Public-private partnership in Hungarian dialysis care.

Sir, We read with great interest the article by Rutkowski [1] on the epidemiology of renal replacement therapy in Central and Eastern Europe. Hungary belongs to the countries of Central and Eastern Europe where private dialysis centres entered into the market at an earlier stage, in the middle of 1990s. From the point of view of the Hungarian National Health Insurance Fund Administration (the one and only healthcare financing agency in Hungary), we emphasize the increase in market share of private dialysis providers from health insurance reimbursement [2]. Figure 1 shows how the market share of privately owned dialysis centres increased from 46.3% in 1995 to 90.1% in 2004. For the process characterized by the increased number of private dialysis centres in Hungary, we would suggest using the phrase private finance initiative (PFI) or public–private partnership (PPP) [3] instead of privatization. Privatization generally refers to the process whereby the owner (the state) sells its product or property to a private investor, but the Hungarian case preferred the mid-term (15–25 years) rent of existing dialysis centres; the private investors renovated the old centres or built completely new ones. Private investments were facilitated by the relatively sharp increase of reimbursement rates, which suggested a rapid return for investment [4], although since 2004, in addition to the activity-related financing, a global volume contract system was introduced in outand in-patient care, forming an artificial financial ceiling for healthcare providers [5]. Beside the private investments, the relatively higher public reimbursement rates of the National Health Insurance Fund Administration—with the guarantee to spend it only on expenditures related to dialysis—contributed to the successful transformation and development of the Hungarian dialysis care over the past 15 years.