A colleague’s wife is pregnant: third time overall, but first time in Hungary. I learned this during a Friday happy hour. After my colleague announced his news and the requisite congratulations were shared, a Hungarian colleague advised him on something new to me: Hungary’s “envelope culture.”
Turns out, if you go to a public health institution for any kind of treatment or surgery, you pay the doctor “gratitude money.” Some doctors will openly tell you how much you need to pay them; others leave it to your discretion.
In case you’re thinking “well, of course you must pay the doctor,” let me inform or remind you that people are eligible for free medical care in Hungary. The taxes we pay cover health services. But doctors are underpaid here, and they rely on the money as a wage supplement. (A lot nicer way to look at it, rather than calling it a bribe.)
It’s different for private doctors, as you’re paying more for access to them. However, even for private doctors, it’s customary to show them some “gratitude” at the end of each year.
When I asked another Hungarian colleague about this phenomenon, she confirmed the undocumented envelope culture. She also noted that Hungary has been experiencing an exodus of doctors because wages are so low. I found a 2011 Wall Street Journal blog post that discusses this and Hungary’s unsuccessful attempts to stem the tide. Here are a few of the eye-opening statistics mentioned:
“A survey conducted by the association found that 74% of new medical graduates are planning to work abroad. … Some 1,500 medical professionals are missing in the country, which threatens the stability of the system. The situation could soon turn even worse. A survey conducted by the Hungarian doctors’ association found that 6,000 doctors and residents are considering leaving Hungary unless their salaries go up.”
How much will my colleague need to pay for having a baby? A 2008 article by Community Catalyst quotes such gratitude figures as 7,000 HUF (Hungarian Forint) for each examination and 80,000 HUF for the delivery. That doesn’t include money for the midwife, nurse, or any other medical personnel.
To put that into context, Hungary’s Ministry for National Economy reported that “in January 2012 full time employees had an average monthly gross salary of 219,000 HUF in the national economy, and net salary was 141,600 HUF…”
Now consider this: A 2012 Budapest Times article noted the following: “Recent estimates by the GKI-EKI Health Research Institute suggest that an average HUF 32 billion (EUR 111.57 million) in gratitude money – or just under HUF 10,000 (EUR 34.86) per working Hungarian – passes from patients to doctors yearly.” That’s a lot of gratitude.
From what I understand, Hungary is not unique in this situation. This envelope culture exists throughout central and eastern Europe and is a hold over from the Communist years. If you’re interested in learning more, I found a paper that discusses the issue and its history.
Life: Rebooted 
I’m looking forward to reading the paper you linked to, as I’ve mentioned to you that there’s a similar phenomenon here in China (both with the doctor situation and the envelope culture in general). One difference, though, is that whenever you give money in China, you give it in a red envelope.
The red envelope is a nice touch.
This is really interesting! Recently, I was listening to an old NPR Planet Money podcast from 2011 on tipping in the U.S. One of the issues discussed had to do with why Americas are OK with tipping wait staff and bartenders, but not doctors, dentists, etc.
A really interesting piece of trivia about tipping: the word tip originates from 17th century England. It was a phrase put on boxes in pubs, restaurants, etc., and stood for “To Insure Promptness.”
Finally, the podcast stated that, in the U.S., Americans tip over $4 billion per year!
I never knew that–thanks for sharing! And $4 billion–wow!