Consequences of centralized healthcare systems: changing role and autonomy of hospital managers – insights from a Hungarian case

PURPOSE: The objective of this paper is to investigate how top managers in public healthcare interpret and perceive their autonomy within a highly centralized system and how their roles and attitudes have evolved in response to centralization. DESIGN/METHODOLOGY/APPROACH: The research examines how increased centralization and reduced organizational autonomy affect decision-making in hospitals, employing qualitative analysis through in-depth interviews with top managers. The study collected and analyzed data from 15 hospital managers in year 2015 and 2022 (eight interviews each year, one person interviewed twice), to capture changes following significant centralization efforts and the effects of the pandemic and health sector reforms. FINDINGS: Centralization has reduced financial and operational managerial autonomy for many institutions, leading to delays in decision-making, especially in financial matters and has also brought significant administrative and reporting burdens. Despite this, hospital managers reported retaining some professional autonomy in developing and managing their service portfolios, but this autonomy is primarily operational rather than strategic and is limited by financial constraints. RESEARCH LIMITATIONS/IMPLICATIONS: This study examines the Hungarian healthcare system, influenced by unique political context, which also presents a methodological limitation concerning the transferability of findings. PRACTICAL IMPLICATIONS: Hospital top managers' professional autonomy is often obscured by heavy administrative and financial pressures; thus, enhancing their strategic mindset is essential. SOCIAL IMPLICATIONS: Policymakers should adopt a comprehensive perspective in hospital maintaining, with a particular focus on balancing financial and medical perspectives. ORIGINALITY/VALUE: The paper focuses on an under-explored area: the organizational autonomy of hospital top management in the context of centralization efforts, delivering a message to both hospital managers and policymakers by emphasizing organizational aspects.