Israel’s Health System and Health Status of the Population

1. 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

2. 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 19th C

3. NewBeginnings • 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

4. 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

5. 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

6. TipotHalav (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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

41. 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

42. 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

43. 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

44. 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

45. THANK YOU