Spatial characteristics of access of third-country citizens to the Hungarian public health care system 71Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80.DOI: 10.15201/hungeobull.65.1.6 Hungarian Geographical Bulletin 65 2016 (1) 71–80. Introduction The national health care system is built up as an elaborated structure. The rules of ac- cess and of service provision are complex in Hungary. This inherently compound struc- ture is further supplemented by distinct in- ternational rules to third-country nationals. Key stakeholders of the system are the health care providers themselves that are required to put the national, international and supra- national legal rules into practise. They are required to solve the fi nancial and adminis- trative tasks and to sort out the concrete cases related to third-country nationals. They have direct contact with the patients, they commu- nicate with the persons concerned and, most importantly, they provide for the appropri- ate medical care (Gellérné Lukács, É. 2012; Bell, D. et al. 2015). The heterogeneity of third country pa- tients, the frequency of demand of medical services, the type of the treatments within public health care are all fundamental re- search terrains to be investigated since health is one of the main elements of wellbeing and inequality, too (Thomas, F. and Gideon, J. 2013; Jakab, Zs. and Tsouros, A.D. 2014). The research aimed at examining the access and participation of third-country nationals in the Hungarian public health care system. Within the framework of the research car- ried out between 2006–2010 the following specifi c questions arose: What is the citizen- Spatial characteristics of access of third-country citizens to the Hungarian public health care system Sándor ILLÉS1 and Éva GELLÉR-LUKÁCS2 Abstract The eff ect of international migration on public health care system is one of the emerging themes within health and mobility studies. Unfortunately, there is scarce information on health situation of international migrants in Central and Eastern Europe. This research paper tries to contribute fi lling in this gap with a case study related to Hungary and it deals with the access and participation of third-country nationals to the Hungarian public health care system as patients. The study integrates quantitative and qualitative methodologies coupled with a holistic approach. Macro data of the National Health Insurance Fund was analysed and fi eld works in the National Ambulance Service and at the Semmelweis University (Budapest) were carried out. The volumes and rates of nationals of Ukraine, China, Vietnam, Serbia, former Yugoslavia, Russia and Mongolia are the dominant groups in the provision of acute care, in-patient care, out-patient care, dental care and cash benefi ts. Acute care is relatively the most populous and medical treatments in capital institutions as opposed to countryside ones. The main spatial factors aff ecting the provider and supplier side of public health care system in Hungary are identifi ed while concluding that third-country migrants utilize selectively the institutions of the Hungarian public health care system. Conclusions subscribe to the need for future research in this theme in the light of most recent international mobility upheavals. Keywords: international migration, public health care system, third-country citizen, mobility, spatial patt ern, Hungary 1 Active Society Foundation, H-1094 Budapest, Liliom u. 8. E-mail: dr.illes.sandor@gmail.com 2 Eötvös Loránd University, Faculty of Law, Postgraduate Institute. H-1051 Budapest, Egyetem tér 1–3. E-mail: drlukacseva@gmail.com Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80.72 ship distribution of third-country nationals? What kind of services and medical treatments are frequently used by them? Are the demo- graphic and medical characteristics of foreign patients (sex, age, consumption of medical treatment) similar to that of Hungarian pa- tients? Are there special challenges towards foreign patients for service providers? International migration context In Hungary quantitative and qualitative changes began in 1988 aft er four decades of a controlled and restrictive migration regime. Due to the political transformation process in Central and Eastern Europe there was also a turn in the types of international migration fl ows. Hungary got integrated into the Eu- ropean and international migration systems again (Tóth, J. 2012). There was a signifi cant growth of international migration of foreign citizen fl ows in Hungary which became a receiving and a transit country aft er a long period of being a sending area. As a result of the continuous infl ows and moderate out- fl ows the number of foreign citizens staying in Hungary rose steadily. At the end of 1999 more than 150,000 long-term immigrant were living in Hungary, so their share within the total population rose above 1.5 percent. It is worth mentioning that it was a low propor- tion in European context (Kincses, Á. 2015). An increase of international immigration flow could be measured in the years fol- lowing Hungary’s EU accession (1st of May, 2004). The number of immigrants exceeded 25, 000 per year. The surplus came from other countries of the European Union. However, neighbouring countries played a rather small role in the quantity of immigration (Gellérné Lukács, É. 2011). The att raction of Hungary has been gradually decreased in parallel with Hungary falling into economic crises from the end of 2008. The number of foreign citizens living in Hungary in 2009 was 184,358 persons, so their share within the total population increased above 1.8 percent. 36 percent moved from Romania, at about 10 percent from Ukraine and Serbia. Only 3 percent came from the neighbour- ing Slovakia. Germans had 9 percent plus other non-German Europeans owned 17 percent. Chinese possessed 6 percent plus other non-Chinese Asians had 7 percent . Citizens of American countries had 2 per- cent while Africans had 1 percent (Gödri, I. et al. 2014). The issues of asylum seekers and refugees are treated diff erently from the regular inter- national migration. The Offi ce of Immigration and Nationality (OIN) collects and publishes data about them. The legal regulations es- tablished three diff erent categories: refugee (menekült in Hungarian) according to Geneva Convention temporary protected asylum seekers (menedékes) and persons granted subsidiary protection (oltalmazott -befogadott ). In the middle of the 1990’s, with the escala- tion of the Yugoslav war, ethnic Bosnians, Serbs and Albanians arrived in Hungary and applied for temporary shelter and they ob- tained asylum-seeker status. Before the accession of Hungary to the EU the average number of asylum applications was high (5,000 per year). Soon aft er the ac- cession it diminished to an annual average of 2,000. All in all asylum applicants were 41,000 between 2001 and 2012. More than 75 percent arrived illegally with the help of human traffi ckers. Many applicants moved forward to the West from the refugee camps even before the Hungarian offi cial decision was passed, because they initially wanted to reach Western Europe. Only a few applicants were granted refugee status (less than 10%). For instance, between 2001 and 2012 only 1,616 persons received conventional refugee status in Hungary. Asylum applicants were Afghan, Iraqi and Bangladeshi. Considerable quantitative change has been started from 2013 due to the liberalisation of Hungarian legal rules. It means that asylum applicants who arrive illegally are not arrested during the examination of their application. During the fi rst half of 2013 11,741 asylum applicants arrived in Hungary mainly from Kosovo, Pakistan and Afghanistan. The stock 73Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80. of recognised applicants was as follows in January 2013 in Hungary: 1,513 persons as refugees, 1,121 temporary protected asylum seekers and persons granted subsidiary pro- tection. New sort of international movement of people of third nationals has been emerg- ing since 2013. The number of quasi-transit tourists-migrants-asylum seekers reached the tens of thousands of people in 2013 (18,000) and 2014 (47,000). This value increased to 177,000 people till 15 September 2015 only that year. Hungary – as member of the European Union and part of the Schengen area – is committ ed to fulfi l all requirements concern- ing controlling and protecting the external borders of the EU. Hungary is situated on the illegal migration route from the Balkans to Western Europe. As a transit country em- phasis needs to be placed on handling the „transit traffi c”, intensifying border control and maintaining internal security. Hungary’s accession to the Schengen area in December 2007 has not aff ected the illegal migration routes in short-term, it has not changed in any signifi cant way. Main source and transit areas of the continuously increasing illegal migration fl ows are the Middle East, Asia Minor, Northern Africa and the Balkans. Legal context Hungarian public health care system is hori- zontally accessible for economically active third-country nationals. Persons in paid em- ployment or self-employed persons who are paying social insurance contributions are en- titled to access the public health care system. Two sorts of health related benefi ts exist in Hungary for third country nationals: health care (in kind) benefi ts and sickness (cash) benefi ts (EMN-Hungary 2013). Additionally, access to health care for those third-country nationals who are not pursu- ing economic activity is, as a main rule, sub- ject to the registration of habitual residence and possession of the permanent residence permit. Persons who are insured or qualify as insured have access to medical treatment and justify their entitlement with the posses- sion of TAJ (Social Insurance Identifi cation Number). The public health care provider controls the eligibility of the patient via the on-line database, on the basis of the TAJ number. For refugees and asylum seekers Hungary operates the same system of health care as for nationals (including double or multiple citizens), with no additional requirements and no forms of care excluded. Refugees and asylum seekers do not have to pay premium costs. It is fi nanced from state budget. Higher costs could be in those cases where refugees or asylum seekers turn to private institutions. On the question of the extent of coverage for asylum seekers we stress that they are on equal footing with nationals. As a main rule, Hungarian health care is free of charge for eligible persons, no ex- tra charges shall be paid by the benefi ciary. However, a remarkable exception is dental care, which is mostly a privately run busi- ness. It is only free of charge for the age group 0–6 and over 65. If the third-country national has no entitlement (e.g. the migrant has not lived in Hungary for at least one year or he/ she is undocumented), he/she is required to provide for his/her medical coverage on private basis. Emergency health care, how- ever, is provided by the Hungarian public system without previously controlling the entitlement, and if there is no entitlement, the costs must be reimbursed a posteriori by the international migrant. The same applies to Hungarian nationals in lack of entitlement. The Hungarian health insurance is based on individual legal relationships. Every in- sured or entitled person acquires rights on its own. Following from this, health insurance provisions do not acknowledge the second- ary rights of family members for accessing healthcare. The legal situation and rights of children and other relatives of the insured person shall be decided individually. The public healthcare system is operated by the National Health Insurance Fund (NHIF), via its central service and with the involvement Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80.74 of its regional organs. Regionally the opera- tion is based on the health insurance fund directorates of the capital and county govern- ment offi ces (Gellérné Lukács, É. 2012). Beyond national and EU law, Hungary has a limited number of bilateral agreements which also give basis for entitlements of third- country nationals. Among the social security agreements these are the agreements with Montenegro and Bosnia-Herzegovina that give entitlement to Hungarian health care benefi ts. Additionally, foreign citizens coming from the below-enumerated countries are en- titled to have access to the undoubtedly neces- sary in-kind benefi ts of the Hungarian health care system if their state of health urgently requires: Jordan, Angola, Iraq, Mongolia and Cuba.2 For example in the fi eld of healthcare, in the year of 2012 the Hungarian compe- tent institution, NHIF, issued CG 111 forms (for Montenegro) amounting to 954, in re- lation to Croatia HR111 amounting to 29, HR112 amounting to 14. No forms were is- sued in relation to Bosnia-Herzegovina. On the receiving side, in 2012 insured persons of Montenegro applied for 117 medical treat- ments in Hungary while insured persons of Croatia for 661 cases. From 1 July 2013 Croatia became Member State of the EU; consequent- ly, Regulation (EU) No 883/2004 supersedes the bilateral agreement in this fi eld. In sum, as a main rule, entitlement is grant- ed on an individual basis for third country nationals, based on national law, EU law and bilateral agreements. Those holding long-term residence permits (both in terms of Directive 2003/109/EC3 and as defi ned by national leg- islation) and third-country nationals (holding 2 Jordan (incorporated by 15/1981. MT regulation), Kuwait (incorporated by 33/1979. MT regulation), People’s Republic of Angola ( incorporated by 17/1984. MT regulation), Iraq (incorporated by 47/1978. MT regulation), Mongolia (incorporated by 29/1974. MT. regulation), People’s Democratic Republic of Korea (incorporated by 14/1975. MT regulation), Cuba incorporated by Law-Decree No 16 of 1969). 3 Council Directive 2003/109/EC of 25 November 2003 concerning the status of third-country nationals who are long-term residents. either long-term residence permits or time- bound residence permits) if they are economi- cally active workers or self-employed possess entitlement. If the third-country national has no entitlement (e.g. the migrant has not lived in Hungary for at least one year or s/he is undocumented), s/he is required to provide for his/her medical coverage on private basis. Emergency health care, however, is provid- ed by the Hungarian public system without previously controlling the entitlement, and if there is no entitlement, the costs must be reimbursed by the international migrant. Methods Various data types were collected and com- bined methodology (Zurc, J. 2013; Morgan, D.L. 2014) were utilised during the research due to the complex interrelationship between international migration and health (Gatrell, A.C. 2011). For the sake of comparability quantitative data from administrative sources were also collected. Additionally, fi eld works were carried out according to the require- ments of the holistic approach. The basic macro data of the project came from the NHIF. The time interval of the data ranged from 2006 to 2010 and related only to the third country nationals who obtained pub- lic health care in Hungary. The private health care providers were out of the scope of the NHIF data base. The general characteristics of the data were as follows: full scope and register-based. Firstly, it meant that the inevi- table distortions of representatives did not burden the validity of information. Secondly, we wished to create time series in order to discover short, medium and long term trends related to demographic, labour market and le- gal status. However, relevant economic, social and health features of third country nation- als (gender, age, family status, educational at- tainment) have not been gathered by NHIF, unfortunately. Dual citizens access to health care benefi ts on the basis of their Hungarian nationality (cp. Serbia, Croatia, Ukraine, USA). Thus, data on third-country health care 75Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80. consumers relate to those who do not possess Hungarian nationality (Töttős, Á. 2013). Two primary institutions formed the ba- sis of the qualitative data collection. These are the Semmelweis University (Budapest) and the National Ambulance Service. Within the framework of the project 51 in-depth, semi-structured interviews with health care providers (doctors, nurses, administrative offi cers, managers) were carried out, in or- der to reveal the opinion of the stakehold- ers of these two institutions (Gyeney, L. and Kovács, G. 2012; Kereszty, É. 2012). Research results The unique database provided by the NHIF contains information related to third-country nationals possessing TAJ between the years 2006 and 2010. The database consisted of the public health care consumption of third- country nationals staying legally in Hungary. As methodological notes it is put forward that the private health care consumption of third-country nationals was out of the scope of this paper. The analysis was based on data of administrative nature deriving from full- scale register that already had archive data fi les as well. We distinguished the types of care: emergency health care (acute care), out- patient care, in-patient care, dental care and cash benefi ts. According to the advantages of the administrative data available the focus will be on citizenship matt ers in the follow- ing sections. Utilisation of acute care services The absolute number of third country nation- als who received acute care in Hungary was 11,776 between 2006 and 2010. The distribu- tion of acute care treatment by citizenship mirrored strong concentration by citizenship. 82 percent of the care recipients came from seven countries, namely, Ukraine, China, Vi- etnam, Serbia, former Yugoslavia, Russia and Mongolia. It is to be traced that the structure of third-country nationals echoes the block of former socialist countries of the past century. It is suggested that, albeit the research aims at describing current trends, it severely faces the heritage of the past, almost 50 years long history. The nationals of Ukraine had the highest number (4,810 persons) within the mass of third-country foreign citizens. Chinese peo- ple were situated in the second place with a severely less absolute number (2,430 per- sons). Vietnamese citizens held the third place (1,204 persons). These third-country nationals were followed by the citizens of neighbouring countries like Serbia and former Yugoslavia (370 plus 881 nationals). The third country nationals from Russia had limited absolute number (770 persons). Finally, citizens of Mongolia could be seen with 376 persons. The full scope register based statistics con- tain data on the costs of acute care. So it is possible to compute a fi nancial indicator, too. The average price was 34,400 HUF (ca. 110 EUR) per acute care recipient per year (Table 1). Table 1. Aggregate data on third-country national’s medical care recipients in Hungary between 2006 and 2010 Type of treatment Number of care recipients Average cost per person, 1,000 HUF per year Rate of the 7 most considerable nationalities within third-country care recipients, % Rate of the third-country care recipients treated in the 7 most considerable receiving counties, % Share of Budapest, % Acute care In-patient care Out-patient care Dental care Cash benefi t 11,776 9,414 72,306 18,123 3,961 34.4 34.4 3.0 1.1 81.6 82 94 79 86 93 94 95 85 86 94 61 63 57 55 66 Source: NHIF data and the authors’ own calculations. Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80.76 Utilisation of in-patient care services Altogether 9,414 third country nationals re- ceived in-patient cares. The distribution of in-patient care treatment by citizenship mir- rored stronger concentration compared to acute cares. 94 percent of the in-patient care recipients came from the same 7 countries, namely, Ukraine, China, Vietnam, former Yu- goslavia, Serbia, Russia and Mongolia. We received data about sex only in case of in-patient care. It is to be mentioned that Chinese and Vietnamese male had medical problems requiring in-patient care only to a very limited extent. Even urological inci- dents were negligible. In case of female, gynaecological medical interventions, prenatal and newborn care were outstandingly dominant. The over rep- resentation of these two nations were the highest in the context of immigrant share by citizenship. The statistics of NHIF contain data on the costs of acute care. The average price was 34,400 HUF per acute care recipient per year (see Table 1). Utilisation of out-patient care services Altogether 72,306 third country nationals got out-patient cares. This was the most nu- merous group among the types of treatment analysed. But the distribution of out-patient care treatment by citizenship was least con- centrated. 79 percent of the out-patient care recipients came from the seven countries un- der investigation. The full scope register based statistics con- tain data on the costs of each type of treat- ment. The average price of out-patient care was 3,000 HUF (ca. 10 EUR) per out-patient care recipient per year. This was one of the smallest average costs if we compare it with the average acute care and average in-pa- tient care costs (both 34,400 HUF) (see Table 1). We did not discover peculiar cases from a citizenship point of view in the Hungarian counties. Utilisation of dental care services Altogether 18,123 third country nationals ex- perienced dental cares in Hungary between 2006 and 2010. The distribution of dental care treatment by citizenship mirrored medium level concentration. It was an intermediary position between in-patient care (94%) and acute care (82%). 86 percent of the dental care recipients came from seven countries. The nationals of Ukraine had the highest number (6,617 persons) within the mass of foreign citizens. Chinese people were in the second place with much less absolute numbers (3,038 persons). Vietnamese citizens held the third place (1,718 persons). These nationals were followed by the citizens of former Yugoslavia (1,636 people). The full scope register based statistics contain data on the costs of dental care. The average price was 1,100 HUF (ca. 3.5 EUR) per dental care recipient per year. This was the smallest average cost (see Table 1). The average value of the indicator seems too small at fi rst sight according to the everyday experiences in Hungary but we did not ex- plore peculiar aggregate dental cases from citizenship point of view through the lens of receiving counties. Access to cash benefi t Altogether 3,961 third country nationals got cash benefi t in Hungary between 2006 and 2010. This was the least numerous mass among the types of treatment analysed. The distribution of cash benefi t gainers by citizenship echoed one of the strongest con- centrations. 93 percent of the care recipients came from seven analysed countries, namely, Ukraine (1,317 persons), China (992 persons), Vietnam, (758 persons), former Yugoslavia, Russia, Serbia and Mongolia. The average amount was 81,600 HUF per cash benefi t recipient per year. This was the highest average cost among the types under investigation. We did not explore peculiar cases from citizenship angle in destination counties. 77Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80. Discussion The potential explanatory factors of the structure of citizenship are according to Figure 1. and relevant literature as follows. The signifi cant weight of Ukrainians among the immigrants in Hungary is a satisfactory statistical determinant about the dominance of Ukrainian citizens in all sorts of cares. However, the deep causes are embedded in ethnic Hungarians living near the Hungar- ian-Ukrainian border and the discrepancies between the development stage of Ukraine and Hungary including public health care systems (Karácsonyi, D. and Kincses, Á. 2011). Ukrainian sort of explanatory factors do not work among the citizens of China and Vietnam. Their share is higher among all cases than their corresponding values as foreign citizens in Hungary. Their overrepre- sentation mainly correlates to their economic status. They work as self-employed persons. As an additional determinant we may add to the diaspora lifestyle formulating. It must be mentioned that the overwhelming major- ity of services for Chinese and Vietnamese was provided in the capital city of Budapest (Egedy, T. and Kovács, Z. 2010). The share of citizens of former Yugoslavia and one of the successor states of Serbia was low comparing to their weight among third- country foreigners in Hungary. The role of ethnic Hungarian communities and their wealthy economic positions is enormous (Kincses, Á. and Takács, Z. 2010). Contrary to the nationals discussed above Russian and Mongolian people are over rep- resented among all types of care compared to their share among immigrants in Hungary. In the Russian case the value would be closely related to the former medical tourist activity, mainly the cases of acute care. The Mongolian case is completely diff erent from the Russian. The explanation is hidden in the phenome- non of work driven migration of Mongols. But it is not similar to the Chinese or Vietnamese cases because Mongolians are guest-workers that is not self-employed status (Figure 1). On the basis of the analysis of in-depth in- terviews at National Ambulance Service and Semmelweis University Budapest (Gyeney, L. and Kovács, G. 2012; Kereszty, É. 2012), the following main observations can be dis- covered from the angle of time-space forces. Three main difficulties can be identified: problems of language, communication and culture; absence of medical history; questions of aft ercare. Language, communication and cultural factors Except for ethnic Hungarian immigrants dif- fi culties are discovered in diff erent language knowledge between suppliers and providers of health care (Feith, J.H. et al. 2010; Eke, E. et al. 2011). The health workers are usually not been helped by an interpreter and/or cultural mediators in public institutions. We must dis- tinguish for example the Semmelweis Uni- versity’s institutions from regional or local health care centres. Physicians working in clinics spent several years in foreign institutes so they have no communication problems in English and/or German. Although physicians speak quiet good foreign language(s) only few nurses and other healthcare employees have appropriate language skills. Interview- ees agreed that it is important to speak at least one foreign language on basic level for health workers in an institution which has a lot of foreign patients everywhere in the country. Religion is the main factor in the fi eld of cultural diff erences among third-country na- tionals. Beyond the religious rules covering clothing, patients cannot pursue their every- day life (habit, rituals). For instance, amongst in-care patients, problems arise concerning one of the basic human needs, the meal. The question of cultural diff erences puz- zled our interviewees. According to the opinion of ft he irst group the medical staff handle this question with much more pro- fessional ethics of practice (according to the international requirements emerging on the culturally competent and diversity sensitive services) than a few decades ago. The second Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80.78 group of interviewees found that the prob- lems come from cultural diff erences which would not be eliminated or solved com- pletely in the healthcare institutions (Crush, J. and Tawodzera, G. 2014). Majority of the interviewees agreed that there should be employees knowing or practicing particular cultures in such institutions because a lot of patients having cultural diff erences. Role of medical history The starting point of each physician-patient relation would be the initiation of the anam- nesis (Rezonja, R. et al. 2010) except for the life-threatening situations in acute care. Mis- understanding and lack of medical records are the source of serious problems if foreign patients cannot understand the physician’s questions and/or at fi rst stage cannot pro- vide any document on the previous troves (medical fi ndings, records) belong to their own medical history. Moreover, medication of foreign patients should be problematic because drugs used by the patient at home or his/her previous destination are oft en un- known and/or unavailable in Hungary. Aft ercare The patient’s aft ercare could be problematic in case of emigration, if she/he interrupts the connection with the previous health workers. This problem arises not only in relation to foreigners but also to nationals. But the rapid development of information, transportation technology and telecommuni- cation, the distinctive function of emigration Fig. 1. Regional distribution of types of treatment in Hungary by seven most considerable sending countries, 2006–2010 in percent 79Illés, S. and Gellér-Lukács, É. Hungarian Geographical Bulletin 65 (2016) (1) 71–80. has been eroding. Circulation as the system of multiple and recurring international mi- gration form emerging in the epoch of glo- balisation (Illés, S. and Kincses, Á. 2012; Ma- tiscsák, A. 2013) may diminish the weight of this problem. Conclusions There is a strong interrelationship among three elements: eligibility to public health care, economic activity and lawful residence in Hungary. The third-country migrants appear more frequently in the fi eld of emergency care. Ukrainian, Serbian and ex-Yugoslavian na- tionals appear in relatively huge numbers in Ambulance Services, however, contrary to the previous expectations not in the border counties but rather in the capital city, Buda- pest. In the case of Chinese nationals obstetri- cal interventions are dominant. Probably, due to cultural diff erences the role of traditional Western medicine is less signifi cant within the Chinese community. A remarkable alternative can be the private (presumably Chinese) health institutions. The relatively big Vietnamese population appears solidly in the out-patient and in-pa- tient care and they hardly use the National Ambulance Service. Russian and Mongolian citizens are over represented among all types of care compared to their weights within third-country nationals in Hungary. In the relatively high Russian values medical tour- ist activity plays a role. The explanation of Mongolian values hid- den in the phenomenon of work driven mi- gration because of Mongols who are mainly guest-workers in Hungary. When language, communication and cultural barriers do exist, patients tend not to reach primary health care or preventive medical treatments but immediately the spe- cial care. The high territorial concentration of treatments narrow down the eff ective func- tion of public health care system for third- country nationals. In the near future we would like to embed our research results in a broader scientifi c context, but we have found few opportuni- ties to perform international comparisons. The investigation of public and private health care systems utilised by internation- al migrants on macro scale is fundamental worldwide. The emerging databases across countries may be important resources for in- ternational comparisons and may allow us to test the robustness of the fi ndings of this Hungarian case study. Acknowledgement: “Research about access to the health care system” project is co-fi nanced by Tullius Ltd., the European Integration Fund and the Ministry of Home Aff airs of Hungary. This paper was fi nanced by Pallas Athéné Geopolitical Foundation, Active Society Foundation and the Local Government of IX. District of Budapest. 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