.

The Tiszántúl market town network will be differentiated significantly on the long run in proportion

to the supporting capacity of the region and agriculture and due to the rearrangement of

transportation geography positions. The agricultural and food industry production expanding as a

result of national development policies and fish farming will take their positive effect to different

degrees in the region. It will prevail primarily in the growing tax incomes of certain settlements, while

currently it improves the living conditions of the population only to a limited degree. On the slowly

emerging impact zone of the M4 motorway, those smaller and larger centers emerge that are of

secondary, regional significance and play a role in interregional economic networks and the space

50

organizing role of which will increase. At the same time, this can also bring about significant population

loss and the narrowing of the local economy for the majority of settlements in the Tiszántúl region.

However, the negative effects become more acceptable due to the improvement of transport

connections and institutional cooperation and division of work, as well as the conscious strengthening

and network organization of the local economy. Moreover, certain settlement communities survive

the hard years of this transformation stronger at the end, showing numerous exemplary social-

community innovations as well building on their own resources and capabilities for self-organization.

With cooperation and labor division built on the specific economic and institutional profiles of cities

within the differentiating market town region, with the application of new economic directions

inherent in the adaptation to climate change and in sustainable resource management and

settlement operation, by 2030 the new system of balance for the settlements will become stable by

2030. The city network ensures for its region a quality of life corresponding to a country standard

much higher than today at the appropriate level to the support capacity of the area, its macro-regional

position, and the abilities and skills of the population. The basis for the strengthening of the Tiszántúl

region in terms of tourism is also provided by differentiation, cooperation, pole formation (on the

regional level) and division of labor. The strengthening of existing flagship attractions (besides the

Tisza lake region, Berekfürd" and emerging Kisújszállás) is primarily built on the function-extending

development of the affected settlements. With the organization of the other tourist destinations into

a system, with the diversification-enrichment of the area, and the creation of the complex bicycle-

water tour infrastructure along the Tisza, the economic performance of the tourism of Tiszántúl

reaches a significantly higher level on the regional level.

The connection of the Jászság region from multiple directions with the Budapest metropolis region

expands with the quality improvement of the connection to the M3 and M0 motorways. With the

building of the section of M8 leading to Eger, the connection of the county and Jászság will be complete

to the continuously strengthening Budapest-Eger-Miskolc-Kassa(Kosice)/Nyíregyháza-Transcarpathia

development zone along the M3 motorway. The Jászság region maintains its industrial employment-

GDP production role that is outstanding nationally as well, with the urbanization of industrial

settlements, the development of recreational, educational, cultural services, the ability of the region

to attract capital will be more solid and will become a target of migration. The coordinated,

integrated development of water management, regional agriculture, and recreational attractiveness

will contribute to the strengthening of the industrial agglomeration of the Jászság and that of regions

in the countryside in a complex manner.

Szolnok in the medium term connects to the Vienna � Budapest � Belgrade/Bucharest corridor with

the section of M8 reaching Kecskemét, which is further strengthened by the international contacts of

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the modern railroad lines no. 100 and 120, the M4 motorway built continuously, the Budapest �

Debrecen � Nagyvárad (Oradea) axis. Organized around the V0, the role of the Szolnok � Szajol logistic

zone is becoming more significant in the Eastern section of the Carpathian basin. The cooperation

between Szolnok and Kecskemét is also becoming stronger, the Közép�Alföld agglomeration, a highly

organized urban network hub based on the division of labor, is becoming a well-perceptible,

geographical factor (Szolnok-Abony-Cegléd-Nagyk"rös-Lajosmizse-Kecskemét-Tiszakécske-

Kunszentmárton-Tiszaföldvár-Martf!-Törökszentmiklós-Szajol). The economic weight and logistic role

of the urban region of Szolnok becomes clearer in this process and those key sectors become more

crystallized which strengthen the service, cultural, and educational chains of the functional urban

region.

Figure 4: Vision of Spatial Structure� The extent of development axes, urban network hubs. Source: JNSZ

Regional Development Concept, 2014-2020

The role and position of �Szolnok, the capital of Tisza� solidifies and expands with the complex water

management knowledge center and economic basis of national significance developing in Szolnok

and its region (Nagykör") in its focus. The design, implementation, production, computer

programming innovative small businesses specialized in innovation in water and land management are

organized around its intellectual and innovation institutional center together with the increasing

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number of sample programs organized by regional centers that are becoming recognized

internationally as well.

In the Szolnok functional urban region (FUR) the system of cooperation and division of labor develops

to a high level and this extends to the logistic, economic, and settlement management roles of the

region as well. In the process of the development of 15-20 settlements into an integrated urban region,

effective contacts than can work on the long term emerge across administrative boundaries.

As a result of urban rehabilitation processes taking place in Szolnok, the area of the city does not

increase because the brownfield sites are utilized (industry, railroad, military barracks) and the already

existing industrial parks, economic areas will be filled with operating businesses. In the area of the

Szolnok FUR, the intensity of settlement areas increases and the sustainable segments of

environmental management develop in a way that with the integration of settlement operation and

settlement management the region achieves an ever-higher stage in the implementation of the

model of a �self-sustaining settlement.�

The great efforts of the county will bear fruit because its continuously developing system of institutions

is working more and more efficiently and the population of the county is healthier than today, which

is due to healthcare but also the change in lifestyle. Due to the improving level of employment and the

dialogue focusing on mutual understanding and conflict management and supported by the

institutional and financing system established by 2020, stable coexistence between different

populations within the society is created, mutually accepted local norms are established, several

segments of the local labor market become available for the Roma population. A change of similar

magnitude takes place in the field of training and education. These factors, i.e. a learned, educated,

and healthy population, will be the significant forces of the county still �shrinking� with regards to its

population but exhibiting marked improvement with regard to quality of life.

4.3.1. OVERALL OBJECTIVE NO. 1: A STRONG LINK WITH THE DEVELOPMENT AXES OF

THE MACROECONOMY

The 2030 period represents the focus of the overall objectives when the extending, intensive economic

and regional organizing effect of the Vienna/Bratislava-Budapest-Kecskemét/Szolnok-Szeged-

Belgrade/Szeged-Arad-Timisoara-Bucharest development corridor reaches over the river Tisza. In the

Middle Tisza area, Szolnok will represent the region where two systems of Europe with a huge impact

will join in the force field of the Budapest metropolitan area, i.e. an intensive trans-European urban

network � economic � logistics axis and the ecological corridor of European scale crossing over the

Great Plain, the Tisza. In the middle region of the Great Plain the two central cities of the middle Great

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Plain agglomeration (Szolnok and Kecskemét) are becoming increasingly interconnected through

numerous types of contacts and the role of Szolnok, the �Capital of Tisza� can be realized in full this

way. The various intensive economic sectors are located in this zone, the population and all those

institutions, services that are essential for safe and effective operation are concentrated here. The

vigorous logistics corridor along the M4 motorway reaching Debrecen strengthens the regional roles

of Szolnok.

The no. IV. Helsinki railroad corridor (Dresden-Prague-Brno-Bratislava-Gy"r-Budapest-Szolnok-Arad-

Sofia-Instanbul) also contributes to the dynamism of the Mez"túr region, besides that of Szolnok. The

linking of the southern part of the county into the macroeconomy improves significantly with the

Kecskemét-Kunszentmárton-Szarvas-Békéscsaba axis (M44). The cooperation between Szarvas and

Mez"túr � by means of links established by the bridge between the two cities and thus the fixed track

Helsinki corridor and the strengthening of the East-West road corridor� can improve the position of

regions on the county borders pushed to the periphery of Jász-Nagykun-Szolnok and Békés counties

markedly.

The other concentration point of macro-regional economic integration is the north-western part of the

Jászság region, which almost meets the Budapest agglomeration. In the cities of Jászság the range of

services expands considerably and the quality of the built environment improves together with the

accessibility of the region both from the M3 motorway and the neighboring villages. One of the tools

to employ the locals, boost entrepreneurship, and to support the impoverished groups involves

intermediate technical training, which also serves as one of the important points of cooperation with

Heves county.

The Budapest-Cluj-Napoca expressway that crosses the entire Great Plain is of outstanding significance

for the county due to its powerful effect regarding relations and economic organization. The building

of the M4 motorway could slow down the further erosion of the market town network in the Tiszántúl

region, the reorganization of this network can be partly founded on this.

4.3.2. OVERALL OBJECTIVE NO. 2: DYNAMIC BALANCE OF DIVERSE CULTURAL

LANDSCAPES

The marked identity of certain regions of the county � Jászság, Nagykunság � which have a several-

centuries-long tradition (with many elements of it revived) is a significant advantage as opposed to the

weak willingness for cooperation characterizing the country. This tradition forms the starting point of

cooperation between cities and businesses in the region, which will provide a foundation for the long-

term development strategy in the 2014-2020 budget cycle. At the same time, due to the special

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features of the county, this kind of relationship building takes place not only internally but externally

as well. The strengthening of internal and external contacts becomes one of the main tools of

population retention especially along the borders of the county and the region where the multiple

effects prevail by means of the decreasing disadvantages of the population.

The system of the new type, sustainable management of natural resources, the agricultural-food

industry-green industry. renewable energy verticality as well as the coordinated, differentiated

renewal-strengthening of the network of small towns built on the division of labor, founded on the

adequately sensitive utilization of unique characteristics, can result in the emergence of regions that

exist in an equilibrium on the long term. In the field of agriculture, there is a need for a more mosaic-

like land use and more complex production structure, together with the establishment of connected

water management in harmony with the use of funds for rural development. These conditions

incorporate the fact that the internal cores of cities will become more urban, more intensive, while

their peripheries could become more rural, which can be helped by appropriate regional regulation as

well.

Accepting the unavoidability of the concentration of the traditional institutional network, the quality

of life and the attractiveness of cities could be improved with the reduction of settlement operation

costs primarily through the differentiated strengthening of city centers, diversification of their

functions, the transformation of under-utilized buildings to multifunctional facilities (e.g. daycare

home for the elderly, library, cultural center, museum, daycare home for schoolchildren, study hall),

and the improvement of the regional accessibility of centers. The synergy, the disappearance of which

greatly contributed to the degradation of cities, will be rebuilt in a novel way, within a different

framework.

The unique market town architectural and cultural heritage of the smaller towns suffering from the

loss of population and institutions is becoming threatened. The affected counties (Szabolcs-Szatmár-

Bereg, Hajdú-Bihar, Jász-Nagykun-Szolnok and Békés) do everything they are capable of to bring this

heritage to the attention of the heritage protection institutions being renewed with a business

management system, to become a strategic program area, also as a heritage closely related to and

inseparable from the Hortobágy world heritage cultural landscape. The registration of values and the

programming of preservation management is carried out, together with building up its institutional

and professional base. The four affected counties create a joint tourist destination. The interest by the

media, the connected professional events attract tourists and professionals to the region in a scale not

seen before, the income from which can be returned to heritage preservation, contributing to the

increase of employment in the tourism sector.

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In the coordinated and interrelated growth of the competitiveness, landscape retention and

employment capacity of commodity producing agriculture, regional and rural development that is

based on cooperation and concentrates on local features has a major role, together, of course, with

the fact that the special features of the county with strategic significance (water, alternative energies,

Tisza region unique in Europe and special organic products, forestation, landscape beautification) have

come to the foreground in the national and international markets. The county plays a key and leading

role in the creation of the eco-highway along the Tisza and the innovative land management cluster.

Szolnok and Nagykör! connected to it, as well as Tiszaföldvár with gradual integration (as Poroszló is

Heves county), as middle-Tisza regional centers, become the innovative knowledge and training bases

for the integrated water management of the Tisza-Valley. In connection with the renewing roles and

regional development effect of water management, fish farming is revalued in the economy of the

county with the connected background industry, processing industry, and educational-training

capacity.

With the new, integrated system of water management, the creation of a new type of relationship

between the settlements and water, the Tisza water system (including the rivers Zagyva and Hármas-

Körös) becomes the center and backbone for tourism development, recreation and landscape building

in the county. Medical tourism is already dominant today and the national bases for cultural and MICE

tourism are becoming stronger and are organized on the rivers, as external organizing centers.

4.3.3. OVERALL OBJECTIVE NO. 3: HEALTHY, WELL-EDUCATED POPULATION,

COOPERATIVE SOCIETY

In the investment-centered approach of former development cycles, social renewal played a

subordinate role and as a result many investments failed to live up to expectations. The situation of

settlements and employment did not improve or did so only slightly, while the crisis undermined the

realized economic achievements dramatically. Social sustainability received even less attention than

environmental sustainability. The new thematic objectives of the European Union and the less funding

available for investments move the focus of development towards social renewal. Social renewal

covers two main, closely interconnected areas:

1. human resource (human capital) development, where the target group is made up of

individuals for whom the tangible improvement of the quality of life is of primary importance;

their opportunities in terms of access to a healthy environment and housing, as well as to

services and knowledge, define their quality of life and �value� on the labor market in a closely

related manner;

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2. social resource (social capital) development, where as a result of cooperation,

communication and division of labor between individuals extra social benefit is created; this

added benefit increases continuously as a result of targeted programs aimed at the

development of the ability and willingness of individuals, businesses, the social care system,

local communities, and local governments to cooperate.

As it has been revealed by the National Development and Regional Development Concept, after the

change of the political system in Hungary it was not only that this extra energy could not be born, but

in many cases it appears as if the energies invested by the individuals and the other actors cancel led

each other, which strengthens all other conflicts and makes their treatment impossible. This is

apparent on the level of settlements, small regions as well as with respect to different sectors, the

public sphere, the civil sphere and the private sphere as well.

The objectives and future mid-term strategy of Jász-Nagykun-Szolnok county aim to follow a path

which puts equal emphasis on the development of human resources and social resources, one used

as the tool for the development of the other, It is our goal to strengthen social networks and

individuals, to increase their ability to adapt to changes. The reaction to new challenges (e.g.,

adaptation to demographic �shrinking�) simultaneously requires the acquisition of competitive

knowledge and skills, the increase of innovative potential, the preservation of physical and mental

health in the county�s population, while the organizations, institutions and forms of cooperation

required for this should also be created, strengthened and/or renewed. The new type of regional-

program based development also strengthens this or partly presupposes it. In this respect the planning

process itself becomes the crucial element of the realization of the development objective. The

unfolding of these social processes is unfeasible without adequate regional institutions (to be created

on the level of functional urban regions), which are closely connected to the subsystems of

education/training, health/lifestyle, inclusion, and culture. These institutions should be supported

from the level of the county with a differentiation appropriate for the characteristics of the region.

This includes the organizations to be developed together with those mentioned above, e.g., the new

type of settlement management systems organized on a regional level, the integrated landscape caring

organizations managed in accordance with the complex objectives of land use. The organizations,

institutions and forms of financing which ensure the inclusion of social groups falling behind and which

are capable of close cooperation with the business sphere also belong here. These design and

implement social innovations, experimental programs aimed at inclusion and make sure that their

experience is used widely.

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4.3.4. OVERALL OBJECTIVE NO. 4: THE REGIONAL-STRUCTURAL FRAMEWORK AND

RELATIONS OF REGIONAL DEVELOPMENT IN THE COUNTY

In line with the vision, the four so called functional urban regions (FUR) that are to be treated together

functionally emerged based on the social, economic, and environmental features and challenges of the

county as well as the answers to be given to the latter, the traditions of public administration, the

regional-structural relations, the expected development of systems of the larger region, and the

opportunities and abilities of cooperation. This specifies the main lines of the framework of the

planning process and regional development. This framework, as a starting point, also considering

organizational aspects, is adapted to the new district borders (and with some exceptions to the former

micro regions). As the system of relations of a region evolve and change continuously (it is not by

accident that the legislation on districts makes the revision of border every five years possible), the

regional framework of planning should not be perceived as one set in stone, the specific development

programs can be modified in line with or can be adapted to the circumstances.

These four functional regions with their unique characteristics oriented the creation of the system of

strategic objectives, four out of the five regional strategic objectives (T.1-T.4.) create one unit out of

an intervention package related to the area of functional urban regions, with a ripple effect over the

regions. The fifth regional plan (T.5.) is directed at the water system of the river Tisza and its region

(including the Hármas-Körös region), as a regional axis. In the table below, the peripheries of secondary

impact areas can be affected and can benefit from the developments of neighboring regions in many

ways. The settlements on the peripheries of certain regions could, in this way, benefit from

developments in both regions, turning their peripheral position into an advantage.

The specific objectives of the strategy (S.1-S.4.) are not connected to particular regions due to their

nature, programs aimed at the implementation of these objectives can be planned in any part of the

county either integrated into the regional programs aimed at the realization of regional objectives, or

in another context that can be clarified in the process of operative programming

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Figure 1.: Vision of Spatial Structure of JNSZ county, 2020. Source: JNSZ Regional Development Concept 2014-

2020

4.4. SZABOLCS-SZATMÁR-BEREG COUNTY

THE VISION FOR SZABOLCS-SZATMÁR-BEREG COUNTY: �IN 2030 SZABOLCS-SZATMÁR-BEREG

COUNTY IS A PLACE WHERE IT IS GOOD TO LIVE.�

Even though in the county economic development and income in the traditional sense does not reach

the level of developed regions, it has caught up with the developed parts of the country in terms of

quality of life. This reflects a conscious choice of values: instead of a developmental policy that places

regional and economic competition above all, there is a realistic development strategy with the people

and values in its center. The development policy of the county does not focus on the incentives for

consumption- and output-oriented growth aimed at the continuous increase of income but the

creation and preservation of conditions for quality life.

The essential conditions for a European quality of life are given to all inhabitants of the county, in all

regions of the county. These are the following:

· A decent income from work guaranteeing people�s livelihood

· Access to the basic conditions of a healthy life, public goods and public services;

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· Strong, cohesive local communities.

The competitive positions of Szabolcs-Szatmár-Bereg county are improving in certain areas, as a result

of which the standard of life, employment are increasing, together with income. Large segments of the

local population benefit from the income generated in the county, the activity rate is high and the

level of employment is stable in the county, which, due to the open labor market and the special

position of the county, is provided together by the strengthened social economy (reacting to real

demands).

The county seat and the agglomeration emerging around it (together with the closely cooperating

network of economic subcenters of the county) serve as such a center of the economy and

employment, public administration and cultural life that is competitive on the European level as well.

The attractive business environment provided by them encourages the settlement of external

investors as well as the development of local SMEs.

With regard to the employment of inhabitants of country regions and the provision of high-quality

public services to them, the county network of strengthening and functionally rich small towns plays

a crucial role.

Besides the plastic, rubber and optomechatronics industry that have traditionally been strong in the

economy of the county, the competitive agriculture built around the production and high-level

processing of unique local agricultural products, tourism supported by attractive tourist products built

on special features and values, and the continuously expanding green economy are also significant.

The development of the economy is supported by advanced vocational training and higher education

that is continuously and flexibly adapted to the needs of the county�s economy and the innovation

and research and development capacity built around it.

The basic conditions for environmentally-friendly mobility are given in the county within and between

settlements, as well as between the county and its wider environment and between national and

European centers. This is important both for employment opportunities and for ensuring equal access

to public services and public goods.

To guarantee access, it is also crucial besides good transport conditions to use the most modern ICT

tools, networks, and solutions widely.

Moreover, other significant elements of the quality of life include the preservation of the built

environmental and natural values, high level energy efficiency, and the conscious ad continuously

expanding use of renewable energy sources.

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Extreme poverty was ended gradually in the entire county, The Szatmár-Bereg region situated in the

outer periphery of the county and struggling with its historical heritage is catching up gradually; this

was facilitated by targeted, integrated regional interventions built on solidarity.

Besides physical conditions, the strong and self-conscious communities, strengthening county

identity, local patriotism in a good sense, also play an important role in the development and life of

the county. As a result of social and economic changes, the external perception of the county has also

changed radically and the formerly negative image has been replaced by a positive one.

The communities and collaboration play an important role in the fact that locals consciously choose

local products and services, and that the significant portion of resources arriving to the county really

stay and are utilized within the county. The role of communities is also significant in the support of

those in need.

As a result of all the above, the former negative trend has also been reversed: the highly qualified

young professionals from the county return in growing numbers and they settle down in the county.

4.4.1. THE COUNTY�S SET OF OBJECTIVES

Szabolcs-Szatmár-Bereg county has been working hard ever since the change of regime in Hungary to

reduce the gap separating it from the more developed regions of the country. Almost all of the created

county development strategies set the dynamic growth of GDP and the gradual reduction of the gap

as the objective.

The attempts to end the difference have all failed unfortunately, as the county is still in the last but

one position in national rankings after 20 years and the scale of the gap has not decreased either.

It would not be fair, however, to state that there has been no progress at all; actually numerous such

forms of development projects (primarily costly infrastructural) were realized that can provide a sound

basis for the next period:

· The communal infrastructure is fully developed, the most pressing shortcomings have

been resolved, the county is not lagging behind significantly in this respect (except with

regard to waste water and storm water drainage);

· The majority of public institutions have been developed or renewed � with the exception

of a few areas, the county has adequate capacities both in terms of quality and quantity;

· The main transport routes ensuring the external accessibility of the county have been built

or will be completed in the foreseeable future (M3, road no. 4);

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· The settlements and centers of settlements are nicer � this is true both for cities and

smaller settlements;

· Some tourist centers have been developed, event series of national fame have been

created, it was shown that with devoted work and appropriate development projects a lot

can be achieved and visitors can be attracted to this county as well;

· Several large investors from abroad have settled down with long-term commitments and

some of the innovative businesses of the county became stronger;

· The network of industrial parks have been developed in the county and although a part of

this is still empty, they provide potentially favorable conditions for businesses, investors.

At the same time, besides the (very important) positive changes according to situation and SWOT

analysis the county still faces serious problems in several areas:

· The health condition of the population is alarming, primary health care shows serious

shortcomings;

· The activity (labor force participation) rate is especially low, unemployment is high;

· The number of the most disadvantaged regions is the highest in the country, where a

significant portion of the population struggles daily with living problems;

· The number of families living under the poverty line is outstandingly high (especially

among the Roma people) in small settlements;

· Productivity is dramatically under the national level as well, a significant portion of small

businesses in the county faces grave problems in terms of competitiveness (e.g., the

weakness of the information-communication background);

· The agriculture of the county � which is capable of producing outstanding quality in terms

of fruit growing � is continuously threatened by inland water, drought, and flooding in

many areas, a significant portion of produced agricultural goods leaves the county with

low added value and at a low level of processing;

· The county � despite its favorable age structure� loses young, talented professionals

continuously and at a growing scale.

Studying all these factors together, it becomes clear that the time has come for a paradigm shift in

terms of the development of the county � there is a need for a development policy that builds on the

realistic characteristics, realistically assessed comparative advantages of the county; a policy that is

strongly focused and considers the target groups, market opportunities, and competitors as well and

which builds on new principles leaving behind numerous established, traditional objectives.

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Based on the conclusions of the assessment of the situation and the vision to be realized for Szabolcs-

Szatmár-Bereg county by 2030 the set of objectives can be specified for the county, including the

overall, strategic, and horizontal objectives for the period leading up to 2020.

The development concept of Szabolcs-Szatmár-Bereg county formulates three overall objectives which

reflect the choice of value by the county, the main direction of developmental objectives. In order to

realize the three overall objectives, seven strategic objectives have been established, four out of which

are thematic objectives and three are regional ones. The realization of the set of objectives takes place

in line with intelligent, sustainable, and inclusive growth (as horizontal objectives).

4.4.2. OVERALL OBJECTIVE NO.1: THE ACTIVE COUNTY

Value-creating employment and increased participation

For the future and development of the county it is crucial that as many people should perform useful

work that creates value as possible and thus get a decent earned income � to realize his, new jobs are

needed on the medium-term already. The other important element of helping employment involves

the increase of the activity (participation) rate. The participation rate in Hungary is one of the lowest

in the European Union and labor market participation is the lowest within Hungary in Szabolcs-

Szatmár-Bereg county. One of the key development policy objectives of the next period will be to lead

back those people who left the labor market into the world of work. It is important that most of those

who are not competitive on the open labor market should also get a job; for this purpose the value-

creating social economy has to be strengthened. Within the social economy, however, instead of public

works such a form of public employment should be provided for people that creates long-term

workplaces and that gives useful work to them.

For the creation of new jobs, there is a need for a competitive economy and such businesses that are

competitive internationally as well. Szabolcs-Szatmár-Bereg county needs a stronger, more self-

confident small and medium-sized enterprise sector, for this purpose we have to encourage the

willingness to start enterprises and improve business culture. Besides the creation of new jobs, we also

have to pay special attention to the protection of already existing workplaces.

The development of the economy and the expansion of the labor market should be supported primarily

through the improvement of the profitable sectors of the economy in the county (food industry,

optomechatronics, rubber industry, plastic industry, logistics, packaging industry, green economy,

tourism); the economic subcenters of the county and the Nyíregyháza agglomeration can play a key

role in this respect. In social economy, likewise, we have to focus primarily on profitable fields, thus

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creating stable jobs. In the rural regions of the county, the most important area of employment policy

and economic development is the food industry, which is the key focus of the county�s rural

development policy.

4.4.3. OVERALL OBJECTIVE NO. 2: THE COUNTY SHOWING SOLIDARITY

Ending extreme poverty and supporting underdeveloped regions

The situation of those living in extreme poverty is a serious and continuously growing problem in the

county, many of the people involved are of Roma origin. These major social problems contributed to

the segregation of certain parts of the county, expanding to significant areas. The marginalization of

certain layers of society created regional crises centers; thus the support, convergence of these areas

is closely connected to the convergence of the local population. This represents a complex

employment, housing, educational, social and integration question to which we have to provide an

integrated solution. Although the management of the situation of groups falling behind does not fall

only within the competence of the county (without support from the state these social problems

cannot be solved), it is, on the one hand, the clear interest of Szabolcs-Szatmár-Bereg county to find

the appropriate solution, and, on the other hand, there are many related interventions which can be

completed most effectively on the county level. Ending extreme poverty is possible only with income

thus there is a need to create jobs in these areas. Due to the under-qualified position of the society

and its low labor market activity, the significant portion of the people in these areas cannot find a job

in the open labor market. Primarily, there is a need for social public employment that creates value

and which is realized with active state involvement until a competitive salary is not available. This way

the building of the social network takes place with the development of the social economy. In this

sense, the social economy is the sector which provides job opportunities for those most threatened by

exclusion, while in the social sector it provides help for the creation of new, independent business

activities.

Social inclusion should be carried out in accordance with the principle of social partnership, through

cooperation in consortiums, social pacts, in which the civil sphere and volunteering play a crucial role.

There is a need for a change in approach in the development of settlements, especially villages, for the

purposes of successful social inclusion, in which the gradual termination of segregated residential

areas receive a central role.

4.4.4. OVERALL OBJECTIVE NO. 3: THE ATTRACTIVE COUNTY

Creating an attractive natural, social, cultural, and economic environment

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The improvement of the quality of life is in the center of the county�s vision; this has many other

components besides income. In order to help those living in the county feel good it is crucial to have

an attractive and clean natural environment. It is our key task to preserve and improve the ecological

values and natural environment of the region and to provide an environmentally friendly energy supply

for the county.

It is also crucial to establish such a social milieu that is an important component of both the attractive

rural and livable city environment. The provision of access to public goods and services by everyone is

a significant element of this together with guaranteeing the conditions for both external and internal

mobility.

The conscious development of the county�s cultural spaces will also play an important role in the

development policy of the next years for the purposes of creating a vibrant cultural life in the county.

In this respect we should focus on the improvement of the cultural image of the region, with the

development of the county�s tourism as a key area.

Besides the creation of an attractive economic environment, it is necessary to have a concentrated

and organized investment-incentive activity, primarily focusing on the central region and the

subcenters. Keeping the value-creating small and medium-sized enterprises that provide employment

and companies that act as major employers is a central task.

The conscious development of the image of the county can be based on the achievements of the

environmental results of the attractive county, which shall start such mechanisms in the local

population that strengthen people�s identity. The attractive county image also contributes to the

emergence of positive attitudes in the existing and potential investors and tourists.

4.4.5. STRATEGIC OBJECTIVE NO. 1: COMPETITIVE FOOD INDUSTRY

The focused strengthening of agriculture.

The county�s agricultural economy has strong traditions, and with regard to certain products, favorable

features. Building on the already existing, favorable agricultural achievements, our aim is the complex

development of the agricultural economy: this includes stimulating the development of food

processing capacities, the strengthening of local processing, but also the improvement of specialized

agricultural machine production. The strengthening of food processing has two main elements: (i) on

the one hand, the strengthening of local processing capacities supplying smaller regions, groups of

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settlements (ii) on the other hand, the strengthening of larger processing capacities capable of export

activities as well, which

· rely on the agricultural products produced in the county;

· generate significant added value, creating new value, new products;

· are based on innovation, innovative solutions.

The basis for exportable food industry products is represented by such high-quality, local agricultural

products which can be produced by means of production integration. With the complex development

of food processing, the economic profitability of the county and its employment role can be improved

greatly.

4.4.6. STRATEGIC OBJECTIVE NO. 2: GREEN COUNTY

Green economy, climate-friendly energy management, adaptation to climate-change.

For the purposes of the long-term development of the county and the creation of an attractive

environment, it is a key to switch the energy supply of the county gradually to renewable, alternative

sources. This, on the one hand, can bring about the decrease of external energy dependency of the

county (the strengthening of self-support in terms of energy) as well as the direct and indirect carbon

dioxide emissions of the county, while it can also stimulate the strengthening of green economy. The

latter is of key importance for Szabolcs-Szatmár-Bereg, as the green economy can play an important

role in the social economy as it employs people with lower qualifications (integration of the green

economy and social economy).

Climate change has such negative effects and risks that that can affect the county especially. We have

to prepare to be able to alleviate the negative effects and avoid the risks. Due to the unique position

of the county, water management has to be treated as a key area (flood and inland water, drought)

and a conscious climate strategy has to be applied. Besides the energetic renewal of the physical

environment, the promotion of environmental awareness will be a major task in the following years

within the population, businesses, and settlements.

4.4.7. STRATEGIC OBJECTIVE NO. 3: PROACTIVE COUNTY

Creating the conditions for economic and social self-organization on the county level.

The county specified ambitious objectives and the realization of these is possible only if it takes

initiative, �takes its fate into its own hands�, and provides for the proactive harmonization,

coordination of the development activities of different actors in the county. There are numerous areas

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where no achievements can be realized without appropriate county-level coordination and the

cooperation of those involved: such areas include, among others, the development and sales of

tourism products, investment incentives, county image building, support for small enterprises,

agricultural marketing activities, and the strengthening of social economy. Without an adequate

organizational background, tools, human resources, these county management activities cannot

achieve the required results.

The deepening of the international integration of the county also forms a part of proactivity, which

takes place partly with the utilization of the closeness of Eastern markets and the strengthening of

contacts along the border. The use of comparative advantages deriving from the borderland position

is a key development policy focus of the county�s strategy.

It is also an important task to establish agency-type institutions with professional human resources for

the purposes of the county�s economic and regional development. Economic self-organization shall be

facilitated primarily in the areas of county-level tourism coordination/tourism development, regional

development, rural development, the county�s marketing strategy, innovation incentives, business

development, social economy, and agricultural production and sales. The most important direction of

social self-organization focuses on community development, strengthening identity, preservation of

values, and social inclusion.

The creation and development of a complex, integrated regional marketing policy built on unified

community marketing tools, which includes the performance of the county�s promotional tasks with

regard to tourism marketing, investment incentives and the conscious transformation of community

agricultural marketing. Marketing-oriented community development is a distinctive element of the

county�s regional marketing approach.

The support of the exportable products of the county to enter the market with community marketing

tools is a key task.

4.4.8. STRATEGIC OBJECTIVE NO. 4: WELL-EDUCATED COUNTY

Creating a flexible vocational training, higher education and innovative environment.

The existence of a competitive society, outstanding due to high qualifications, is a prerequisite to the

creation of a competitive economy. The extension of employment and the strengthening of the

economy are not possible without well-qualified professionals and an adequate research and

innovation background. The basis for this is available but it is important to create and continuously

develop vocational training, higher education and research capacities that reflect the needs of the

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economy better and which can adapt to its changes quickly and flexibly. It is necessary to establish an

R&D activity that harmonizes with the economic and regional development policies of the county and

satisfies the needs of the market and which is supported by viable and marketable adult education

that is based on a range of unique programs. It is also important to establish the conditions for life-

long learning as well as raising the awareness of people in this regard.

The paradoxical situation that there is unemployment and labor shortage simultaneously is especially

characteristic of the county; there is a need for an adequate, qualified labor force in the local economy.

Providing access to education, training, and vocational training in the regions lagging behind is a key

task together with the educational integration of disadvantaged social groups.

4.4.9. STRATEGIC OBJECTIVE NO. 5: DEVELOPED CENTER

The development of the Nyíregyháza agglomeration as an economic, employment, public service, and

cultural center.

The driving force behind the development of the county especially that of a competitive economy is a

strong central settlement. Nyíregyháza � in close cooperation with settlements in its agglomeration �

is capable of filling in this function and it can play a significant role in the dynamic development of the

county. In the regional development of Szabolcs-Szatmár-Bereg county, the development of the

Nyíregyháza agglomeration can be seen as one of the poles of regional-type strategic objectives. In the

next period, the development of the agglomeration in a wider sense should be managed in a more

complex way for the purposes of exploiting the impacts of agglomeration. In order to achieve this, it is

important to (i) provide investment incentives, encourage the settlement of additional large investors,

(ii) strengthen the conditions for the international touristic attractiveness affecting the entire county,

(iii) to create the conditions for climate-friendly (community and bicycle) transportation both within

the city and establishing connections with the settlements in the agglomeration and with other

Hungarian and European central settlements, and (iv) develop attractive urban living spaces and (v)

further strengthen active international contacts.

The expansion of the economic and social benefits of the county seat can be made more dynamic by

the agglomeration processes in the next years, thus it is a major objective to make sure that effects of

agglomeration prevail in the widest range and largest area possible (the development policy clearly

has to support this).

In the process of developing the Nyíregyháza agglomeration, another regional aspect has to be

considered. The opportunities provided by the Nyíregyháza-Debrecen urban axis that has emerged in

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the last decades should be exploited more intensively. For the purposes of strengthening the contacts

between the two cities, there is a need for focused intervention, primarily with the aim of

strengthening the economic (with R&D and innovation occupying a key role), employment, and

transportation functions.

4.4.10. STRATEGIC OBJECTIVE NO. 6: DYNAMIC CENTERS AND SERVICE-

PROVIDING DISTRICT CENTERS

The functional extension and coordinated development of economic subcenters and district centers in

the county.

Besides the Nyíregyháza agglomeration as a center, the county�s economic subcenters also play an

important role in the development of the county as a whole. The subcenters of Szabolcs-Szatmár-Bereg

county are Mátészalka, Nyírbátor, Kisvárda-Záhony (the latter is to be treated together from the

perspective of planning). The economic subcenters of Szabolcs-Szatmár-Bereg county are primarily

industrial centers.

The Kisvárda-Záhony subcenter is an international logistics center, which improves its strategic role in

the county and the country. The cultural and tourism-related functions of Kisvárda are also important.

Mátészalka plays the role of an economic center in the fields of optomechatronics, furniture

production, and the food industry.

Nyírbátor has central functions in the plastic industry, food processing, and tourism.

Due to their location outside the center, they play a significant role in the economy of the eastern part

of the county. As because of its geographical position Nyíregyháza is not capable of fully extending its

economic development impact on the eastern part of the county, the subcenters are of strategic

significance in the network of cities. The dynamism of subcenters and their integrated development

can have a positive effect on the development of neighboring regions. The subcenters are the other

focus points of the development policy of Szabolcs-Szatmár-Bereg county, their improvement is a

regional strategic objective due to their significance. Building on the existing infrastructure in the

subcenters, the development of existing businesses should be encouraged together with the

settlement of new enterprises (especially that of industrial businesses), the urban and center functions

should be developed, and the system of public services shall be extended. These subcenters are not

only economic but also cultural subcenters in the county; thus, their attractiveness in terms of culture

and tourism should be strengthened. In order to extend the positive effects, the (climate-friendly)

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access of subcenters from the neighboring settlements should also be improved, to be able to serve

the population fully. The subcenters are the key areas of business infrastructure development.

Besides the subcenters, the district centers of Szabolcs-Szatmár-Bereg county are also of great

significance; these play an important role in the concentration of urban goods and services and in the

provision of city functions for rural regions. In the development strategy of the county, the

improvement of district centers is oriented primarily towards the development of quality services and

thus to create the basis for a district network providing high-quality services. Those regions should

receive special attention, where the subcenters are weak (eg. Nyíri Mez"ség, Szatmár-Bereg region);

the economic development role of cities should also be strengthened in these areas (Tiszavasvári,

Fehérgyarmat, Vásárosnamény).

All in all, this regional strategic objective specifies the basis for a two-level urban development strategy,

in which the economic subcenters and district centers have preference.

4.4.11. STRATEGIC OBJECTIVE NO. 7: LIVABLE COUNTRYSIDE AND CONVERGING

EXTERNAL PERIPHERIES

The complex inclusion of the external peripheries of the county and the integrated development of

rural areas

The strategic objective also specifies a two-pole regional objective, which at the same time is also the

major rural development orientation of Szabolcs-Szatmár-Bereg county for the 2014-2020 period. It

includes the complex development of border regions and the development of rural regions, which

represent the most critical point of the county�s development policy. It is especially because of this

that their special treatment is necessary and it is needed to generate a complex strategy for the local

orientation of the development policy that helps them catch up.

The border regions of the county � especially the Szatmár-Bereg region � are in a disadvantaged

position, gradually left behind. These regions can clearly be considered as the external peripheries of

the county and the country. The external peripheries, due to their unique history, face problems and

challenges, which require special intervention. The Szatmár-Bereg region is a well-defined crisis area,

the development of which primarily requires a complex, integrated convergence program and

targeted, complex interventions in order for the county to prevent the permanent decline of external

peripheries. It is still a key task to help the reintegration of contacts with the old, historical centers,

which can help the strengthening of the region�s economic contacts with their former attraction poles.

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The majority of the rural areas of the county not on the external periphery are also in a difficult

position, their development cannot be guaranteed by the impact of the centers and subcenters.

Integrated, sustainable interventions are also needed in the rural areas to manage problems. Special

attention should be devoted to the internal peripheries within the county, where the characteristics

of the multiply disadvantaged status are also perceptible (western villages of Nyíri Mez"ség, eastern

corner of Dél-Nyírség).

It is a common feature of these regions that physical and virtual access are of crucial importance just

as the strengthening of the social economy due to the pertaining serious employment problems. The

improvement of community cohesion (practical application of community development policies) and

social competitiveness are also significant elements of the county�s rural development policy, which

includes the renewal of rural regions while also preserving and protecting their values.

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5. STAKEHOLDERS IN DEBRECEN

5.1. REGIONAL BUSINESS MAP

Szinapszis Kft. conducted primary research on behalf of the Municipality of Debrecen among the

health industry businesses in the Észak-Alföld region. As part

of the research, the businesses of the region have been

mapped and identified with the help of KSH (Central

Statistical Office) and the list of companies was finalized in

cooperation with the local government. Besides the creation

of the business map, the executives who were willing to

participate were interviewed first within a telephone

interview and then with a self-administered questionnaire about their current activities, operation,

and future plans, development projects. The research was carried out in November 2013.

The following figure illustrates the most important indicators of the current key actors in the Észak-Alföld

health industry:

Figure 2.: Health Industry Business Map of the Észak-Alföld Region. Source: Szinapszis research, Nov. 2013.

Research Methodology: Self-

administered quantitative survey

after telephone interviewing. Target

group: health industry executives in

the Észak-Alföld region. Size of

sample: 457. No. of respondents:

N=58. Length of questionnaire: 10

min. Fieldwork: November 2013.

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Figure 3.: Distribution of companies in the Észak-Alföld region according to form of business, revenues, and

no. of employees

The red biotech as a health industry segment is outstanding in the Észak-alföld region as well but the

health industry service providers are in the majority. The largest companies in the region produce

primarily to the Hungarian market but in certain cases they have international contacts as well and

there are companies (especially in Debrecen) with HUF 100 million in revenues, which get the majority

of their income from abroad. Still, we can see that 84.5% of revenues come from the national market.

With regard to export markets, the neighboring EU member countries are the most significant,

including, Romania, Germany, Austria, and Slovakia but the USA and Poland are also among the most

frequently mentioned target markets among export countries.

46.6 % of executives who completed the questionnaire find the current status of the economy �rather

good� or excellent but this ratio is higher among companies in Debrecen (58.82 %).

Close to 80 percent of executives are planning some kind of a development project, investment or

staff increase. The majority would develop the infrastructure but every third company is planning the

employment of new workforce also. Twenty-five respondents claimed that they were planning to

introduce a new product or service.

They see the increasing costs in most cases as the main hindering force behind growth and

development, while high taxes occupy the second position. The economic crisis and decreasing prices

were also mentioned by many. The shrinking of target markets was another often mentioned factor.

This factor, together with the fact that 85.5% of the companies produce to the Hungarian market only,

indicates that the reduction of Hungarian healthcare and research and development expenditure

already shows its effect in the case of health industry businesses. At the same time, it cannot be seen

yet that they would turn towards new markets in large numbers (despite the fact that during the

introduction of international trends we saw that we could join numerous emerging sectors). This issue

should also be studied from the perspective of what could be the obstacles for the exploration of

foreign markets and whether the companies are ready to develop in this direction. Another direction

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could be represented by the stimulation or changing of the domestic demand in connection with the

cost effective transformation of the healthcare system, for which, however, the businesses need to

be prepared.

The situation of health industry businesses in Debrecen can be illustrated as follows:

Figure 4.: The distribution of health industry companies in Debrecen according to registered seat. Source:

Szinapszis research, November 2013

Figure 5.: Distribution of companies in Debrecen according to form of business, revenues, and no. of

employees

It can be seen from the figure that most of the businesses can be regarded as micro companies, the

majority of limited partnerships seated in the city are businesses of doctors not employing external

workforce.

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The executives completing the questionnaire indicated own funds and tender resources as the main

sources of development, they consider investors only to an insignificant extent. This can be due to the

fact that close to 80 percent of the companies operating in the region do not exceed 50 million HUF in

revenues.

In terms of human resources, there is the largest need for doctors, pharmacists, medical and dental

technicians in the health industry of the region, however, there is also a need for those coming from

an economic background (economists, logistics, financial, and sales personnel, etc.); this represents

the second most frequent mention by executives after the profession-specific workforce.

It was also asked what kind of help, support do the executives expect from the local government of

Debrecen. The following are the three most frequent mentions:

1. Targeted tender opportunities

2. Creating opportunities for cooperation between sectors

3. National and international marketing of �Debrecen, the Vital City�

In the following sections of this chapter, the different local health industry sub-sectors are presented

and analyzed separately.

5.2. PHARMACEUTICAL INDUSTRY

The pharmaceutical industry is a key sector in Hungary. Actors in one of the most important sectors of

the Hungarian economy produced more than HUF 1,155 billion in 2012, this way providing close to 5

percent of the national gross added value. At the same time, the Hungarian pharmaceutical companies

paid to the state more than HUF 68 billion in 2012 and employed more than 13 thousand people.3 They

also spent almost the same amount on domestic R&D (HUF 62 billion).

The present situation of Hungarian pharmaceutical production, its role and weight in the national

economy is the result of achievements of the past decades. Thanks to pioneering inventions and the

application of new technologies, Hungary got involved in pharmaceutical production among the first

and became a great power in the sector within a few decades only. Currently, the Hungarian

pharmaceutical companies transport their products to close to one hundred countries in the world and

millions of patients are healed with Hungarian medicine.

Besides the national level, pharmaceutical production in Debrecen also has a close to a century-old

history thanks to Biogal (formerly known as Hajdúsági) Pharmaceutical Factory, which was bought by

3 http://www.webbeteg.hu/cikkek/egeszseges/15587/huzoagazat-a-magyar-gyogyszeripar

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TEVA Magyarország Zrt in 2004. R&D activities connected to production are also performed in the

Debrecen plant and they also produce pharmaceutical materials and solid dosage forms (capsules,

tablets, suppositories, etc.).4 Today this is not the only pharmaceutical company in the city with a

global significance; in 2012 the Biotechnological Plant of Richter Gedeon Gyógyszergyár Nyrt. was

opened in Debrecen. The plant produces samples necessary for clinical trials (recombinant proteins).5

In April 2014 the foundation stone of the Pharma-Flight International Scientific and Service Center was

placed. The activity of the research and training center to be realized within a year close to the

Debrecen international Airport covers three main areas: Aviation Center, Clinical Research Center,

Small Series Pharmaceutical Production Center.6

The presence of the University of Debrecen and the Nuclear Research Institute of the Hungarian

Academy of Sciences, their research and scientific potential, and their results are key factors in the

past and present development of the pharmaceutical industry in Debrecen.

Development directions and potentials:

The small and medium-sized pharmaceutical enterprises can greatly contribute to the growth of

pharmaceutical industry in the region. Infrastructural investment is not a prerequisite today for

starting a business as at the Debrecen site of Richter Gedeon Nyrt. the biotechnological incubator

house is available with well-equipped labs, research and office infrastructure. The Clinical Research

Center and Small Series Pharmaceutical Production Center to be completed by Pharma-Flight Kft. by

2015 also aims to help the local SMEs The Pharmapolis Innovative Pharmaceutical Industry Cluster can

contribute to this process by itself and also through its member companies.

It is an important question, however, what percentage of local companies can join the activities of

actors in the pharmaceutical industry. Based on business data, it can be seen that the presence of

biotechnological companies that can be perceived as pharmaceutical industry suppliers is not

significant locally (max. 10 companies), who, with a few exceptions, sell their services to the University

of Debrecen and Richter or some other company in Hungary. The large projects realized so far can be

connected to one of the strong local players, however, in the number of staff of small and medium-

sized businesses no significant growth can be detected.

5.3. MEDICAL DEVICES, MEDICAL APPLIANCES AND DIAGNOSTICS (INCLUDING

EHEALTH, MHEALTH)

4 http://www.teva.hu/gyogyszergyar/teva-gyogyszergyar-zrt 5 http://www.richter.hu/HU/Pages/biotech.aspx 6 http://www.pharma-flight.com

76

There are approximately fifty companies operating in this area, in most part with medical device

manufacturing, development, and service profile and as dental suppliers. A significant portion of

businesses are suppliers of local healthcare. At the same time, there are some actors who are present

successfully on the international market.

Medical device manufacturing has a half-century-long history in Debrecen due to the presence of

Dispomedicor Zrt. and its legal predecessor. A smaller part of the products manufactured by the

company are sold in Hungary, while the majority in various countries in Europe, Asia, Africa, and

America. Thanks to continuous renewal, a quality-centered approach, and commitment to customer

values, the single use, disposable medical devices proved to be the most suitable for exportation as

the company opened its Egyptian joint venture in 2011 with expansion in Africa as an objective.

Medicor Kézim!szer Zrt. is a leading medical hand instrument manufacturing and distribution company

in Hungary with a six-decade-long history and a significant position globally as well. The company went

through major transformations since its foundation in terms of its profile, organizational structure, and

staff number. However, in one aspect it remained the same throughout: they continue to produce in

high quality those hand instruments and devices the use and application of which are indispensable in

modern medical sciences. This is proven by the National Quality Award and the European Quality

Award (EFQM) received in recognition of the continuous quality production and its development, as

well as their extensive customer base from the United States to Japan.

Of course, besides the large Hungarian companies, there are several small and medium-sized

enterprises working in the field of medical device, medical appliance, and diagnostics. The professional

staff of MEDIROLL Kft 7 is made up of electrical and mechanical engineers also dealing with the

production, distribution, and repair of medical devices. The company focuses especially on

audiometry, medical lamps, sterilization techniques and hygiene products and it has been successful

on the market for more than 10 years with 8 employees and has been serving both the smaller and

larger healthcare providers, labs of the region. EMD Endoszkóp M!szer Kft8 was started in 1997 as a

company with Hungarian ownership and its seat located in Debrecen. The company employing more

than 40 people provides services for the great majority of Hungarian healthcare institutions (and

European ones as well) both with their optical instruments and devices made with world class

technology due to constant innovation and their service covering almost the full range of a surgical

appliances and devices. EMD Kft. has worldwide patents and its own R&D team that guarantee its

global market leading position with regard to some technologies. Continuous development is

7 www.mediroll.hu 8 www.emd.hu

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indispensable to make competitiveness sustainable on the Western-European and North-American

markets, while in the Arab countries a competitive advantage can be achieved also with the level of

Hungarian production costs.

It was reveled in the interviews made as part of the

business map section (Chapter 3.3.1.) that there is a large

international demand as well for products (and

connected services) manufactured by Hungarian small

and medium-sized businesses developing medical

devices and medical technology instruments. Their

competitive position is weakened by the limited liquidity

of the Hungarian market outlets (hospitals, clinics), as the

majority of receivables is high because of the late

payment of the Hungarian market outlet or their failure

to pay. Several SMEs have suffered from this negative cash flow trend, which has caused the

termination of companies as well due to the late payment by hospitals and clinics that could amount

to several months

Following international trends, SMEs have also appeared in Debrecen in the eHealth/mHealth sector.

One of the examples is PharmaPromo Kft. The company has several years of experience in healthcare

and pharmaceutical online communication. 9 Taking into consideration the special needs and

objectives of the different pharmaceutical companies, they provide flexible, professionally reliable,

and high-quality service. Their activities include online communication solutions, e-detailing, online

communication strategy advising in the fields of the healthcare and pharmaceutical industry, and the

development of mobile applications. Examples for the latter include Hölgynaptár [women�s calendar],

a gynecological calendar application, GynAssist, an application developed for gynecologists which

makes the reception and illustration of logged data in Hölgynaptár easier, and Súlypont, a weight

control monitor.


Based on our survey, the condition for the support of development projects in the medical device and

technology market is the simplification of regulations. With regard to the suggestions formulated

concerning the local regulation system, the extension and development of specific SME investments is

worth supporting even with accelerated approval processes as quick reaction on market trends is the

9 www.pharmapromo.hu

Development example: Remote

monitoring

Devices (heat and motion sensor cameras,

pulse monitoring vests, blood pressure

measuring bracelets, etc.) placed on the

body and/or in the environment of the

person requiring supervision (someone

with a serious disease, elderly family

member living alone) can record data using

the Internet and can contact the

family/carer in case of an anomaly. Quick

reaction can be started from a data center

with the notification of specialists.

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key advantage of SMEs. Based on the responses of companies, from the part of central budget

institutions a general business ethics approach could also increase competitiveness: the termination

of late payments, compliance with commercial conditions of the market can keep the domestic micro

and small businesses alive that often operate with small revenues but high employment.

The support of SMEs to reach new international markets is of key significance in this area. The

enterprises interested in foreign markets have to be introduced to the available opportunities. With

the collaboration of local companies, the experience with healthcare services and the medical device

and diagnostics production and development background (among others) could serve as the basis in

this respect. Debrecen has the potential to make it possible for these companies to introduce new and

in certain cases integrated products and services in the field of eHealth/mHealth.

The health industry element of the Debrecen - Smart City concept is the next program. The city is

currently at the start of the merger of the two large healthcare providers. The consolidated service

range, the jointly utilized infrastructure, and the available knowledge base can represent a competitive

advantage for the city on the long-term. In connection with this, following the integration of the city�s

healthcare institutions, the client-level integration of the IT systems of healthcare providers of the city

(hospital, clinics, health promotion office, GP offices, spa, etc.) is necessary. In line with the

expectations of a 21st century population, health services have to be made available on the web and

smartphone interfaces which would make it possible to get general information, make appointments,

provide information on health screenings, get information with regard to medical records, and have

access to simplified administration. The advantages of the system include multi-level integration and

client-centered automation, as a result of which healthcare workers are not overburdened either. The

basis of the system in practice is that the medical records are available online for the whole population

of Debrecen together with online medical consultation appointments to the GP, and through the GP

to the specialists. (The system now operates in the Spanish Basque region.) After making an

appointment electronically, the intelligent system sends information automatically in connection with

the targeted tests, problems (for example, before the

ultrasound tests of pregnant women, it can send

informative articles on the process, its importance, etc.).

Finally, after the medical examination, the GP

automatically receives the patient data electronically

(which are added to the online medical database), as it is

the task of the GP to care for the patient in the future.

After treatment, the patients would also automatically

get important and interesting articles, materials

Development example: Open data

A health promotion opportunity for large

databanks involves the anonymous

processing of actual medical records and

patient profiles and the creation of new

services based on the perceived needs. For

example, community sports programs for

those patients with inadequate physical

activity, restaurants processing functional

food for people with diabetes, etc.

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concerning the preservation of health together with calls for free events in the neighborhood (e.g.

open days of maternity clubs, to stay with the previous example). The creation of a patient information

system that is more general and which can be accessed easily and freely is a necessary additional

element of the patient path tracking system. With the placement of easy-to-use online terminals, the

whole population gets access to up-to-date information available on the Internet. The terminals can

be located at the provider, spas, and health tourism centers. Finally, the local pharmacies could also

be added to the system: where the prescribed medicine is available, at what price, packaging,

discounts; thus the patient does not have to visit several pharmacies. With this digital urban healthcare

service model, Debrecen would have an innovative market leading position in Hungary and thanks to

the modular system of the model it would be transferrable (in full or in part) to other cities both in

Hungary and abroad that provides a return of investment. The adequate and timely education of the

population concerning the use of the integrated online healthcare information system is of key

significance. Today�s X and Y generations (up to 40 years of age) have a positive attitude towards new

technologies and can use smartphones, online systems, technical novelties. In the process of

dissemination, special attention should be paid to the idea that the development project should not

only be noted but supported, used, further developed, and accepted by the population as its own.

The biotechnology Innovation Center is a new industrial park investment close to the production

facilities with their seat in Debrecen. With regard to its professional activity, it is a health industry

biotech innovation center, which provides the development background for medical device

manufacturers already successful in foreign markets.

5.4. HEALTHCARE SERVICES, PRIVATELY-FINANCED PATIENT CARE

Privately-financed patient care, within human healthcare, is one of the most outstanding sectors in the

health industry that can directly contribute to the economic growth of the city and the country. Patient

care itself can show high employment figures and thanks to reimbursement by the Hungarian Health

Insurance Fund it has an indirect economic effect on the budget. Those organizations and initiatives

that utilize high level domestic health services and healing knowledge for commercial purposes can

already boast significant international success. This is well illustrated by the growing number of private

clinics as well.10 Moreover, a Hungarian representative survey also revealed that in 2012 again (after

2008), the evaluation of private healthcare provides was better, people trust the quality of privately-

financed care more than the public system.11

10 http://www.webbeteg.hu/keresok/maganklinika 11 http://www.webbeteg.hu/cikkek/egeszseges/14335/egeszsegugyi-szolgaltatasokba-vetett-bizalom

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In Debrecen, with the merger of the Kenézy Gyula Hospital and Outpatient Clinic and the Clinical Center

of the University of Debrecen, the largest human healthcare institution of Hungary is created.

Currently, both institutions have their own organizational framework for meeting the demand for

private healthcare. The MedHotel section of Kenézy Hospital provides special care for all patients both

in the case of inpatient and outpatient care.12 The Regionális Egészségügyi, Oktatási és Fejlesztési Kft.

(REOF) was established by DOTE fejlesztési alapítvány [Debrecen Medical Science University

development foundation] in 2006 with the aim of providing patient care, educational, and research

tasks; as part of this, privately-financed patient care was started in 2007 with the help of which

foreigners and those without social insurance can use the high quality services of the University of

Debrecen for a fee.13 With the integration of the institutions, the cooperation with regard to the range

of tasks of the two institutions can be predicted together with the merger of opportunities as well.

When studying privately-financed patient care we should consider that Hungary represents the East

for Western countries and the West for Eastern countries. In the service sector this means that

Western patients can be served only at the level of care and infrastructure they got used to at home,

which is currently available in Hungary around Sopron and Budapest. Privately-financed patient care

is provided in Debrecen within the public infrastructure with a higher quality level in terms of service.

The patient care provided for EU citizens takes place in practice at the expense of social security,

meaning that this service does not bring extra income for the provider while it results in extra expenses

for the state.

Besides public healthcare there is another pillar in Debrecen. By means of private capital investments,

there is a growing number of private clinics in Debrecen (Apollo Medical, Diagnoscan Magyarország,

Aesthetica Magyarország, Divinus Hotel BHC, Medicover, etc.). At the same time, there is a growing

need for special home-care. The appearance of private capital in this form stimulates the economy,

creates jobs, and as a result of competition increases the quality of service and reduces prices.

Due to demographical changes, the opportunities of home-care and care for the elderly should also be

studied. Such a home-care system should be considered that is modern and effective on the long-

term. The conditions for this include the application of new technologies and the support for the

introduction of business solutions sustainable in this area. The spreading of home-care opens up new

market opportunities for local businesses from the perspective of industrial development. Keeping in

mind that this market is facing development in East-Central Europe and to the East of us as well, those

12 http://www.kenezykorhaz.hu/medhotel-betegellatas 13 http://www.reof.hu/index.php

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companies will have a competitive advantage who are already developing products and services for

the home-care market.

The integrated approach can create a platform here as well for local companies: the Shared Care

Service Center (SCSC) already operates successfully in the Southern part of the Netherlands. In this

model, different healthcare providers and SMEs work together in the area of care provided for the

elderly and disadvantaged groups. The basis for the model is a joint info-communication infrastructure

which serves the care providers simultaneously with the services provided for their clients. A novel

aspect of the model is that the center is a marketplace at the same time, where the new innovative

products and services also appear, which can spread among the different service providers based on

their usefulness on the market thus creating an attractive market output for developments by local

small companies.

Home-caring is becoming more widespread in Hungary as well through various businesses and non-

profit foundations and associations (for example, Magyar Hospice Alapítvány operating since 1991).

With the spreading of this home care culture, a multi-level system can be operated that utilizes the

healthcare system more effectively both structurally and financially:

Figure 6.: The population dimension of the central healthcare system cooperating with home-care.

The goal of the local government is to develop this home care system through its entire spectrum.


Family care:The family can provide care for the patient by reorganizing their lives.

Home care service:The family cannot provide care for the patient on its own, thus a nurse is employed to provide care during worktime.

Curative treatment:In the case of pain it should be alleviated immediately, thus the patient receives curative, professional care within 24 hours within the central home care service in the center. They can return daily if necessary.

Inpatient care: If the disease intensifies, the patient stays in a hospital room , which in an ideal case should resemble a hotel room with a bed and armchairs for the relatives. This creates the appropriate ethical and moral environment.

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When developing privately-financed healthcare, the ratio of risks and income should be considered as

the possible malpractice lawsuits of high-risk operations do not make them feasible in the case of

providers building their services on public infrastructure but private service providers can undertake

the higher risk in hope of higher income. When developing the services, those markets should be in

the focus where the infrastructural level of patient care is lower than the one in Debrecen. This means

the Eastern countries. This direction is strengthened by the care provided to EU citizens at the expense

of social security as privately-financed patient care should target those markets from which the service

providing institution can hope to get extra income. It is the joint objective of public and private

providers to increase the number of patients arriving from the East. This requires a patient

management system whose first task would be to create a network of agents. This task can be

performed by an office, a company, a travel agency as well. The objective is the organization of patient

paths without a profile as Debrecen is competitive in the fields of dentistry, eye care and gynecology,

as well as oncological treatments with the realization of the interdisciplinary radiation therapy center

between 2014 and 2020.

The first and second points of the complex economy-stimulating healthcare program of the University

of Debrecen match the above development ideas. The three elements are (1) the integration program

of healthcare providers: the integration program of the Kenézy Hospital and the Clinics for the

purposes of the quality development of patient care and the effective management of costs. The

program includes infrastructural development, transformation, and service development. (2) Complex

health industry service center: the organization created as a result of the integration process becomes

suitable for higher level patient care, to meet the placement needs of domestic and international

purchasing power. (3) Complex sports economy development program with the quality of life in its

focus: the objective of the complex, systematic sports economy development program is the firm

definition of sports-related industry and services in the city of Debrecen for the purposes of meeting

the needs of the city, the region, and the country on an economic basis through the extension of the

city�s high-added-value activity into this area and the increase of its competitiveness.

Besides the three development directions above, we also recommend the development of the systems

for home care. The local demographic trends provide a growing burden for the healthcare institutions.

We have to consider such a system of home care that is modern and effective on the long term. This

requires the support of the work of nurses with modern tools. This way they could provide care for

several patients at the same time faster, more accurately, and simply, this way increasing the number

of people who can be involved in home care.

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One of the developmental directions of privately-financed patient care is the creation of the eHealth

medical record evaluation center. This would be an added-value service of clinical care that could also

contribute to the generation of income. The medical records evaluation center would be an IT solution

for the evaluation of data on medical records and for the online access of medical record information.

Besides this, privately-financed patient care also requires marketing development so that the high level

services can reach the consumers (the use of celebrities in marketing communication could be one

tool for this, among others).

The objective of the creation of the Interdisciplinary Radiation Technology Research and Therapy

Center in Debrecen is to contribute to the growth of the economy and R&D competitiveness of the

country, and within it the Észak-Alföld és Észak-Magyarország twin regions, to improve the potential

of its healthcare system, to increase the regional and national GDP. The accelerator-based technology

can be used in numerous interdisciplinary fields, for example: energetics and environmental research,

health and biotechnology research, industrial application areas, material sciences, space technology,

space physiology. The creation of the research center is a strategic investment and planning at the

same time: the infrastructure to be created will be fully compatible with the technologies of the

present and the future; it will also satisfy the needs of patients, doctors, researchers, and industrial

partners.

5.5. MEDICAL TOURISM

Medical tourism is a development area to be exploited for the benefit of the region and directly

Debrecen. Currently, there is limited overlap between tourism and medical services; there is no

medical tourism in the region, in the Western-European sense of the world. Thus there is a need to

develop the transition between tourism and medical therapy. In cooperation with organizations that

have achieved great success both in Hungary and abroad in the field of tourism (for example, Debrecen

és Hortobágy Turizmusáért Egyesület14 [Association for the tourism of Debrecen and Hortobágy]),

additional economic development and employment growth can be realized. The Faculty of Agricultural

Economics and Rural Development at the University of Debrecen provides for the human resource

needs of the field by means of its training program for Touristic Destination Managers.

The other branch of medical tourism includes the development of medical services and their

channeling into the current tourist services and programs. In this respect Hajdúszoboszló is performing

outstandingly in the Észak-Alföld region: the city administration together with the bath and spa, hotels,

and various health service providers can cater for the premium category needs of Western and Eastern

14 http://www.tdmszovetseg.eu/debrecen_es_hortobagy_turizmusaert_egyesulet

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European as well as Hungarian guests. It happens frequently that specialists form Debrecen go to work

there.

By studying East-Central European countries, it can be seen that in the region privately-financed

services connected to medical tourism are not built on tourism. Generally, there are two directions in

neighboring countries: either services related to rehabilitation are connected to bath services or the

complete privately-financed patient care spectrum is offered without bath or other touristic services.


From the international trends of medical tourism, in general the East-Central European one stands out

in terms of medical therapeutic care and with regard to relaxation and recreational services. Besides

these, providing services for the aging society at the highest possible level (connection of medical

therapy with tourism-type services), alleviating the pain of people with chronic diseases, the

revaluation of customized services, the health conscious lifestyle-balance approach, the matching of

physical well-being with emotional and mental balance are main tendencies. The combination of

medical therapy and wellness services includes a market opportunity for wellness and spa hotels and

local private clinics active in medical tourism: as it can be seen in Chapter a 3.3.1.3. on healthcare, in

privately-financed care the city has a great potential and opportunity for growth with the connection

of privately-financed patient care and medical tourism. With the utilization of synergies, the city can

build up a competitive advantage, for example, in the following model. It is the objective of Debrecen

to improve its own infrastructure as well and to connect its premium private healthcare services

(Clinics and Kenézy Hospital), baths (Aquatikum, Bath), and hotel services (Termálhotel, Lícium, etc.).

A central health management task should be performed on a commercial basis, with travel

organization and the connection of service providing companies as its main activity.

The main professional objective of the thermal health industry cluster established in Debrecen is to

offer thermal health industry services that have industrial property rights and that are unique and

scientifically well-founded for different disease risk target groups. The raising of Tourist Destination

Management to a high level is part of this project. The Thermal-Therapy Institute will be founded with

the purposes of performing the tasks.

5.6. FUNCTIONAL OMICS

As it can be seen in the chapter on the analysis of international trends, genomics, proteomics and other

international basic research related to systems biology become part of medical practice quickly and

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more and more intensively; they play a role in the development of new therapies and in the field of

diagnostics and food development as well.

The University of Debrecen is one of the three universities in Hungary with a University of National

Excellence title, which clearly shows that the university performs operating, stable activities that

showcase serious professional values both in education and research covering a wide range of

disciplines. In 2010 it was among the first to win the title of Research University. In 2011 the university

was active in close to 230 research fields, it had 1,456 full time instructors, with 1,023 having doctoral

degrees and 122 doctors of the Hungarian Academy of Sciences. Between 2009 and 2011, there were

close to 7,000 publications at the university, close to half of them in languages other than Hungarian.15

Several research groups of the University of Debrecen and the Nuclear Research Institute of the

Hungarian Academy of Sciences are involved in the field of functional omics wit their internationally

acclaimed research findings. The research university focus areas specified in the Institutional

Development Plan accepted by the Senate of the University of Debrecen also underline the advantages

in this segment.

The Center for Clinical Genomics and Personalized Medicine has been operating at the University of

Debrecen from 2001 with an outstanding infrastructure, adequate human resources background and

an international network of partners.16 One of the most successful spin-off companies of the University

of Debrecen (founded jointly by researchers and the university) is UD-GenoMed Kft,17 which shows

with its revenue over HUF 100 million that the market also provides positive feedback for this sector.

The Center is operating within the Biochemistry and Molecular Biology Institute, located in the Life

Sciences Center. The Life Sciences Center was awarded the Centre of Excellence of the European Union

prize in 2002, given to the most outstanding research centers in Europe. This was not only in

recognition of the infrastructure but that of all the interdisciplinary research groups working in the

Center. This is the only research center in Debrecen where researchers from all areas of life sciences

work and think together (agricultural, environmental, chemical, biological, health sciences, etc.)


One of the bases of personalized medicine is the production of personalized drugs. The process is

made up of the following steps: the specialist explores the problems with gene diagnostics and on the

basis of this the appropriate, personalized drug can be produced in small volume. The technology of

15 Statisztikák forrása: http://unideb.hu/portal/hu/node/369 16 http://genomics.med.unideb.hu/hu/bemutatkozunk 17 http://www.ud-genomed.hu/

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biologically produced medicine active agents is already available in the city, in the Debrecen

Biotechnological Plant of Richter Gedeon, while a small series pharmaceutical production plant

necessary for application is being built by Pharma-Flight Kft.

This field focuses primarily on basic research, there are only a few biotechnology, bioinformatics

service companies connected to the activities directly. At the same time, the findings of international

basic research, the results of research currently in progress or to be started become part of medical

practice unbelievably quickly and probably more and more intensively; these lead towards

personalized medicine that is considered to be one of the greatest promises of the future, providing

significant assistance in the development of targeted medicine. Such processes are important, for

example, in healthcare (e.g. the assessment of therapeutic efficiency), the development of new

therapies, as well as diagnostics and functional food development. For the local sectors it is crucial to

build on the objective that the University of Debrecen and the Nuclear Research Institute of the HAS

should continue their research at a high level, building on their extensive international contacts, and

to join the work of international consortia started in this area.

It is the common interest of industrial, governmental, and academic players in Debrecen to join the

American Personalized Medicine Coalition18 created to clarify the financing and regulatory system of

personalized medicine and similar networks as a member.

The RDI Concept of the University of Debrecen for the 2014 and 2020 period was created with the idea

of (RE)VITALIZATION. The concept aimed at the improvement of the quality of life of people on multiple

levels includes the following:

· The understanding, identification, and treatment of severe human diseases appearing with a

growing frequency (human (re)vitalization)

· The optimization and continuous improvement of the relationship between people and their

environment (environmental (re)vitalization)

· The development and improvement of society (social (re)vitalization)19

These projects facilitate the introduction of ideas on the market, the provision of services that are

capable of commercially utilizing the existing technology and knowledge. Infrastructural and

organizational support should be provided for this purpose.

5.7. FUNCTIONAL, HEALTHY FOOD

18 http://www.personalizedmedicinecoalition.org/About_Us/About_PMC 19 Source: Észak-Alföld intelligens szakosodási stratégiája, INNOVA, 2013., 62. oldal

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Creating a healthy society is the key objective of the present strategy. To preserve our health, our most

basic task is to do exercise regularly and to have a healthy and varied diet. The latter is supported by

functional food that also performs a preventive, health preservation function, decreasing the

development of chronic disease.

Functional food should be studied as one product chain as starting from crop production through

animal husbandry to the processing industry the entire product chain will become functionally valuable

and naturally authentic this way. The product chain has the following three distinguishable but closely

connected pillars: (1) basic research, (2) applied research (innovation and adaptation), (3) consumer

education (marketing). Basic research is time consuming and cost intensive but it is worth the

investment. The university knowledge base (Agricultural Center and Clinics) represents a market

advantage. Applied research moves together with the basic research project with the adaptation of

innovative product development ideas being the objective. By means of looking for the best European

solutions consciously and through their adaptation, it is domestic construction that provides the good

examples for the sector, through those who were capable of building up the entire functional food

product chain. The MasterGood group covers the entire product chain in the poultry sector, from feed

production through hatching, nurturing, and processing. This way it has achieved success

internationally and as a market leader in Hungary due to an organic growth process.20 It is a visible

trend that from the perspective of product line management the role of export companies has

increased in terms of access to market information and their knowledge base. The third pillar of the

Hungarian functional food product chain involves the education of customers. Currently, functional

food holds great potential for domestic companies as a new, patriotic consumer thinking can emerge.

The process of this kind of education is long and continuous, perceptible results can be expected after

10 years approximately. However, functional food can also pull along the general but premium quality

products as well this way also strengthening small farms.

The advantages of the food industry are very strong in Hungary, the size and quality of arable land is

outstanding proportionately. Hajdú-Bihar county is a key agricultural area in raw material processing,

as is Debrecen. In the agricultural history of the city the meat, canned food, and processing industry

were at a high level but by today this withered away. Due to the global population increase and our

internationally open domestic economic policy, agriculture is a key sector.

The world�s largest meat goose breeding and market leading waterfowl sales company, Tranzit-Ker

Zrt., has its seat and roots in Debrecen.21 The company group operated as a family business and

20 http://www.mastergood.hu/termekpalya.html 21 http://goldenfood.info/zolddio/wp-content/uploads/2012/09/agrarium-2012_04-Tranzit-Ker.pdf

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employing close to 1,000 people is one of the top, exclusive taxpayers in Debrecen. The success of the

company is due to its quality-oriented development and integrated meat industry system as they track

the produced goods from the field to the table. The Tranzit group will carry out a large R&D program

in the following years. The program includes a product line producing safe, premium-quality,

�environmentally and consumer friendly� duck and goose meat that can be tracked in a guaranteed

way as well as the connected IT system (customized signs, information available using barcodes and

QR codes, online information portal, etc.). In June, the company announced a USD 100 million (HUF 22

billion) investment in Kazakhstan, where they implement full, integrated duck and goose breeding

from hatcheries to the slaughterhouse.22

The Innovative Food Industry Cluster can also be found in Debrecen. More than 60 out of the 76

members are SMEs. The majority of members require real development, they serve as outlets for the

developments created in the plant. There are many great examples and the need for development is

continuous. The I-bolt [I-shop] serves as a continuous outlet and showroom of the newly developed

products.


To support the process of introducing functional food on the market there is a need for an authentic

and serious product chain. There is no quick and at the same time spectacular success in the process,

functional foods are not a panacea. The urging of the process threatens the most important value,

authenticity. At the same time, providing support for the functional food product chain should be a

key task of the city of Debrecen as the development ambitions of currently active industrial players

might subside if they do not receive due attention reflecting the importance of the sector. As a result,

the local government of Debrecen should support the coordination of the functional food product

chain that can take the form of regular discussions with actors in the industry.

The municipality of Debrecen can play a key role in the revival of agriculture and its development that

focuses on local values. The payers in the industry can profit a lot from special support without any

direct financial subsidy. The local government of Debrecen can help the local realization of investments

by facilitating the regulatory environment and providing sites. Through its contacts both in Hungary

and abroad, the local government could popularize the products and services of local producers (fairs,

exhibitions, conferences, tender meetings, business delegations, etc.). It would also represent

significant support for the agricultural sector if the local government could help in getting special state

22 http://www.hirado.hu/2014/06/05/szazmillio-dollaros-megallapodast-kotott-egy-kazah-ceggel-a-tranzit-ker-

zrt/

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support for the largest development projects (see, for example, the mediation of the mayor of Mohács

to gain key development project status for the local agricultural investment23).

The local government of Debrecen is devoted to supporting local products and producers. Those

development projects are also important, which are aimed at the improvement of the quality of life,

connecting functional food development and production with actors in sports economy. The Sports

Economy Development Program and the Program for Stimulating Local Farming and the Consumption

of Healthy Food (Open-lab) serve the above objectives. Open-lab is a complex operated jointly by the

university and the members of the functional food cluster including a test plant (among others the

following: development kitchen, educational room, and food laboratory).

At the same time, if we wish to treat the functional food sector as a key sector, it should be a long-

term strategic objective to have the local companies enter the international market. As part of the

Cooperation Platform for Entry into the International Market program, after the targeted preparation

of the companies, the local businesses can join international development projects and can also create

their market entry strategies.

The city of Debrecen needs to build and operate its own functional food industry brand. With this the

city acknowledges that healthy and functional food is recognized as a strategic area for the city

receiving priority support. The �Debrecen Brand� is built on a carefully planned system of criteria with

the following main points: a Hungarian product produced in Debrecen and in its close proximity that

improves the quality of life, offers functional help and replaces drugs. The building of the brand and its

popularization in Hungary and abroad is supported by the city.

5.8. HEALTH AND BIOINFORMATICS

23 http://www.mohacsiujsag.hu/mohacs/hir/helyi-hireink/nemzetgazdasagi-szempontbol-kiemelt-jelentosegu-

lehet-a-mohacsi-vagohid-felepitese

The Open-lab Concept:

Open-lab is an open innovation system. The objective of the place is to create an innovative unit appreciating

every idea and supporting their realization with the help of the human infrastructure of the University of

Debrecen and the Innovative Food Industry Cluster and the equipment provided by the cluster. Open-lab

includes a development kitchen (50 m2), educational room (kitchen) (120 m2) and a food laboratory (200 m2),

meeting room (20 m2), offices (30 m2) and common areas, changing rooms, toilets. The basis for successful

operation is that some of the employees of the university, the current Nanofood laboratory, and the cluster

with its research move into the laboratory rooms.

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In Debrecen there are only a few small and medium-sized enterprises specialized in healthcare

information technology. The oldest bioinformatics company in Debrecen is AstridBio,24 which split into

two parts with the limitation of its activities in 2013; the genome sequencing activities with a 10-year-

long history were taken over by LarkBio Kft,25 while the activities related to the support of the IT

background of biobanks remained within the competence of AstridBio. Even if there are two ItT

clusters operating in Debrecen (Észak-alföld IT Cluster, Silicon Field Regional IT Cluster), unfortunately,

there is no direct contact between the enterprises in the two sectors. The same kind of dialogue is also

absent with regard to healthcare workers and IT businesses, thus it is necessary to strengthen and

coordinate the cooperation and commercial utilization of the two sectors. The interdisciplinary

cooperation visible in the case of medical device development (medical and engineering) could be

transplanted into these sectors as well.


Although there is a potential for growth in the sector, several external factors influence its

development. The sector is directly connected to the processes of genomics, genetic research. At the

same time, due to the fact that in most cases there is not only a genetic problem in the background of

diseases, in the future those research can gain ground, which analyze the genetic background together

with the environment, lifestyle, and other factors. For companies in the field of bioinformatics it would

be an opportunity if they could joint this kind of research through the contacts of the local university

or any other institution. Therefore, the main development direction for these companies as well

involves the strengthening of international relations and the support of their participation in

international R&D projects. At the Cooperation Platform there is an opportunity for companies to

exchange experience and for the support of international contacts in this field as well.

At the same time, the potential of IT companies could be utilized in IT solutions increasing the efficiency

of healthcare. It is worth supporting the IT clusters in the city (Észak-alföld IT Cluster, Silicon Field

Regional IT Cluster) because they include the most important IT companies, on the one hand, and as a

professional organization they are aware of the development directions and potentials on the other.

Both the leaders and members of clusters should be supported with regard to their participation in

international projects, exchange of experience with foreign partners, and they should be helped with

the organization of trainings and the solution of human resource problems. In an ideal case, the

enterprises of the sector could learn bioinformatics, healthcare IT solutions from such cities where a

decade-long solution and accumulated practical experience is available. The involvement of these

24 http://astridbio.com/ 25 http://larkbio.com/

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actors in the social internalization of the present strategy and the implementation of development

projects (e.g. the Cooperation Platform) is of crucial significance following the above logic as well.

In order to exploit the international trends and new market opportunities connected to Big Data

research and development, the local initiatives have to be examined and it should be studied how

Debrecen could capitalize on its existing potential: such local initiatives include, for example, the

Server Park and Regional Internet-Exchange Center Program element of the Debrecen 2014-2020

economic development program and the development directions of the Molecular Medicine Research

Center or the supercomputer at the University of Debrecen, etc.

In harmony with the projects of the Smart City Europe 2020 initiative26 and supporting the integration

of the city�s healthcare institutions, the client-level integration of the IT systems of the city�s

healthcare providers (hospital, clinics, health promotion office, GP offices, spa, etc.) is necessary. In

line with the expectations of a 21st century population, health services have to be made available on

the web and smartphone interfaces which would make it possible to get general information, make

appointments, provide information on health screenings, get information with regard to medical

records, and have access to simplified administration. The management-oriented expertise of

healthcare managers is necessary in relation to the project, which could be developed with further

training and relevant research.

26 http://ec.europa.eu/europe2020/index_hu.htm

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6. HUMAN RESOURCES

6.1. THE HUMAN RESOURCE BACKGROUND (DOCTORS, DENTISTS, NURSES)

Human resources in Hungarian healthcare are in crisis and the current system supports change only to

a small extent. The human resource supply in the system is in a verifiably bad position. According to

data published annually by the Migration and Monitoring Department of the Health Licensing Office,27

the number of doctors emigrating increased continuously until 2011, since then a slow decrease can

be seen. With regard to emigration among the other healthcare workers (dentists, nurses,

pharmacists) the growth did not stop. In 2013 1,850 healthcare workers left the country, half of them

doctors and one quarter nurses.28 If we consider that in Hungary only close to 1,000 people get a

medical degree then the negative trend is clearly visible.

2013 2012 Change

Doctor 955 1108 -13,81%

Dentist 263 255 3,14%

Nurse 555 518 7,14%

Pharmacist 77 65 18,46%

The aging society is also a growing problem all over Europe, including Hungary. Technological

development can compensate for the quantitative problems of human resources but only if the new

professionals are appropriately trained with regard to the use of the new technologies. Although the

smaller human resource need of technological development can itself be questioned, for example, in

imaging diagnostics, where there has been exponential growth in the last years, still there is a need for

the same number of radiologists as before.

The lack or decrease of motivation due to the overburdened, expensive and wasteful system is also a

disadvantage. The role of clinics and hospitals has become stronger in this respect as local initiatives

can turn this worrying trend more positive. The health faculties and clinics of the University of

Debrecen have introduced personalized healthcare HR management several years ago. The system is

capable of motivating the employees and can also maintain this level. It creates a career plan for

everyone for the purposes of predictability; it is cost effective and pays attention to appropriate

working conditions. Moreover, it guarantees legal protection as well in the case of possible malpractice

lawsuits

6.2. THE NEED FOR NEW COMPETENCIES

27 www.eekh.hu 28 http://www.vg.hu/vallalatok/egeszsegugy/itt-vannak-a-legfrissebb-migracios-adatok-420038

93

Several local and international studies have been published which clearly call attention to those threats

according to which the health industry can build successful companies from new enterprises if the

manager is competent in several professions. Several programs provide qualifications in economics

and finances as well as spread the innovation and management approach in Debrecen. There are two

possible ways leading to the training of biomanagers: the financial (further) training of students and

researchers interested in the business approach from the fields of medical and health sciences, life

sciences, agricultural sciences, or the other way around, the health science education of people with

qualifications in economics, finance. The former approach is generally accepted and can be realized

more easily, it can be adapted successfully even with minor changes in the system. The knowledge of

business should be integrated systematically in the above mentioned health industry programs and all

such self-motivated forms of education operating next to the educational system should be supported

that aim to strengthen the business knowledge of the population. It was the need for the training of

healthcare managers and their supply that resulted in the creation of the Department of Health

Systems Management and Quality Management for Healthcare at the Faculty of Public Health at the

University of Debrecen in 2012.29 The aim of the training programs offered at the Department is to

help those professionals participating in the program to effectively meet the requirements they have

to face in the public, business, governmental, and non-profit sectors as well.

The health industry depends on all the actors in the triple or quadruple helix, thus from the regulatory

bodies as well. The aim of the local government is to support, educate, and prioritize in the

organizational structure those managers, who have management skills, international experience, and

knowledge of foreign languages.

It is the joint innovative education development program (supporting the development of the

economy) of the Municipality of Debrecen and the University of Debrecen to establish a Healthcare

Management Training Center at the Faculty of Public Health and to provide the necessary conditions

for it. The University of Debrecen, as the Research University and University of National Excellence of

the Észak-Alföld region as well as that of the Észak-Magyarország twin region, has a clear social and

professional policy responsibility with regard to providing future managers who are adequately

qualified and have appropriate management competencies. With the creation of the manager training

center, the framework is created for demand-based HR planning, system-level competence

development, managerial talent management, management brand development, while the

continuous expert support of managers and their further training also receives attention. The target

groups of the training programs offered by the center are the civil servants, public employees

29 http://emmt.unideb.hu

94

(healthcare, public and higher education) and the health industry sector. Besides this, the center, in

cooperation with the multinational companies, SMEs of the region, also provides internal training

programs customized to the needs of the business sphere.

Together with the management, it could provide continuous support for the managers and employees

in the business/public sector with individual career planning and competence development, and with

the involvement of managers it facilitates the harmonization of individual objectives with the

organizational ones.

It supports the process of talent management as a partner either through finding talents from the

outside (recruiting) or with the identification and special training of hopeful talents from within the

company with the appropriate methodology.

Besides all these, the Center supports the definition of the company�s strategic objectives with a

methodology based on scientific research findings as well as the completion of the processes related

to the management of changes in company culture necessary for the realization of the strategic

objectives.

The direct participation of TEVA Gyógyszeripari Zrt. in the educational program of the University of

Debrecen is also a good example for the importance of the proper training of future professionals.

There are two departments operating within the university with the support of TEVA; these are the

External Pharmaceutical Industry Department (Faculty of Science) and the External Pharmaceutical

Manufacturing Department (Department of Pharmacy). The experts of TEVA also participate in the

educational work of these external departments starting from the writing of the curriculum to

teaching. Moreover, the practical experience of students is also strengthened by the company with

visits to the factory, the modernization of the department�s infrastructure, and by providing summer

internship positions. Specialists of TEVA are also open to work with graduating students as advisors to

their theses. This relationship, however, has two sides: the specialists working at TEVA also apply to

the doctoral school of the university, who this way can acquire a doctoral degree while contributing to

the up-to-date range of programs of the doctoral schools with their practical experience. Those

students graduating from the external departments can find a job more easily within the

pharmaceutical industry, the majority is employed already before they receive their diploma.

95

7. SWOT ANALYSIS

Strengths and weaknesses come from the current situation of regional innovation, where the main

obstacle is of financial nature. The dominant constraint is the lack of capital in the diffusion of

innovation. The overly rigid and inflexible legal background makes the system also very complicated.

The regulatory framework and the business infrastructure can be characterized by the lack of structural

solutions for authorities to address regulatory market and financial risks raised by new bio products,

sometimes there are heavy administrative burdens, too. The majority of research and development is

conducted at universities or institutes and collaboration with the industry is limited. Therefore, the

lack of entrepreneurial experience in public research institutes and administration is also a big obstacle

to development. Regarding the financial background, it can be contested that the risk-sharing

mechanism is not designed for entrepreneurs. The process for funding applications is relatively

uncoordinated. There is a lack of business advice for start-ups. Venture capital investment is limited,

there is only pre-seed funding. There are no available local financial sources for biotech companies,

only national and international ones. Research is mainly related to higher education and public funds.

The reasons behind this� which have to be changed - are the risk-averse culture in the financial and

risk sharing structures, the lack of international culture and of entrepreneurship recognition, the lack

of communication on role model entrepreneurs and on reward of their success. Therefore, knowledge

and technology transfer platforms are welcomed. The availability of professional and business advice

is increasing, but remains expensive for most of the SMEs. Forming a supportive development

environment is essential, where mediator organizations and adequate external advisors can play a

larger role. The importance of the innovative approach has to be understood by the companies, the

public and the private sphere as well in practice, via workshops, good examples, municipal and

governmental incentives. In order to create better funding, it is indispensable to better understand the

end-users, the needs of the people. Development and service has to be offered for them, because as

for today, they have and they provide most of the sources. Customers, clients, patients, we can call

them in many different ways.

Table 2: Regional SWOT analysis

INTERNAL FACTORS

REGIONAL HEALTH

SYSTEM

STRENGTHS

1. REGULATORY FRAMEWORK

Regional Knowledge Centre of the

University. Intensive cooperation

between the corporate and

university spheres on regional as

well as on national/ international

WEAKNESSES


Shortage of Institutions aimed at

assisting start-up companies

Lack of mechanisms to ensure the

supply for capital of start-ups

(equity funds)

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EXTERNAL FACTORS

REGIONAL HEALTH

SYSTEM

levels (encompassing the entire

R&D verticum of the sector)

Good practice in cooperation

between the University of

Debrecen and R&D companies (e.g.

Biosystems)

Operating bio-incubator centre at

the University of Debrecen, health

science parks

Centre of Excellence in Molecular

Medicine

2. FINANCE

University of Debrecen leadership

is engaged in entrepreneurship

R&D expenditure and investments

have been constantly rising since

1997 in the NGPR

Remarkable R&D expenditures in

the academic field

Motivated SMEs and spin-off

companies. Due to the successful

activity in accessing grants,

significant involvement of grants

and state funds.

3. HUMAN CAPITAL

Significant intellectual potential,

high number of holders of

advanced degrees

Poor infrastructural conditions of

research

Shortage of focused research

programs

Weaknesses of Pharmapolis Cluster

e.g. Richter dominance

Lack of synergy between the

industrial needs and academic

research areas.

2. FINANCE

The financing system of innovation

is inflexible and bureaucratic.

Companies have limited knowledge

of non-competition, innovation

financing options (bank finance,

venture capital, business angels),

domestic tenders, national funds

and possibilities provided by EU

3. HUMAN CAPITAL

Lack of management and strategic

resources

Shortage of business leader and

developer

Shortage of expert on the field of

technological transfer (UD TTO)

Coordination of innovation

interests, negotiation and effective

representation

The regional education demand

does not meet the needs of the

labor market

OPPORTUNITIES

S-O STRATEGIES


Enhancing the role and innovation

capacity of entrepreneurship �

establishing an innovation system

Forming of such a legal

environment that supports

innovation related investments and

investors, makes more effective

the sessions and helps the better

understanding of modes of

procedure.

W-O STRATEGIES


Improving the academic regulatory

framework for scientists

Easing the launching procedures

for international companies

2.FINANCE

Mainly public dominance (public

funds) in R&D

Encouraging the involvement of

venture capital, private equity and

co-financing methods

97

Core shared facilities and

technology platforms for business

and scientific aims as well

Role models

2. FINANCE

Attracting knowledge-and capital

intensive foreign-owned or

domestic enterprises in order to

increase competitiveness.

Promoting market expansion

towards Asian markets

3. HUMAN CAPITAL

Better marketing and wider

presentation of regional research

results

Strengthening the potential in

clinical trials, testing, certification

(animal testing and chemistry as

well)

Promoting interregional and EU

networking

Exchange program (clusters,

experts, training)

Promoting application possibilities

in broader perspective

3. HUMAN CAPITAL

Teaching entrepreneurship to

scientists and researchers

(commercial potential and

importance of technology transfer)

Location: state-border �

development of cross-border

cooperation

THREATS

S-T STRATEGIES

ARE USING STRENGTHS TO COPE

WITH THREATS


Strengthening the incubator

structure and services including

business mentoring and scouting

Enhancing the forms of

cooperation

2. FINANCE

Willingness to improve

(Municipality of Debrecen,

University)

Existing good experiences in grants

3. HUMAN CAPITAL

Better exploiting the existing

intellectual property

W-T STRATEGIES

ARE OVERCOMING WEAKNESSES

TO COPE WITH THREATS


Lack of flexibility (shared

mechanism, public to private and

vice versa, rules of use)

Risk averse culture

Unclear regulations

2. FINANCE

Lack of incentives promoting the

new products/technologies on the

market

Strengthening funding mechanisms

for start-ups / spin-offs.

Increasing seed funding also

coming from private sector

3. HUMAN CAPITAL

Economic involvement of

researchers

98

8. BIBLIOGRPAHY

- Az Észak-Alföldi Régió Stratégiai Programja, [Strategic Program of the Észak-Alföld Region],

2007-2013

- Regional Health Industry Strategy of Debrecen, 2014-2020

- Hajdú-Bihar Megyei Területfejlesztési Program [Regional Development Program of Hajdú-

Bihar County], 2014-2020

- Hajdú-Bihar Megyei Területfejlesztési Koncepció [Regional Development Concept of Hajdú-

Bihar County], 2014-2020

- Jász-Nagykun-Szolnok Megyei Területfejlesztési Program [Regional Development Program of

Jász-Nagykun-Szolnok County], 2014-2020

- Jász-Nagykun-Szolnok Megyei Területfejlesztési Koncepció [Regional Development Concept of

Jász-Nagykun-Szolnok County], 2014�2020

- Szabolcs-Szatmár-Bereg Megyei Területfejlesztési Program [Regional Development Program of

Szabolcs-Szatmár-Bereg County], 2014-2020

- Szabolcs-Szatmár-Bereg Megyei Területfejlesztési Koncepció [Regional Development Concept

of Szabolcs-Szatmár-Bereg County], 2014-2020

9. TABLES AND FIGURES

1. Figure: The Financing Environment (Dózsa Cs. 2007) Egészségbiztosítási Reform 2007-2009. [Health

insurance reform, 2007-2009] http://www.eum.hu/archivum/hirek-esemenyek/egeszsegbiztositasi-

090921 ................................................................................................................................................... 10

2. Figure: Outpatient specialist care in Hungary (Kincses Gy. 2007) Egyenl"tlenségek a magyar

egészségügyben [Inequalities in Hungarian healthcare]

http://www.eski.hu/new3/publ/eloadasok/2007/egyenlotlensegek%20%202007%20NET%20r_eleme

i/frame.html .......................................................................................................................................... 12

3. Figure: The types of healthcare systems according to dominant funding body in EU member

countries (Borbás I - Kincses Gy 2007) Egészségügyi rendszerek az Európai Unió régi tagállamaiban

[Healthcare systems in the old member countries of the EU]

http://www.eski.hu/new3/kiadv/zip_doc/Nyugat_Europa.pdf ........................................................... 17

4. Figure: Development of Yearly Balance of the Health Insurance Fund (2012, 2013, 2014) Source:

Table prepared based on the annual reports of the Budgetary and Financial Department of the

Hungarian Health Insurance Fund. ........................................................................................................ 20

5. Figure. The relationship between healthcare expenses and the annual average growth of GDP (%)

in OECD countries, 1993 � 2008 (OECD Health Data, OECD Publishing, Paris, 2010a) ......................... 21

99

Figure 5.: Vision of Spatial Structure of JNSZ county, 2020. Source: JNSZ Regional Development

Concept 2014-2020 ............................................................................................................................... 58

Figure 6.: Health Industry Business Map of the Észak-Alföld Region. Source: Szinapszis research, Nov.

2013. ...................................................................................................................................................... 71

Figure 7.: Distribution of companies in the Észak-Alföld region according to form of business,

revenues, and no. of employees ........................................................................................................... 72

Figure 8.: The distribution of health industry companies in Debrecen according to registered seat.

Source: Szinapszis research, November 2013 ....................................................................................... 73

Figure 9.: Distribution of companies in Debrecen according to form of business, revenues, and no. of

employees ............................................................................................................................................. 73

Figure 10.: The population dimension of the central healthcare system cooperating with home-care.

............................................................................................................................................................... 81

Documents

HEALTH EQUITY -2020 PROJECT REDUCING HEALTH …€¦ · Szinapszis Kft. 15.11.2015 This document arises from the project HEALTH EQUITY -2020 which has received funding from the European