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Health care in Israel.

In general, the health of Israelis compares favorably with that of residents of other developed countries. In 1996, the average infant mortality was 6.3 for every 1,000 live births, similar to the average for countries whose per capita GNP is high (World Bank, 1998: 22). Life expectancy at birth is 75.5 for men - slightly higher than the average for high-income countries, and 79.5 for women - somewhat lower than the average for high-income countries (ibid: 18). Whereas in Europe women outlive men by an average of 7 years, in Israel the difference narrows to 4 years (ICDC, 1998: 55-57). Two-thirds of all deaths in Israel are caused by heart disease, cancer, and cerebrovascular disease - the leading causes of death in the developed world.

Israel belongs to that part of the world in which people generally eat too much rather than too little: studies (based on local rather than national samples) have found about a fourth of subjects to be overweight; and 16% of 20-64 year-olds to have high cholesterol levels. Other localized studies have shown that 30% of men and 25% of women smoke. Although alcohol consumption is low compared to that in European countries (ICDC, 1997: 16-17), it appears to be increasing among the younger age groups.

In Israel, pre- and post-natal, geriatric and mental health services are provided by the Ministry of Health, while curative services are dispensed by four non-profit health funds - General (insuring about 60% of the population), Maccabi (20%), Meuhedet (10%) and Leummit (10%). The funds operate community-based curative clinics and regional specialist centers for members (General and Maccabi also have their own hospitals). They contract with hospitals and other public and private service providers on behalf of their members.

Israel has an extensive preventive care network of about 1,000 public Mother and Child clinics dispersed throughout the country that provide pre- and post-natal care for women, well-baby care, and on-time inoculations for 91 % of Israeli infants and children. However, some services considered primary in other developed countries - dental care, mental-health services, long-term nursing care for the elderly and contraceptives for women - are not an integral part of the public health care system.

In 1995, there were 259 hospitals in Israel with 5.91 beds per 1,000 persons, a ratio that is on the decrease (average ratio of OECD countries - 7.5 per 1,000 in 1992). The average duration of hospitalization for persons in general care has also decreased, from 7.2 days in 1976 to 4.4 in 1996 (CBS, 1997a and 1978, Table 24.8). Annual general hospitalization days per 1,000 persons have been decreasing steadily as well: in 1996, the figure was 793 (ibid). The average occupancy rate of hospital beds is 94% - indicating a high level of efficiency (ICDC, 1997: 269). In contrast, the average occupancy rate in OECD countries was 78% in 1992 (Calculated from Ben-Nun and Ben-Uri, 1996:25).

The doctor/population ratio - 461 per 100,000 persons - is among the highest in the world. Contrary to popular opinion, the latest figures indicate that Israelis do not visit the doctor more often than residents of OECD countries - Israelis make an average of 6.8 visits a year (CBS. 1997. Health Survey; calculation from Ben-Nun and Ben-Uri, 1996: 18).

The National Health Insurance Law

Prior to 1995, Israel had a voluntary health insurance system, under which about 96% of the Jewish population, and only 88% of the Arab population, were covered for ambulatory treatment and hospitalization as members of health funds. Among Arabs, those without health insurance tended to be poor and young (18-24). The highest uninsured rate - 36% was among 18-19-year-old Arab youths; young Arab women who lived with their parents and were unemployed also tended to be uninsured. The benefits package differed from fund to fund and was not publicized. Financing came from four sources: membership fees, co-payments, a tax on employers (the "parallel tax"), and subsidies from the State Treasury.

In 1995, the National Health Insurance Law made health insurance both compulsory and universal. All formal residents were obliged to join a fund, and no fund was permitted to refuse membership on the basis of age, state of health or any other consideration. A uniform benefits package was stipulated and the list of services promulgated. In lieu of membership fees, which had differed from fund to fund, a health tax with two income gradations was imposed, to be collected by employers and transferred to the National Insurance Institute along with a health tax paid by employers (the latter was abolished in 1997). The law obligated the Treasury to cover the difference between the cost of service provision and the income collected.

Another change instituted by the National Health Insurance Law was the application of an age-adjusted capitation formula to the distribution of all health tax monies among the four health funds; the change increased equity among the health funds.

Patient's Rights Law

In 1996 the Patient's Rights Law established the following basic rights for persons in need of medical care: the right to unconditional emergency treatment, the right to information about the caregiver, the right to a second opinion, the right to continuity of care, the right to human dignity and privacy, the right to informed consent for medical treatment, the right to access to medical information, and the right to medical confidentiality (Society for Patient's Rights, 1998). Among other things, the law requires professionals and hospital emergency rooms to dispense emergency treatment regardless of whether or not the patient has medical insurance.

Disparities in Health and Health Services

A wide range of factors impact on the health status of a population, including heredity, environment, lifestyle and the health care delivery system itself. It is generally agreed that one of the most important determinants of health is socioeconomic status. Social class has been shown to have a major influence on levels of health in every country in which it has been studied (Giraldes, 1991). Likewise, educational level, particularly that of mothers, is directly related to the health of the community, and especially its children. Unemployment has detrimental effects beyond the obvious financial ones, and leads to multiple psychosocial and psychosomatic ailments in the unemployed and his or her family (Westcott, 1985).

In the following pages, we will be looking primarily at the health status and services available to men and women, to Jews and Arabs, and to Ashkenazi (whose origins are in Europe or the Americas) and Mizrahi Jews (whose origins are in North Africa or the Middle East).

The same ranking order appears regardless of which measure one takes - education, income or occupation Ashkenazi Jews are on top, followed by Mizrahi Jews and Arab Israelis.

Some of the figures underestimate the gaps that exist; for example, income statistics are based primarily on earned income, and they fail to take into account the residents of small communities, including the 80,000 residents of unrecognized Arab villages where deprivation is greatest. Perhaps the most telling statistic in terms of official policy is the effect of social support interventions by government agencies on the percentage of poor among Jews and Arabs: in 1996, 56% of Jews who were poor on the basis of their earned income, compared to 39% of Arabs, were lifted above the poverty line due to the effects of transfer payments and direct taxes (Calculated from National Insurance Institute, 1998). The differential impact is the result of differences in the level of support provided and the depth of poverty of the recipients.

For second-generation Ashkenazi Jews - the median educational level is 13.6 years, for Mizrahi Jews, 12.1 years, and for Arabs, 10.4 years (CBS, 1997a, Table 22.1, 22.2); 27.5% of second-generation Ashkenazim, but only 8.2% of second-generation Mizrahim and 4.8% of Arabs have 16 or more years of schooling (ibid). The average income (1996) for urban households in which the head of the household is a wage earner is NIS 13,097 for second-generation Ashkenazim, NIS 8,762 for second-generation Mizrahim - and NIS 6,474 for Arabs. It is NIS 6,886 for new immigrants (who came in the 1990s) from the former Soviet Union and NIS 4,228 for those from Ethiopia (CBS, Income Survey 1996, Table 3). About 30% of Israeli-born Ashkenazim, compared with 50% of Israeli-born Mizrahim and 80% of Arabs work in blue-collar occupations or sales. (CBS, 1997a: Tables 12.15 and 12.14). Women's wages are an average of 60% of men's; their average hourly earnings come to 80% of men's (Alexander, 1997: 38). Nine percent of families with chil dren are headed by women, and one-fourth of them live in poverty, compared with 16% of all families (ibid; National Insurance, 1997: 54).

Finally, infrastructure development impacts on health. Adequate sanitation and sewage disposal are critical to the prevention of gastroenteritis, parasites and other diseases transmitted by the fecal-oral route. In a 1996 study conducted by the Galilee Society, the National Arab Association for Health Research and Services, only 11 out of the 148 Arab communities surveyed had a functioning central sewage system (Hassan, 1996), a basic amenity enjoyed by all Jewish localities.

As the following pages will show, health profiles match the socio-economic levels of the different groups that make up Israeli society.

Infant Mortality

The most sensitive measure of the overall social and physical well-being of a population is the infant mortality rate, the number of deaths during the first year of life per 1,000 live births. In 1996, the average rate was 5.0 for Jews, and about twice as high for Arabs -- 9.3 (CBS, 1997a, Table 3.1).

The graph of infant mortality shows clear disparities between Arabs and Jews. Although there are exceptions, most affluent Jewish communities are at the top, most Jewish development towns cluster around the middle and most Arab communities are near the bottom of the infant mortality graph. Whereas all but two Arab localities -- Kufr Kara and Reina -- exhibit infant mortality rates above the national average, only two Jewish localities -- the development towns of Or Akiva and Migdal Ha-emek -- have rates below the national average (which is composite figure for both Arabs and Jews).

Standardized Mortality Ratios

Geographic variation has also been found in the Standardized Mortality Ratios (a measure based on the actual number of deaths, standardized to account for differences in the age and gender composition of the populations). Excess (higher than average) deaths were found in the big cities and in localities with heavy industries. A comparative analysis of Standard Mortality Ratios by district for Jews in 1983 and 1986 revealed significantly higher than average rates for Haifa and Tel Aviv (Ginsberg and Tulchinsky, 1992). Another study of the Standard Mortality Ratios of eight municipalities in the central coastal area of Israel over the same time period found the highest rates (for all causes of death combined) in the development town of Or Yehudah and the lowest in Givatayim (an affluent Jewish locality) and B'nai Brak (a poor city with a large concentration of ultra-Orthodox Jews). The same study also found higher than average Standard Mortality Ratios from all causes combined among 30-44 year-old males and fem ales, and among 45-65 year old males. Looking at causes of death, excess mortality was found in Tel Aviv among both sexes from malignancies and from external causes, and these excesses increased between 1981-84 and 1985-87. The authors are cautious about suggesting explanations; they refer to factors like ethnic origin [differences in the prevalence of diseases of the circulatory system] and socio-economic status, and point to the need for analyzing inter- and intra-community differentials (Lusky, Gurvitz and Barell, 1994).

The table opposite shows the latest published age-adjusted mortality rates by geographical area. It should be noted that these are over 10 years old and that they predate the mass immigration from the former Soviet Union; thus the situation may have changed.

A CBS-Ministry of Health profile of localities of 10,000 or more persons for 1990-94 reveals excessive mortality rates for most age groups in the Northern and Southern districts of the country (CBS, 1997d, Diagrams 25-26), areas which have large concentrations of Arab citizens and of Jewish development towns with Mizrahi majorities.

A health profile of the Negev (southern part of the country) compiled by Tulchinsky and Ginsberg for the Israel Ministry of Health for 1990-92 reveals Standard Mortality Ratios that are 16% above the national average. The profile shows that the Negev has excess death rates from diabetes, cerebrovascular diseases and other ischemic heart diseases. The authors suggest that poor socio-economic conditions and lack of information about or compliance with medical services in Beersheba (Tulchinsky and Ginsberg, 1996: 32-33) may be contributing factors. Disaggregation of the figures reveals that compared to Jews, Negev Arabs (Bedouins) suffer from higher age-adjusted mortality rates from infectious diseases, whereas Negev Jews have higher mortality rates from chronic ischemic heart disease (ibid: 12).

Mental Health

Mental health services in Israel are over-concentrated in hospitals, whose beds are distributed unevenly: the center of the country has much higher bed/population ratios than the North and the South (Feinson et al, 1992); this may be the reason for the finding that clinic utilization rates are highest in the Tel Aviv and Jerusalem districts (ibid: 1). Self-help organizations point out that the crowded conditions of psychiatric hospitals and the dearth of community support services cause undue suffering to persons with chronic disorders and their families (National Forum, 1996).

A recent (1996) estimate is that about 1.2% of the adult population of Israel (36,000 persons) suffer from chronic mental illnesses (Aviram et al, 1996: 4). Compared to chronic mental illness, mental distress is experienced by far more persons: a 1995 telephone survey found that 27% of Israeli adults reported experiencing "emotional distress or mental health problems which they had difficulty coping with alone" sometime during their lives, and 13% the same year (Gross et al, 1997). A multivariate analysis found that women, persons with chronic diseases, Russian speakers, divorced or widowed adults, and those with low levels of education were more likely than others to report a need for help (ibid). Some of these findings are in keeping with an earlier (1986) survey of mental health clinic utilization, which found higher use by women, especially older women, by individuals with lower educational levels, and by divorced and single persons, especially single males (but not by widowed persons). The same study als o found that 97% of clinic utilizers were Jews and only 3% Arabs (Feinson et al, 1992). New immigrants from the former Soviet Union appear less likely to turn to mental health facilities than veteran Israelis (Nirel, 1998: 111).

The table on page 5 presents overall utilization rates for different population groups.

The differences in utilization can probably be attributed to the differential availability of services, especially for Arab citizens, but also for Israeli-born Jewish citizens of North African origin, who are concentrated in development towns in the socio-economic, if not the geographical periphery of the country. Another factor that renders mental health services less accessible to Arab citizens is the language and culture of the providers, most of whom are Jewish. Soviet immigrants may also find the services culturally inappropriate.

Health Promoting Behaviors

Research indicates that socioeconomic status is associated with lifestyle factors like diet, smoking and alcohol consumption (Shuval, 1992). Smoking is often considered the single most important behavioral causative factor of morbidity and mortality: A 1996 national telephone survey found that 30% of men and 25% of women smoked. These figures are similar to the average for OECD countries (ICDC, 1997: 237-242). The smoking rate is higher among Arabs than among Jews and higher among Mizrahi than among Ashkenazi Jews (ICDC, 1997:238-240). The higher incidence of smoking among Arab males may be connected with their higher mortality rates from lung cancer. Arab women appear to smoke less - in the same survey, only 12% reported smoking.

Alcohol consumption is lower in Israel than in European countries - an average of 0.9 liters per capita per year, compared to an average of 9.4 liters in the countries of the European Union (ICDC, 1997: 251). In a 1994-95 survey of the adult population of Israel, 50% reported not drinking at all, and less than 2% taking any form of drug other than hashish. Use of hashish was reported by 5% (ibid: 249). Whereas no change was found in the habits of adults over time, the consumption of drugs and alcohol appears to be on the rise among teenagers, though it is still low by international standards.

In Israel, there is increasing awareness of the importance of physical exercise for all age groups. A 1996 survey of 3,000 adults found 24% reporting that they exercised daily and 23% at least once a week (ICDC, 1997: 255-56). These findings differ from those of an earlier (1985-87) survey of industrial workers, only 20% of whom reported engaging in physical exercise (ibid: 255).

Differential Health Care Services

Despite the small size of Israel, there are considerable disparities in health service provision: cities and suburban communities have more and better services than peripheral communities, Jews have more than Arabs, and veteran communities more than development towns.

Health care services and personnel, as well as the most advanced technologies and diagnostic equipment, are concentrated in Tel Aviv, Haifa, Jerusalem, and the suburban ring of Tel- Aviv. More health care workers of every kind with the notable exception of family doctors - reside in the big cities and the central district than in the North or South (Medical Professions, 1994: 6). However, some of them (we don't know how many) work outside of their residential district.

Regarding the distribution and supply of hospital beds, there is a large concentration of most types of beds in the big cities and in the suburban ring of Tel Aviv (Central district) and a lack of beds in the North and South. Whereas Tel Aviv has relatively few psychiatric, obstretric, long-term care and intensive care beds, residents have the option of utilizing surburban hospitals. In both the North and the South, where doctors are in smaller supply, there are large concentrations of Arab citizens and Mizrahi Jews. Moreover, the districts with the lowest doctor/population and hospital bed/population ratios - the Northern and Southern districts - exhibit relatively high infant mortality and mortalily rates from various diseases (CBS, 1998: 38).

Once again, a special word needs to be said about the Negev - the southern part of the country. The main urban center, Beersheba, has fewer beds per 1,000 persons than the national average. It also has the lowest ratio of intensive cardiac care and intensive care to general hospital beds in the country (Tulchinsky and Ginsberg, 1996: 33-34). While the level of ambulatory care in the Negev is the same as the national average, the Negev has fewer long-term care facilities. Also lacking are primary care resources for the management of diabetes, described as "a central issue in the health status of the Negev population," including diabetes centers, dietitians, podiatrists and other relevant services (ibid: 33-35). Health care expenditures lag behind national levels by 6-16%, depending on the method of calculation (ibid).

Differential Utilization of Services

Health-promoting behavior depends on socio-economic factors, on the physical availability of services, and on awareness of health issues. Often those who are at greater risk are precisely those who have fewer health care opportunities; the affluent have the alternative of purchasing private services. In general, the utilization of preventive services (with the exception of Mother and Child clinics) is correlated with socioeconomic status.

The most recent Israel Central Bureau of Statistics survey Use of Health Services (1993) does not provide a breakdown between Jews and Arabs, Mizrahi and Ashkenazi Jews or veteran Israelis and new immigrants, so that comparative data are not readily available. One indication of the differential utilization of services is household expenditures on health (including public health insurance as well as expenditures for private services). In 1992/93 (the latest figures available), Jewish households expended an average of MS 369 a month on health, whereas Arabs spent 24% less - NIS 279. A similar gap was found between the health expenditures of Ashkenazi and Mizrahi Jews: NIS 450 and NIS 327, respectively (CBS, 1998: 36).

As the Mizrahi Jewish population and the Arab population are both younger than the Ashkenazi one, some of the spending gap may be due to age differences.

A recent (1997) study compared service utilization among residents of different Negev localities - Jewish rural setttlements (kibbutzim and moshavim), urban settlements (Beer Sheba, Eilat, Arad and Mitzpe Ramon) and Bedouin Arab localities. It found that kibbutzim - which are relatively affluent - used ambulatory and diagnostic services more frequently than the average Negev population, while they used emergency room and hospitalization services less. In contrast, residents of Bedouin Arab localities - by far the poorest residents - used more emergency room and hospitalization services and fewer ambulatory and diagnostic services. The urban settlements and moshavim had no clear utilization patterns (Weitzman, 1997: 17). Regarding Arab residents of the Negev, whose overall mortality rate was found to be 50% higher than that of Jews, the authors conclude, "Poor quality of care and difficult access to health care facilities could, at least in part, explain this finding, although cultural and behavioral factors of the Bedouin population must be considered as well"(ibid: 18).

While there are no systematic data on health service utilization by the Arab population or by residents of working class Jewish neighborhoods and Jewish development towns, such data are available for new immigrants. An evaluation of the findings of four national surveys (Nirel, et al, 1998) found that new immigrants from the former Soviet Union reported less utilization of health services than veteran Israelis: they visited family physicians less frequently, took less care of their teeth, and ordered fewer ambulances than veterans. Immigrant women had fewer mammograms. The authors point out that service utilization appears to increase with time; they state that the limited use of health services may be the result of "obstacles in the accessibility of the services, like, for example, the costs of treatment, as is the case with dental care and ambulances" (ibid: 112).

The Hazards of Israel's Road Transportation System

Due to emissions from cars and other transport modes, the air in Israel's central region is moderately to severely polluted by US Environmental Protection Agency standards. Carbon monoxide emissions may aggravate cardiovascular disease; nitrogen oxides increase susceptibility to viral infections, bronchitis and pneumonia; particulates and hydrocarbons are potentially carcinogenic; ozone aggravates asthmas and bronchitis and worsens heart disease; and benzene is associated with leukemia and other cancers (Fletcher et al, 1998). It is possible that the excess mortality rates found in Tel Aviv are connected with some or all of these emissions. Indeed, research conducted in the US has found correlations between increases in particulate pollution and death rates (Haaretz, 1997). The health of children and older persons are especially affected (Fletcher).

As can be seen from the table below, Israel is catching up with American cities on air pollution. Moreover, readings taken in Tel Aviv in January 1997 revealed that the pollution level of nitrogen oxides was at dangerous levels for nearly 5% of the month (Haaretz, February 18, 1997).

Other health hazards connected with road transportation are road crashes and collisions. In 1996, 25,000 such "accidents" resulted in reported injuries; 515 persons died. While the rate of road deaths has been stable since the 1980s - 9-10 per 100,000 persons (ICDC, 1997: 163), the number of crashes, collisions and injuries has been rising steadily. It should be noted that in most developed countries, the number of road deaths has been decreasing. The persons most at risk are the young, the old, new immigrants, and Arab citizens (Fletcher et al, 1998). See the graph on p. 10.

Hospitals vs Neighborhood Clinics Hospitals

In Israel, as in other developed countries, most of the national expenditure on health goes to hospitals. In 1995, this accounted for an average of 51% of health fund outlays (Rosen et al, 1998:16). The same year, expenditures on hospitals and research constituted 42% of the national expenditure on health (public clinics and preventive medicine accounted for 36%, and household expenditures for most of the remainder) (CBS, 1998: Table 31). It should be noted that the Central Bureau of Statistics does not include hospital-based ambulatory clinics in the hospital expenditure, but rather in the category of public clinics and preventive medicine; thus the hospital expenditure is actually higher than the figures indicate.

The more expended on hospitals, the greater the pressure to cut health costs not only on hospitalization but also on other services. The first services to be cut are generally preventive ones. This is due to the fact that, in contrast to hospitals, they have no effective lobby to look after their interests. A prime example is Israel's network of Mother and Child clinics; although it constitutes no more than 2% of the national expenditure on health, it nevertheless is a popular target for cutback proposals.

Specialist Services

Since 1994, hospitalization expenditures have been constrained through capping (placing a limit on the per annum sum health funds can expend on hospitalization). However, hospitals have found a new source of revenue: hospital-based ambulatory clinics. Between 1990 and 1995, the financial volume of such clinics located in government general hospitals increased by an estimated 150% (Shalmon et al, 1996:116). Hospital-based ambulatory services compete with neighborhood clinics, and they have come to constitute an increasing financial burden for the health funds.

The expansion of hospital-based ambulatory services has also resulted in (1) increased costs for the health care system, as hospital-based ambulatory care is nearly always more expensive than neighborhood clinics, (2) a possible induced demand, and (3) a conflict of interests for the Ministry of Health, as both setter of health policy and owner and operator of government hospitals (Shalmon et al, 1996:121-123). From a systems point of view, these services are being developed at the expense of local specialist services, which are lacking in Arab localities, and, according to studies conducted in the 1980s, in Jewish development towns as well (no recent data are available as to the accessibility of specialist services in different types of Jewish localities).


Overall Utilization Rates for Israeli-born and Foreign-born Mizrahi and
Ashkenazi Jews, and for Arabs, per 1,000 Persons

Born in Europe/ Born Born in Israel-born: Israel-born:
America in Asia Africa origin Europe/ origin
 America Asia

2.3 1.6 1.6 3.3 3.0

Born in Europe/ Israel-born: Arab
America origin

2.3 2.2 0.5

Source: Fenison et al, 1992, Utilization of Public Ambulatory Mental
Health Services in Israel: A Focus on Age and Gender Patterns, Brookdale
Institute and Israel Ministry of Health, Tables A-9 and A-10 and p. 11.
Age-Adjusted Mortality Rates, per 1,000, 1983-86, by Subdistrict

Ramle 117.8
Beer Sheba 116.5
Ashkelon 115.3
Acre 114.0
Yizrael 111.5
Hadera 110.2
Safed 108.1
Kinneret 105.8
Haifa 102.8
Hasharon 98.9
Tel Aviv 97.7
Rehovot 90.7
Petah Tikva 90.6
Jerusalem 89.4

Source: Ginsberg, Gary, 1992, "Standardized Morality Rates for Israel,
1983-86," in Israel Journal of Medical Sciences, 28:868-877.
Hospital Beds per 100,000 Persons, 1995, by District

Type of Bed Jerusalem Haifa Center Tel Aviv North South

General 3.19 2.97 2.64 2.60 1.68 1.55
Psychiatric 1.14 2.67 2.13 0.59 0.70 0.52
Internal 4.11 3.60 3.93 2.86 2.29 2.30
Pediatric 1.47 1.44 1.16 1.06 0.95 0.73
per 1,000 25.42 25.67 48.68 14.42 19.96 7.87
Obstetric per
1,000 women
15-44 1.77 1.15 1.03 0.79 1.13 1.01
Care, per
1,000 0.10 0.09 0.08 0.12 0.05 0.05

Source: Calculated from CBS, 1998, Health and Health Resource 1900-1995:
117-123 and CBS, Statistical Abstract of Israel 1997, Table 2.7.
Doctor/Population Ratios (per 100,000), 1993, by District

Tel Aviv 517.3
Jerusalem 485.4
Haifa 482.7
Central 430.1
South 323.9
North 266.0

Source: Ministry of Health, 1994, Medical Professions: 16.
Particulate Pollution: Selected Cities in Israel and the United States

 City Annual average, Year of
 micrograms per measurement
 cubic meter of air

Tel Aviv - Center 56 1996
Jerusalem - Center 47 1991
Los Angeles 48 1992
Newark, New Jersey 37 1991

Source: Gary Ginsberg and Mordecai Peleg; The Ministry of Environment,
U.S.; EPA and the South Coast Air Quality Management District,

RELATED ARTICLE: A 1996 evaluation of the National Health Insurance Law from the standpoint of equity, microeconomic efficiency and macroeconomic cost control reported the following conclusions (Adva Center, November 1996):

1. The changes introduced by the law do not appear to have significantly increased or decreased the national expenditure on health. In 1993, the national expenditure was 8.2% of the GNP, in 1994, 8.9%, and in 1995, 8.7%.

2. Efficiency is defined as the maximization of quality of care and consumer satisfaction at minimum cost. While there are no objective measures of quality of care before and after implementation of the NHL, a consumer satisfaction survey conducted by the Brookdale Institute nine months after the law came into effect found most respondents reporting no change in the quality of the services they received (Farfel et al, 1997: 2). However, differences were found among the members of different health funds: 23% of General Health Fund members reported that services had improved, compared with 11% of Leumit Fund members, and 8% and 7% of Meuhedet and Maccabi members, respectively.

The highest level of satisfaction was found in the Arab population: 31% stated that services had improved, compared with 17% in the veteran Jewish population and only 2% among new immigrants from the former Soviet Union (ibid: 3).

Analysts of the Israeli health care system, like Professor Dan Michaeli, chair of the Board of Directors of the General Health Fund, point out that the system is still beset with inefficiencies. He cites, for example, the duplication of diagnostic and specialist services in hospital and health fund clinics (Michaeli, Haaretz September 10, 1996).

3. Both the World Health Organization and the OECD consider equity the most important criterion of success in health reform. Here the law has stood the test - with the following qualifications:

A. The Israeli health care system is characterized by inequities between center and periphery, between the big cities and the development towns, and between Jewish localities and Arab ones. The National Health Insurance Law has no provisions for distributing resources among different geographical areas and social groups in a more equitable manner, and no program for closing existing gaps.

B. Prior to the National Health Insurance Law, inpatient nursing care for the elderly was not included in the health funds' benefit packages; the law failed to right this inequity, and senior citizens continue to suffer discrimination.

C. Likewise, dental health was not included either in the health funds' benefit packages prior to the law or after it. On the positive side, the National Health Insurance Law made the system more equitable in the following ways:

A. By extending coverage to all residents of Israel (but not to foreign workers).

B. By giving consumers the right to join the fund of their choice, and by stipulating that health funds could not refuse membership due to age or health problems.

C. By imposing a uniform health tax with an element of progressivity, resulting in low-income persons paying out less than they had paid prior to the law and middle and high income persons paying more.

D. By encouraging funds to compete for new members, an incentive which resulted in funds building new clinics in peripheral areas and improving existing services.

E. By distributing all health taxes on a capitation basis, adjusted for the age composition of the health funds. The General Health Fund, which insures about 60% of the population, including most of the elderly, the chronically ill and the poor, receives a larger share of revenues under the National Health Insurance Law (Rosen and Nevo, 1996).

Technion expert Noam Gavriely estimates that a reduction of 20 cubic micrograms of particulate pollution per cubic meter would result in the saving of 192 lives per million (Haaretz, February 18,1997). Ecologist Zeev Nave contends that Israeli anti-pollution standards, where they exist at all, are too low, and that the combined effect of different pollutants at "safe" levels in urban centers and on major highways are liable to be extremely harmful to health. He warns against the effects of the constantly growing number of cars in Israel.
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Author:Avgar, Amy
Publication:Israel Equality Monitor
Geographic Code:7ISRA
Date:Nov 15, 1998
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