Israel s Health System and Health Status of the

Israel’s Health System and Health Status of the Population TH Tulchinsky MD MPH Braun School of Public Health, Hebrew University-Hadassah, Jerusalem Nov 2010

The Past • Province of Ottoman empire to 1917 • Rampant malaria, diarrhoeal, respiratory and other infectious diseases • High infant and child mortality rates • Charitable and missionary hospitals in 19 th C

New Beginnings • 1911 - Hadassah nurses - MCH clinics – Milk Stations: New York Henry St Mission – Tipot Halav (Goutes de Lait) • 1912 - Sick Funds – Central European origin – Political affiliations • 1917 -1947 British mandate – Colonial law – Civil administration

British Mandate 1917 -1947 • • • British colonial law Professional public health officers Public health structure Business licensing, zoning Sanitation by municipalities Public health laboratories Professional licensing law - doctors, nurses etc. Licensing of medical facilities Food control laws and inspection Malaria control Annual public health reports

Basis of Israel’s Health System • • • Tipot Halav established 1911 Sick Funds, established 1912 Modern hospitals from 1917 Voluntary health insurance - political Sick Funds Ministry of Health, established 1948 National Health Insurance, 1995 1948 -58 establishment, absorption, settlement 1958 -78 development 1978 -2007 reaching world class

Tipot Halav (MCH) • Initiated 1912 as Milk Stations • Min Health (75%), Municipal (15%), Sick Funds (10%) • Nursing staff and visiting MDs • Separates prevention from curative services • Located in every town, village, neighborhood • Parallel to primary care clinics of Sick Funds • Immunization, well child care, play with children • Growth and development • Vits A, D, routine iron supplements (4 -12 months) • Pregnancy care • Care of the elderly • Tipot Halav, an Israeli institution to present time

State of Israel • • • Independence 1947 -48 MOH established Hospitals in old British army camps Public health network expanded Large scale war injuries Large scale immigration – survivors of Holocaust and from Arab countries Lack of basic infrastructure and experienced leadership Improvisation Tipot Halav for all Sick Funds for all immigrants

Immigration and Settlement • • • Massive immigration 1948 -51 Population doubled in 3 years, Sick fund coverage for all immigrants Immigrant camps, new towns and settlements Primary health care in all towns, villages, settlements -Tipot Halav and Kupat Holim Epidemics of polio, diphtheria, pertussis, measles High infant mortality, diarrhoeal and resp diseases Regional hospitals - governmental Opening of nursing schools Hebrew University medical school reopened

Stabilization, 1958 -67 • • • Economic growth and stagnation Control of infectious diseases Immunization controls major childhood diseases Sanitation improves Standards of living increase Nutrition with improved food supply Improved research, Medical, nursing other education Medical/pharmaceutical industries developed

Consolidation, 1967 -1994 • Six Day War – West Bank and Gaza under Israeli occupation and authority for civilian services • Exposure to infectious disease entry from West Bank and Gaza - cholera, polio, measles • Improved disease control in WB/Gaza • Growing sophistication of research with strong science base • Medical schools – now 4 + 2 • School of public health and 4 other MPHs • Medical/pharmaceutical industries - world class

National Health Insurance, 1995 • National health insurance law National Insurance Institute • Compulsory employer/employee contribution • Competing Sick Funds - four • Universal coverage • Standard basket of services • Annual updating • Reduced political manipulation • Capitation payment to Sick Funds • No regional administrative structure

Major Trends • • • Primary care emphasis Reducing hospital supply and ALOS Expenditures about 8% of GNP Longevity among highest in world Men>women compared internationally Declining total mortality Declining stroke, CHD and trauma mortality Expanding immunization program Improving nutrition

Employee Employer Israeli Health System Ministry of Health National Insurance Institute Per capita Sick Funds Additional Funding Public Health Mental Hospitals Mental Health Sick Funds Clinics Taxpayer MDs Tipot Halav Hospitals Ambulatory care

Israel’s Health Achievements • • Universal health coverage and access to care Strong MOH control over hospital sector Strong traditions of public health Control of infectious diseases Control of non infectious disease e. g. CHD, stroke Strong medical-pharmaceutical industry Strong basic and clinical sciences Strong epidemiology training and research • Protective nutrition e. g. fruit/veg consumption

Problems Common to Industrial Countries • • • Inequalities - poverty - 20% of population Health cost control Aging of population Absorbing new technology and pharmaceuticals Social and regional inequities Cardiovascular diseases Trauma Nutrition Diabetes, obesity and related conditions Micronutrient deficiency conditions – iron, iodine, FA, vits B, D, calcium, zinc, selenium

Dealing with Changing Health Needs • • Health targets Priorities Cost effectiveness analysis Reform in structure and content Health promotion Population-based health approach Performance indicators in place of norms

Summary • • • Strong tradition of primary care Increasing attention to prevention Universal access Adoption of leading world standards Research, teaching and service Basic sciences, technology, clinical applications • Nutrition and health promotion • Health as a national priority

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