5. Provision of services
he Ministry of Health provides national leadership in a broad range of public health domains including food safety, control of communicable diseases, screening, health promotion, environmental health and epidemiologic monitoring. Its key partners include HPs, municipalities and the Ministries of Education, Sport and Culture, Finance, and Environment.
Primary care is provided almost exclusively by HPs via salaried physicians (and other professionals) working in clinics owned by the HPs, and independent physicians with whom they contract.
HPs are also the predominant source of specialized ambulatory care, which is mostly provided in community settings. Hospital outpatient departments are also an important, albeit secondary, source of such care. In contrast, the hospitals are the main providers of emergency care, with a relatively small but growing role for community-based providers (such as evening service centres sponsored by HPs and independent urgent care centres).
Israelis have access to a secure, safe and stable supply of a wide range of pharmaceuticals. HPs have community pharmacies of their own, but they also have arrangements with independent pharmacists, and the rapidly growing pharmacy chains, to bill them for pharmaceuticals dispensed to their members. Israel also has a large, successful and growing pharmaceutical industry, with an emphasis on generic pharmaceuticals.
In the LTC area, Israel has a well-developed system of day-care centres for the elderly, a growing system of supportive neighbourhoods, legislation that provides for government financing of non-professional home care, and a relatively high level of LTC insurance coverage. However, the LTC system suffers from fragmentation and other ills.
Palliative and hospice services are covered as part of the NHI benefits package. However, there are no governmental guidelines on when, how and to what extent HPs are required to provide these services. Hospital- and community-based palliative and hospice services exist, but they are less well-developed than optimal.
Responsibility for the provision of publicly financed mental health care (not including substance abuse care) was shifted in mid-2015 from the government to HPs. The government continues to operate most of the psychiatric hospitals and a network of community clinics as well as a comprehensive programme of rehabilitation services for the chronically mentally ill. The private sector is also a major provider of community-based mental health services.
Dental care, particularly for adults, is predominantly provided by the private sector by independent dentists, but HP chains and commercial chains are also significant providers. In the wake of the 2010 expansion of NHI to include dental care for children, this is increasingly being provided by HPs and financed by the government. The government also provides financial support for school dental services and limited programmes of dental care for poor people.
The use of CAM has grown markedly in Israel in recent decades. Moreover, mainstream health care providers – including hospitals, HPs and physicians – are increasingly involved in the provision of CAM.
People living in Israel who do not have formal residency status are not covered by Israel’s NHI Law. However, a variety of special arrangements have been put in place by the government and the HPs to facilitate the financing and provision of care for foreign workers, children who lack residency status and others.
5.1 Public health
The Ministry of Health operates the Public Health Service with national headquarters that, in turn, operates regional and district offices and a variety of field units.20 These units are staffed by career public health physicians, public health nurses, environmental engineers and other public health-related professionals. Several Israeli universities have programmes in place for the training of public health personnel. Five of Israel’s seven universities offer master’s of public health programmes and recently a new undergraduate public health programme was established at the Ashkelon Academic College. The Israeli Public Health Physicians Association is responsible for developing the standards and syllabus for training of public health physicians, in collaboration with the Israeli public health services and the schools of public health.
For decades, the Ministry of Health has had a department of environmental health. An important structural change took place in 1988 when certain responsibilities were reassigned to the newly formed Ministry of Environmental Protection. That Ministry assumed the lead responsibility for controlling noise levels, air pollution, radiation, and waste collection and disposal. The Ministry of Health remained the lead agency for food safety, ensuring water quality and regulating water recycling efforts and the use of pesticides in agriculture. Coordination efforts between the two ministries were not always effective after this 1988 structural change. However, since the mid-2000s, communication and coordination between the two ministries have improved and currently they are working together to formulate and implement a comprehensive national environmental health policy.
An important change in recent years was the opening of a department for environmental epidemiology within the Ministry of Health’s Public Health Service, in addition to the long-existing Department of Environment and Health. The new department is part of the larger epidemiology division that had traditionally a strong focus on infectious diseases.
Water shortage used to be one of the most crucial environmental problems facing Israel, exacerbated by the deteriorating quality of water resources under demographic, industrial and agricultural pressures. The establishment of large water desalination facilities helped to solve this problem in coordination with the Ministry of Health. Issues such as adding magnesium into desalinated water to prevent health risks are among the new challenges for policy-makers. Recently new water quality standards were adopted with one of the consequences being the decision to stop water fluoridation, a mandatory measure that had been employed in Israel. Currently that decision is being challenged in the Supreme Court by several professional associations (public health and paediatrics) as well as by some municipalities.
The main sources of air pollution in Israel are energy production, transportation and industry. Dense vehicle traffic is a major cause of air pollution, especially in the heavily populated urban centres of Tel Aviv, Jerusalem and Haifa. The relatively new Air Act presents the option to declare regions as endangering public health, thus demanding the development of a regional plan to reduce air pollution. Until now no such region has been declared, although several deliberations were held within the advisory committee for the environmental epidemiology department.
The establishment of the Environment and Health Fund in 2007 helped to improve the funding for environmental health research, for example to fund scholarships for postdoctoral study abroad and international workshops in various subjects such as exposure science and health impact assessment.
Control of communicable diseases
The Ministry of Health takes the lead in efforts to prevent, monitor and control communicable diseases, with important support from the HPs, hospitals, community clinicians and laboratories.
The national immunization schedule for children (until 6 years of age) is implemented by a network of mother and child health centres (Tipat Halav; “drop of milk” in Hebrew) that are operated by the Ministry of Health, the HPs and a couple of municipalities.21 They are primarily staffed by public health nurses, with a relatively small number of physicians involved, and have developed both the commitment and the capacity to engage in intensive outreach efforts in the areas of immunization and well-child care more generally. Immunizations after the age of 6 years are given by the school health services and immunizations for adults are given by the HPs.
After the enactment of the NHI Law, the introduction of new vaccines to the national programme has been slow. For many years, the committee responsible for additions to the NHI benefits package did not consider new vaccines. This created the situation that Israel, which for many years had been among the most advanced countries in its immunization schedule, fell behind and several new immunizations were not included in the national publicly funded immunization scheme. Although some of these new immunizations were included in supplementary insurance packages offered by the HPs, the co-payments involved and the fact that they were not offered in the mother and child health centres created a problematic situation of partial coverage and health disparities. In 2008, a scheme to gradually include the new immunizations was adopted by the Ministry of Health, and in the last few years new vaccines have also been discussed by the Basket Committee. The current immunization scheme in 2015 is robust and comparable to those of other developed countries, including immunizations against rotavirus, human papilloma virus, pneumococcal infection, and the combined vaccine for measles, mumps and rubella.
Vaccination coverage in Israel is high, with approximately 92–94% coverage among infants. The vaccination programme is updated regularly, with input from an epidemiological advisory committee. Until recently, vaccination coverage in Israel compared favourably with other developed countries, both in terms of the range of vaccines provided free of charge and the proportion of the population inoculated.
The Ministry of Health’s district and regional offices support and monitor the front-line efforts of the mother and child health centres. They receive reports from physicians, clinics and hospitals on conditions reportable by law, which include routine reports and those related to outbreaks of communicable diseases. An epidemiology unit at the national level within the Ministry of Health uses geographic information systems and other sophisticated tools to identify and analyse suspected outbreaks. This work is performed in coordination with the ICDC, and reports to WHO are routinely made.
In addition, there is a network of school health services providing, among other things, preventive care, immunization and health education, with an emphasis on risk-taking behaviour. In April 2007, the school health system was transferred from the Ministry of Health to a small non-profit-making organization, a move that was criticized and proved to be detrimental, especially in the south of Israel where there are communities of low socioeconomic status such as the Bedouins.
Individual physicians also play an important role in this system, diagnosing and treating patients with communicable diseases and advising patients on steps to prevent further spread of illness within the family and the school system.
Physicians are required by law to report to the Ministry of Health all cases on a specified list of reportable illnesses.
Typically, the Ministry of Health covers the cost of public information campaigns for adult vaccination, while the HPs provide vaccines and are responsible for service delivery at patient level, with some vaccines provided free of charge and others at subsidized prices. For many years, very effective cooperation took place between Israel’s Ministry of Health and its Palestinian Authority counterpart in the area of communicable disease control. The primary types of cooperative activity undertaken were training, research, service development and provision, policy planning and conferences, seminars, dialogues and youth activities (Barnea et al., 2000). This was important to both Israelis and Palestinians because there were substantial flows of people and goods between Israel and the Palestinian Authority. Since the intifada began in September 2000, cooperation in this area has deteriorated significantly. While some improvement has taken place since 2004, especially in response to avian influenza, following the division between the West Bank and Gaza, cooperation has been challenging.
The Ministry of Health has developed a detailed pandemic preparedness plan that relates to the key elements of surveillance, hospital and laboratory preparedness, stockpiling and distribution of antiviral drugs, and risk communication.
During March 2006, an outbreak of highly pathogenic avian influenza (H5N1) occurred in multiple poultry farms in southern Israel. A simultaneous outbreak was identified in the Gaza strip and Jordan. This outbreak was contained by a joint effort of the Ministries of Agriculture and Health (Balicer et al., 2007). Mitigation of this outbreak was characterized by regional collaboration between Israel, the Palestinian Authority and Jordan (Leventhal et al., 2006).
In 2013, the discovery of poliovirus in Israeli sewage led the Israeli Government to institute a polio vaccination campaign in Israel, a highly unusual occurrence in a developed country. The campaign included a risk communication component that used both traditional media and social media. One of the main issues in public and professional discussion was the possibility of reintroducing the oral live “trivalent vaccine” (Sabin vaccine), which had been discontinued in 2004 in Israel as in other developed countries. The response was followed closely by WHO, with whom the Israeli authorities consulted intensively. This case is very relevant to other countries that moved to inactivated poliovirus vaccine only, and more broadly for final global eradication efforts (Kopel, Kaliner & Grotto, 2014).
In 1994, the Ministry of Health established the ICDC. Its primary goal is to collect and analyse updated health-related data, with the aim of providing health policy-makers with the evidence base necessary to make informed decisions. The ICDC plays important data collection, monitoring and analysis roles with regard to both communicable and noncommunicable diseases (including ongoing reporting of surveillance data from the HPs for early identification of outbreaks).
Israel has an extensive and active Healthy Cities Network (Donchin et al., 2006) in which the municipalities, residents, businesses and NGOs work together to ensure the vitality and health of their cities. The Network was initiated in 1990 and by 2015 over 50 cities were participating. The Network has been very important for the larger health promotion initiatives led by the Ministry of Health, including the National Programme to Promote Active and Healthy Lifestyle together with the Ministry of Education and the Ministry of Culture and Sport. Recently, following large cuts in the overall national budget, the programme has suffered from major cuts.
Screening is also characterized by the involvement of both governmental and nongovernmental actors. All neonates are screened for phenylketonuria and congenital hypothyroidism; those found to be positive are followed up in specialized national centres or in mother and child health centres. The latter also offer prenatal screening services, but many women prefer obstetricians, many of whom provide care through the HPs while others practise privately.
Mother and child health centres are the primary source of screening for problems in child development and for vision and hearing problems. They also screen preschool children before this function is taken over by schools. The HPs have become increasingly active in the field of women’s health, including establishing special women’s health centres. Screening constitutes an important part of their activities. Some screening tests – particularly those that are new and whose cost–effectiveness has not yet been proven – are provided by the HPs through VHI. Others, such as screening for breast and colorectal cancers, are carried out by the HPs as part of the NHI benefits package. At the time of writing, screening programmes for these cancers are implemented via special national programmes as part of the effort to increase compliance among target populations.
Health promotion and education
In this field, too, a number of actors are involved. The Ministry of Health has an active Department of Health Promotion, the aim of which is to enable the population to increase control over their own health and to improve it.
To achieve this aim, the Department produces educational tools and provides support to aid health-related behavioural change at the individual, community, environmental and political levels. In addition, a special Health Promotion Committee, reporting directly to the Director-General of the Ministry of Health, fosters collaboration between governmental and nongovernmental actors. The HPs are increasingly involved in both patient education in the care of specific illnesses and health education for their members more generally, making use of their physicians and other professionals, as well as their websites, newsletters and other printed materials. However, currently the “health promotion basket”, unlike the health basket for mainly clinical treatments, is not part of the NHI Law and there is no clear definition of what should be included in promotion and prevention programmes.
As mentioned, a National Programme to Promote Active and Healthy Lifestyle was initiated by several government ministries, yet its viability has been compromised by recent budget cuts.
The Ministry of Health has initiated a major effort to set national health targets for the year 2020, along with strategies for achieving them. (For further details, see subsection Health targets within section 4.2 in Rosen, Samuel & Merkur, 2009.)
Health promotion efforts within the HPs face a challenge in terms of engaging physicians to be active in the area of health promotion. However, the National Quality Measures Programme, which includes many measures related to primary and secondary prevention, is helping to increase the rates of performance of these activities by PCPs.
Recent developments and key issues
A key issue relates to the funding level for public health services. By mid-2015, only 1.2% of total health expenditure was channelled through the Ministry of Health’s Public Health Service. There is a fairly broad consensus that increasing this share could lead to substantial gains in population health.
Other recent activities in the public health field include the establishment of a new coalition, “The Public Health Forum” led by the Israeli Public Health Physicians Association (part of the IMA) in order to promote a public health reform. This includes legislation towards a new public health act22 with a focus both on structural changes (such as creating a public health agency at the Prime Minister’s Office) and ensuring the necessary budget and adequate personnel for addressing Israeli public health needs.
The Israeli Public Health Physicians Association is also working on developing a public health ethics code, in cooperation with other public health, medical and nonmedical organizations.
At the forefront of the Ministry’s efforts is the nationwide system of mother and child health centres. Most of these are owned and operated by the government, although in Tel Aviv and Jerusalem they are run by the municipalities and in some areas they are run by the HPs. In recent years, a group of researchers at Ben Gurion University along with the Ministry of Health’s Public Health Services conducted a study funded by the Israeli National Institute for Health Policy Research to promote a National Quality Measures Programme for the mother and child centres. The recent full computerization of these centres has made the time ripe for such a move.
According to the NHI Law, health plans (HPs) are required to provide child development screening and services. HPs usually provide this via multidisciplinary clinics with various providers within the framework of coordinated care.
Acknowledging the limited time window for screening and treatment for children, in 2006the MoH set maximum waiting times (WT) of 3 months. However, HPs have had difficulty in meeting these times. In 2010, the MoH started enforcing the maximum WT: patients that exceeded the maximum WT at HP clinics were allowed to seek privately provided developmental health care by self-employed professionals, and HPs reimbursed patients according to the MoH price-list tariff. However, allied professionals are allowed to charge above the MoH tariff and patients must pay the extra charges.
A retrospective evaluation raised questions about the extent to which the policy has achieved its goals and its impact:
- The rate and availability of child development services provided directly by HPs have decreased, as a significant proportion of caregivers preferred to work self-employed (they set their own tariffs).
- Since self-employed caregivers are not obliged to have continuous professional contact with HP-caregivers, in many instances decentralizing the provision of services following the reimbursement policy resulted in a break in the continuity of care.
- The rate of services funded through reimbursements has increased significantly and accounts for about a quarter of child development care. Since professionals can charge above the MoH maximum tariffs, this increases the burden of out-of-pocket health spending and inequalities based on socioeconomic status.
In light of the negative externalities imposed by the reimbursement policy (hampered continuity of care and increased private spending), the MoH has proposed a new payment incentive framework to HPs: a retrospective payment on top of the NHI capitation budget. This additional funding is a form of "Pay for Performance" (P4P) and will be given to HPs that prove an increase of volumes of child development services provided within the WT. The MoH intends to allocate NIS 80 million (€20.6 million) a year for this retrospective P4P scheme. the estimated amount paid by the HPs to private caregivers under the current arrangement.The MoH has not yet specified what mechanism will be used to incentivize therapists.
The additional funding is expected to improve access to child development services, reduce the financial burden on patients’ families and increase those working within the public system.
Principles of the provision of services in the field of child development by the HPs, 2006. Available at: https://www.health.gov.il/hozer/mr51_2006.pdf [Hebrew] .
Services in the field of child development, 2010. Available at: https://www.health.gov.il/hozer/sbn01_2010.pdf [Hebrew] .
Child Development Services – Update, 2019. Available at: https://www.health.gov.il/hozer/mkA03_2019.pdf [Hebrew] .
State Comptroller's Annual Report 67B (2017). Treatments in the field of child development. 383-444 [Hebrew].
Since March 2018, Israel has experienced an outbreak of measles with a majority of cases found among ultra-orthodox Jewish communities (60% occurring in Jerusalem). Despite the existing two-dose MMR programme since 1994, Israel has experienced measles outbreaks in 2003, 2007 and 2012. In past outbreaks, the incidence was also high among non-immunized children, from which about 87% were from ultra-orthodox Jewish communities in Jerusalem, but the virus also spread to other areas including health care professionals and migrants in Tel-Aviv.
Measles vaccination is freely provided in Mother and Child Clinics (MCCs), but it is not mandatory. In previous outbreaks, vaccination coverage was lower among ultra-orthodox Jewish communities (88% v 90% among non-ultra-orthodox), but in 2018 the difference widened (95% v 98%, respectively). Muhsen et al. (2012) explain that having parents holding religious beliefs against vaccination, and perceiving the risk of vaccine preventable diseases as low are risk factors for early childhood under-immunization among ultra-orthodox communities. The low rate of vaccination among particular communities might compromise herd (collective) immunity in these populations.
The MoH decided to cooperate with religious leaders to disseminate a call to vaccinate, expand MCC working hours, and temporarily open additional MCCs within communities with low vaccination rates. The Ministry also sent mobile MCC units to vaccinate target neighbourhoods in Jerusalem and launched a mass-media campaign.
Although preventive services are covered by the NHI Law, they differ from most health care services as they are under the direct responsibility of the MoH not the health plans (HPs). For vaccines, the MoH covers about 65% of children, while 10% are provided for by the municipality. HPs are allowed to open MCCs and to voluntarily offer preventive services on behalf of the MoH for an extra payment. In many cities, HPs are the providers of this service, which cover 20% of children, the remaining 5% are served by NGOs (e.g. East Jerusalem).
Interestingly, there are other ultra-orthodox localities where measles did not break out, thus beyond culture another reason to consider is the manner in which preventive services are organized, their accessibility and outreach. For example, babies who are registered with an HP MCC at birth can be tracked, whereas in municipality MCCs parents show up voluntarily so the register of the newborn is not immediate and follow-up vaccination schedules may be less smooth. Moreover, in cities with different types of MCC ownership, there is overlap of responsibility between the MoH, municipality and HPs.
MoH (2018) Number of measles cases by localities in Israel (in Hebrew) (https://www.health.gov.il/Subjects/disease/Pages/Measles_by_Cities.aspx?WPID=WPQ8&PN=3, accessed 15 January 2019).
Muhsen K, El-Hai RA, Amit-Aharon A, et al (2012). Risk factors of underutilization of childhood immunizations in ultraorthodox Jewish communities in Israel despite high access to health care services. Vaccine 30(12): 2109-15.
Israel performs poorly, relative to many other developed countries, with regard to obesity and associated morbidity, which can lead to increased costs in the health care system.
In recent years, there has been a dramatic increase in the prevalence of obesity in Israel: about 30% of children and about 60% of adults are overweight (2016). Roughly 8% of the population has diabetes and among poor populations, the rate reaches 25% (2016). Among OECD countries, Israel ranks second on the rate of avoidable deaths due to untreated diabetes, and fourth on daily intake of soft drinks.
In order to design a policy to promote healthy diets, the Ministry of Health (MoH) established an interdisciplinary committee with representatives of government ministries, researchers, medical specialists, policymakers,representatives of the food industry and the public. Concomitantly, special attention was given to public opinion and ‘the wisdom of the crowd’ through internet surveys and forums (via the MoH website and Facebook), and focus group interviews.
The effort resulted in a programme, which puts the responsibility on the state to create an environment that promotes healthy food choices. The following policy measures are recommended:
1. Mandatory labelling of food packages with nutritional information and clearly differentiating between healthy and unhealthy food though marking packages as positive or negative;
2. Restrictions on adverting unhealthy food for children;
3. Incentives for food manufacturers to produce healthier products and reformulate unhealthy ones;
4. Improving economic access to healthy food though subsidies for fruits, vegetables, and other healthy foods or taxation of unhealthy foods;
5. Improving the nutritional value of food served in public institutions such as schools, the army, prisons, and ministries; and in the facilities of large private sector employers such as the aerial industry.
6. Including education on healthy diets to the school curriculum for young children.
Reference: MoH (2017) Healthy Diet Committee webpage (https://www.health.gov.il/Services/Committee/HealthyDietCommittee/Pages/default.aspx, accessed 26 September 2017).