WHO has taken an active part in the recent Health Policy reform process in Hungary by providing knowledge in the form of analyses and monitoring. Two studies (European Observatory 1999, Gaál 2004) on the transition of the Hungarian Health Care System were produced by the Organisation.
WHO has had a country office in Hungary since 1991, which is to maintain the communication between Hungary and the WHO, to facilitate and monitor the reception of the ongoing programmes, and to promote the flow of information. It also provides professional counselling mainly in health policy issues by allocating international specialists and promoting international consultations. Whereas in Western Europe country offices do not exist any more and the CIS states run huge country offices, Hungary, along with the other CEE countries, has a relatively small country office employing only a director, a deputy director and an assistant. According to the director of the Hungarian office, the unspoken function of the Eastern European offices is to influence governments to improve the cooperation with WHO and to enhance the importance of the WHO initiatives. Despite this, out of the eleven collaborating centres that used to function in Hungary only one has remained in operation, due to the lack of financing from Hungary.
The most important direct relationship between WHO and the Hungarian Ministry of Health is the Biennial Collaborative Agreement (BCA), which is a contract between the Regional Office for Europe and the Government of Hungary. The document includes priorities for cooperation for the biennium, expected results, WHO budget and other sources of funds. The director of the country office is in charge of facilitating the process of contracting. In the course of the preparation of the BCA, the Hungarian Ministry of Health endeavours to localize issues that are important for Hungary, and at the same time also ‘fit’ WHO’s priorities. As a usual consequence, issues that were low on the national priority list move to the forefront of policy discussions. The director of the national office takes the role of the translator-transactor in this process, by on the one hand channelling WHO ideology, language, expectations to the Hungarian actors, and on the other hand formulating the Hungarian initiatives in a WHO-compatible language. This was the case with the issue of mental health, which was added to the national health policy agenda in the course of preparing for BCA 2006–2007 and later BCA 2008–2009 (see later in more detail).
In the mental health field the institution of Mental Health Counterparts is also a formal link between the Organisation and the national levels. While so far we have described the relationship between the State and the Organisation, the institution of counterparts is rather a link between the national professional community and the Organisation. The national counterpart has dual roles in translating knowledge between WHO and the national scenes. His formal role is to inform WHO about mental health facts and related issues from Hungary and to help in the implementation of WHO initiatives in Hungary. On the other hand, being a member of the national professional community, he spreads WHO knowledge (in form of data, arguments, recommendations, international expert opinions) to the professional field, providing the lobbyists of the field with a toolbox for their negotiation with the Ministry.
To put it simply, there is a triangular relation between WHO (Country office), the health professionals and the Ministry of Health, with temporary alliances formed along common interests. Similarly to the above explained channel, in which WHO knowledge is passed on by the Mental Health Counterpart, we found that WHO has a remarkable indirect influence on the government via local (i.e. Hungarian) health professionals and other concerned actors. These actors represent a channel of transmission of WHO’s expert knowledge as they refer to this knowledge in their negotiations with the Ministry.
Parallel to the formal relationship, WHO has other important channels to influence local actors. One of our interviewees, a former senior ministry official was talking about how agenda setting filters down to the national level: “The fact that WHO added an item to the agenda, that it was engaged with it on a serious level, that it was formulated into an action plan, necessarily resulted in the interestedness of the national actors irrespectively of whether these actors had been interested in and receptive of the issue before. These issues sooner or later got onto the table of the Government. The period while WHO was nibbling at the issue, forming committees, calling in experts, having conferences etc., left enough time for the concerned actors of Hungary to form their opinion and worldview, their ideas about what kind of questions and solutions they support, accept, or reject.”
An important element of the adaptation of WHO’s agendas on the national level is the assumption that there would be available funding related to issues prioritized by WHO. It is assumed that whatever is on the WHO agenda, is or will be the agenda of other international and supranational actors (such as EU), which in turn must result in a wide variety of funding possibilities that Hungarian actors should be eligible to apply for.
It is also important to note that in Hungary ‘WHO’ is often seen as simply the embodiment of the ‘influential international actor’, or at least this is how it is represented in both the mental health policy related documents and in the interviews we conducted. Most of the time it is formulated in a way which implies that WHO and EU are some interconnected, inseparable entity, for example: “WHO and EU findings draw attention to”, “according to EU and WHO recommendations”. The director of WHO’s Hungarian country office explicated the interconnection of WHO and EU mental health policies as follows: “While WHO policies are never binding, EU rulings usually are. Being a member of the EU, Hungary should follow EU directions. WHO and EU policies are very similar. For a long time they have not been cooperating, but in the past couple of years they recognized that it is not sufficient to run parallel action plans and since then they are working on the same topics together. WHO was involved in the preparation of the European Pact.”
Although all of our interviewees were involved in mental health policy processes, when answering our question about WHO MHD&AP, most of them started to speak about EU Mental Health Pact or other EU mental health policy documents such as the Green Paper. In their minds there were no difference between EU and WHO, both were seen as international actors that have power over Hungary. “For us they are the same. Although I was invited to several mental health related conferences, right now I could not even tell which conferences were related to WHO and which to EU – it is totally blurred in my mind. Since the situation is so alarming in Hungary, for us the important thing is that either EU or WHO declared that it was a priority.” (Senior mental health researcher)
Thus WHO serves primarily as a catchword for the diverse actors debating about health related issues. Most of the interviewees reported something similar to the following statement, which was formulated by a senior Ministry of Health official. “Hungary is a socially fragmented country, a country without social consensus, and whatever issues we are debating about, it is crucial to have an influential, international actor, such as WHO expressing its stand on the topic. Then we [the Ministry] can say: look, here is the international consensus about this issue that had been approved by international experts, and adapted by several countries. This makes it much easier to have a policy accepted in Hungary.”
The Hungarian interviews with WHO officers also underpinned, in accordance with the findings of the supranational study, that the Organization’s primary vehicle of regulation is authority, in the sense that its regulatory capacity is based on its expert knowledge. As the director of the country office has put it: “What gives WHO a peculiar position is its advisory role. At least this is the role it plays in the European region. Africa and Asia are different, there are different priorities there, but here it is expert knowledge and counselling that the governments in power can utilize. On the other hand, it is up to them [the governments] whether or not they take the advice.”
This authority is stemming from the fact that WHO is regarded in Hungary as a disinterested actor in the Mertonian sense, based on its supranational character, its expertise based knowledge production and its detachment from the pharmaceutical industry. WHO knowledge is considered as consensual, ‘evidence based’, pure knowledge that does not need further verification: “The utmost advantage of such international knowledge like WHO’s is that there are no underlying interests regulating it. I’m much more confident referring to WHO studies, as they are reliable, I do not have to worry who and why ordered the study. WHO studies are created with a noble purpose, I would say.” (Health Ministry officer)
Fernezelyi Bori & Eröss Gábor (2009), Lost in Translation: From WHO Mental Health Policy to a non-Reform of Psychiatric Institutions, KNOWandPOL report, 4-8