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Prepared by:
Iyad Ibrahim Shaqura
Supervised by:
Dr. Radwan Baroud
School of Public Health 2013-2014
Israeli Health care System
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Introduction
Organizational Structure
Health care Financing and Expenditure
Physical and Human Resources
Provision of care
Health care Reforms
Summary
Highlights:
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Geography and socio-demography
Economic context
Political context
Health status
1. Introduction
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The State of Israel was established in 1948; it is a
democratic state with a parliamentary, multi-party
system. It is a small country at the eastern end of the
Mediterranean Sea.
At the end of 2007, it had an estimated population of
7.2 million, of whom 76% were Jewish and 17%
were Muslim Arabs, with other minority groups
including Christians (3%) and Druze (2%)
(Central Bureau of Statistics, 2008a).
Population density is among the highest in the
Western world.
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Israel is a relatively young society; 28% of the
population are under 15 years old and only 10%
are over 64 years. Its total fertility rate (2.88 per
woman) is higher than most developed
countries.
Immigration has played a critical role in the
demographics of Israel. The period 1990–2000
saw the arrival of almost 1 million new
immigrants, the vast majority of whom arrived
from Former Soviet Union (FSU) countries.
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Throughout the country’s history, armed conflict with
neighboring Arab countries and large-scale immigration have
resulted in heavy burdens on the Israeli economy,
creating the need for loans and extensive foreign
support.
Despite these challenges, Israel is a developed, industrialized
country with a substantial high-tech sector, a growing service
sector and a small, technologically advanced agricultural
sector. The 2005 GDP per capita income (with purchasing
power parity (PPP)) was US$ PPP 26 054, similar to that of
New Zealand, Spain and Italy.
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In 2006, life expectancy at birth was 78.5
years for males and 82.2 for females (CBS,
2007).
Life expectancy for Israeli males is among the
highest for OECD countries and that for
women is in the lower range.
The infant mortality rate in 2006 was 3.9
per 1000 live births (CBS, 2007); it has
declined by 38% over the previous 10 years.
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Overview of the health care system
Historical background
Organizational overview
Decentralization and centralization
Patient empowerment
2. Organizational structure
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Israel has an NHI system that provides for
universal coverage. Every citizen or permanent
resident of Israel is free to choose from among four
competing, nonprofit-making health plans (Clalit
53%, Maccabi 24%, Meuhedet 13% & Leumit
10%).
The health plans must provide their members with
access to a benefits package that is specified within
the NHI Law (Gross 2003).
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The system is financed primarily through
taxation linked to income (through a
combination of earmarked taxes and
general revenue).
The Government distributes the NHI funds
among the health plans according to a
capitation formula which takes into
account the number of members within
each plan and their age mix.
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The Ministry of Health has overall responsibility
for the health of the population and the effective
functioning of the health care system.
In recent years, the Ministry has developed strong
capabilities in the areas of : health technology
assessment (HTA), the prioritization of new
technologies, health plan regulation, quality
monitoring for community-based care, and strategic
planning to set goals for population health,
along with strategies for achieving them.
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In addition to its regulatory, planning and
policy-making roles, the Ministry of Health
also owns and operates about half of the
nation’s acute care hospital beds.
The largest health plan operates another
third of the beds, and the remainder are
operated by means of a mix of non-profit-
making and profit-making organizations.
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The Ministry of Finance has multiple points of significant
influence over Israeli health care, which it uses to try to
contain health care spending, improve the services
and increase the efficiency of the system.
The largest health plan, Clalit, has a market share of 53%. It
provides community-based services, primarily via salaried
physicians working in clinics that it owns and operates.
The next largest plan, Maccabi, has a market share of 24%
and provides care primarily through a network of
independent physicians (IPs).
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Although the Ministry of Health’s Public Health
Division operates through regional and district
offices, which have some leeway in responding to
local conditions, the ultimate source of
authority is the national office.
The regional and district offices serve primarily:
to implement the policies and strategies
developed at the national level, both in the
public health field and in terms of the regulation
of long-term and psychiatric care.
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Overview
Health expenditure
Population coverage and basis for
entitlement
Revenue collection/sources of funds
Pooling of funds
Purchasing and purchaser–provider relations
Payment mechanisms
3. Health care financing and expenditure
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Health care accounts for approximately 8% of GDP.
Hospitals and public clinics each account for
approximately 40% of national health expenditure, and
dental care accounts for a further 10%.
There is universal coverage of the population via an NHI
system, providing access to a broad benefits package
including physician services, hospitalization,
medication and so on.
Long-term care services and psychiatric services are
currently not included within the NHI but some public
funds are available for partial coverage of these services
through other mechanisms.
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The NHI system is financed primarily from public
sources – a mixed system of payroll tax and
general tax revenue.
These public funds are distributed among the health
plans according to a capitation formula that, as
mentioned earlier, primarily reflects: 1- the number
of members in each plan and 2- their age mix.
Cost sharing for: pharmaceuticals, physician visits
and certain diagnostic tests also plays a role in
financing the NHI system.
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Services outside the NHI system are financed via
voluntary health insurance (VHI) and direct out-
of-pocket payments for private sector services.
There are two forms of VHI available in Israel:
supplementary VHI, offered by the health plans;
and commercial VHI, offered by commercial
insurance companies.
In recent years, the share of public financing has
declined to 64% of total health system financing,
while the share of private financing, especially
VHI and co-payments, has increased to 36%.
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Hospital revenue derives primarily from the
sale of services, with approximately 80%
coming from the sale of services to health
plans.
Currently, the reimbursement of public
hospitals in Israel takes the form of fee-for-
service payments, per diem fees and case
payments, and is subject to a revenue cap.
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Salaries constitute the primary component of
compensation for most hospitals and health plan
physicians, and salaried physicians were recently
granted a 25% wage increase by an arbitrator brought
in to resolve an impasse in collective bargaining
between the Israel Medical Association (IMA) and the
country’s major employers.
Capitation payments are an important form of
compensation for primary care physicians in some
of the health plans, and fee-for-service payments
play a significant role in the compensation of many
community-based specialists.
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Physical resources
Human resources
4. Physical and human resources
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In comparison with the OECD, Israel is
parsimonious when it comes to many of
the physical and workforce inputs to health
care.
For example, the Israeli supply of acute
care beds per 1000 population is just over
half of the OECD
average (2.1 and 3.9, respectively).
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While the supply of physicians is relatively abundant
(3.5 per 1000 and 3.1 per 1000 population, in
the OECD and Israel, respectively) at the time of
writing, the number of physicians in Israel is growing
much more slowly than in other countries, and a
physician shortage is being projected.
Until recently, the Israeli physician supply relied
heavily on physicians trained in other countries
– primarily immigrants from the FSU and eastern
Europe.
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However, as the massive immigration of the
early 1990s dramatically decreased the FSU’s
reservoir of potential Jewish immigrants
departing for Israel, that source is now
drying up.
To address the projected shortage, Israel is in
the process of expanding its four existing
medical schools and is considering
opening an additional medical school.
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Israel has far fewer nurses per 1000 population than
the OECD average (5.8 and 9.6, respectively) and
is facing a considerable – and growing – nursing
shortage (in part due to the drop-off in
immigration from the FSU).
Efforts to address this shortage include: 1-
expanding academic frameworks for the training of
nurses, 2-encouraging more young people to enroll in
nursing programmes, and 3- developing programmes
for professionals in other fields to retrain as nurses.
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Israeli nurses are increasingly well
trained.
In 2006, Registered Nurses (RNs)
constituted 74% of the total, up from 58%
in 1995.
RNs now account for almost 90% of new
licenses and approximately half of the RNs
have received advanced specialist training.
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Critical components of the Israeli health system
include: 1- a sophisticated public health effort run
by the Ministry of Health, 2- high-level primary
care services provided by the health plans
throughout the country, and 3- highly sophisticated
hospital care.
Israel also has a strong system of emergency care
delivery that was developed to address its needs both in
times of peace and in times of war or terrorism.
5. Provision of care
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Israelis have access to a secure, safe and
stable supply of pharmaceuticals at
reasonable prices, due in part to
governmental regulation and the roles
of hospitals and health plans as the
principal and bulk purchasers.
Israel also has an extensive and
successful pharmaceutical industry.
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لله الحمدالذي
شفانا وعافانا
ابتلى ا مم]كثيرا به
خلقه، منلنا وفّض]
كثير علىعباده من
تفّضيال
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The system of health and welfare services for the
elderly with disabilities in Israel has developed
enormously since the mid-1980s, particularly with
regard to home care and other community services.
The passage of the Community Long-term Care
Insurance Law in 1986 contributed greatly to
the development of these services.
In recent years, palliative care services are also
becoming increasingly available.
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Rehabilitation services are provided within the
framework of the NHI, but mental health care,
institutional long-term care and dental care are
not.
Other sources of public funding provide partial
coverage for long-term care and support for a system
of Ministry of Health community mental health clinics.
Utilization of complementary and alternative health
care is increasing, both within the publicly funded
health care system and alongside it.
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Primary care is highly accessible in
Israel.
In three of the four health plans, the
cost of primary care visits is fully covered
by NHI, and co-payments are limited to
specialist visits.
The Maccabi health plan charges a small
co-payment for primary care visits.
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The most significant reform in Israeli health
care since 1990 took place in 1995, when the
law on NHI came into effect.
Other important changes include: the
introduction of a law on patients’ rights, the
development of a system for prioritizing new
technologies, and the upgrading of the national
emergency response system.
6. Health care reforms
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Several reform efforts, such as the
initiative to transfer responsibility for
mental health care and well-baby care
from the Government to the health
plans, have not been successful at the
time of writing.
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The effort to change the legal status of the
government hospitals to independent non-profit
making trusts has also been unsuccessful, but the
government hospitals have gradually become
more independent in practice.
It should also be noted that, in addition to the
government-initiated major structural reforms, the
Israeli health system has benefited greatly from a
large number of mid-level evolutionary
changes.
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Many of these were initiated by the health
plans, hospitals, universities and other
nongovernmental actors.
In contrast to the government-initiated
reforms, which focused on: financing issues
and the issues surrounding who should
provide the services, these evolutionary
changes focused on how services would
be delivered.
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The Israeli health system provides a high
standard of care to the population as a whole,
which is particularly impressive in light of the
relatively moderate level of overall resources
allocated to health care.
Factors accounting for this strong performance
include:
1- universal health care coverage.
2- a relatively young population.
7. Summary
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3- good access to high-level primary
care services throughout the country.
4- the development of a national health
care system that is: a) predominantly
publicly financed and b) government
regulated, combined with the c)
existence of competition among
providers.
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Important challenges remain:
1- These include the lack of public insurance through
the NHI system for dental care.
2- long-term care and mental health care.
3- a growing reliance on private financing sources.
4- disparities among population subgroups.
In addition, 1- the unique health needs of the
economically disadvantaged, 2- Ethiopian immigrants
& 3- Israel’s Arab minority population pose a
continuing challenge to the health care system.
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معا وسويّــا
نبني وطننــا