Health care in Israel.

• Author: Swirski, Barbara

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...