Health care in Israel.

Position:Statistical Data Included

Israel's national health statistics compare favorably with those of developed countries. In 1989-90, expenditures on health care were 7.8% of the GNP, a level recommended by the World Health Organization. The 1989 physician/population ratio -- 1:340 -- is one of the highest in the world, and teaching hospitals, research institutions and medical technology are internationally renowned.

About 90% of newborns receive services from a country-wide network of public mother and child clinics, including inoculation against polio, diphtheria, tetanus, whooping cough, and, since 1991, hepatitis. Immunizations against rubella, mumps and measles are administered at age 15 months, and boosters given in the schools. (1) The national infant mortality rate is relatively low: 9.9 for every 1,000 live births, and the average life expectancy at birth high: 78.1 for women and 74.6 for men. (2)

The Ministry of Health operates a nationwide network of community-based mother and child clinics, for which there is an annual fee, and the sick funds run community-based curative clinics and regional specialist centers for members. However, many services considered primary in some developed countries, like dental care, preventive care for adults, long-term nursing care, and contraceptives are not covered by the sick funds.

While Israel lacks a national health law, four government-subsidized health insurance schemes or sick funds, the largest of which belongs to the Histadrut, provide coverage for almost 95% of the population.

Israel has an extensive preventive system for pregnant women and infants, but no equivalent for others; public awareness of preventive health care is low, and existing facilities are often understaffed, poorly equipped, and underused.

Disparities in Health and Health Care Services

Health Insurance

The high rate of insurance coverage in Israel is to a large degree due to the fact that union-negotiated contracts include insurance for the majority of full-time salaried workers and their dependents; (5) to government provision of medical insurance for pregnant women and for persons receiving welfare allowances, including the elderly and the disabled; and to temporary government agreements with sick funds which guarantee insurance to new immigrants. For the remainder of the population, health insurance is voluntary.

The uninsured, or partially insured, who constitute an estimated 25% of the Arab population (219,390 persons) and 2% of the Jewish population (78,980 persons), are likely to be unemployed or underemployed. This group also includes young adults no longer covered by their parents' insurance and not insured by virtue of either military service or student status. (6) Persons with no regular employment and their dependents are not accepted by the Histadrut Sick Fund, the main provider of medical services in Arab communities and Jewish development towns, where unemployment is the highest. Neither are drug addicts and their families. (7)

Underlying Determinants of Health Status

Probably the most important determinants of health are socio-economic. The income of individuals and families and their social class, for which the figures on blue and white collar jobs are used as a proxy measure, have been shown to have a major influence on levels of health in every country in which they have been studied. (8) 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. (9)

In Israel, the same ranking order appears whether one looks at education, income, or class: Ashkenazi Jews are on top, followed by Mizrahi Jews and Arabs. The 1983 Census found that for second-generation Ashkenazi women the median education was 12.9 years, for Mizrahi women 11.8 years, and for Arab women, 7.9. Nearly 50% of second-generation Ashkenazim, but only 17.6% of second-generation Mizrahim and 9.1% of Arabs presently have 13 or more years of schooling. The average income for urban households in which the head of the household is a wage-earner is 4,475 MS for second-generation Ashkenazim, 3,046 MS for second-generation Mizrahuxn, and 2,546 MS for Arabs; the official unemployment rate is 5.9% for second-generation Ashkenazim, but 10.6% for Arabs, and 15.8% for second-generation Mizrahim. And about 1/4 of Ashkenazim, compared with nearly 1/2 of Mizrahim and over 70% of Arabs are bluecollar workers. (10) As the following pages will show, the figures on health match the socio-economic level of the three gr oups.

Health Status Indicators

Infant Mortality Rate

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 1977-80, the average infant mortality rate for Jews was 12.7, and for Arabs, 24.6 deaths per 1,000 live births.(11) A study conducted by the Health Services Research Unit at Sheba Medical Center found wide variations among both Arab and Jewish communities, and, on the basis of deviations from a regional norm, designated 36 locations for intervention on the part of The National Program for Reduction of Infant Mortality. (The use of two separate standards for determining excessive mortality, one based on the mortality rate in Jewish communities and the other on that in Arab ones meant that numerous Arab communities with high infant mortality were not slated for intervention.)

The pilot program was instituted in Or Yehuda, a Mizrahi town whose infant mortality rate (19.1) was nearly twice that of the surrounding area (103), and whose socio-economic level was the lowest in the district. Research revealed that the group at risk was characterized by a combination of 4 or more risk factors usually associated with high mortality, including low maternal education (0-8 years), teenage pregnancy, high birth order (4+), and birth weight under 2,500 grams. By 1986-1988, infant mortality in Or Yehuda, as well as in a number of other communities targeted for intervention, like Dimona and Ashkelon, had been considerably reduced, demonstrating the possible benefits of improved health care services for high-fisk groups. (12)

The graph of infant mortality rates for urban communities on page 2 shows clear disparities between Arabs and Jews. It also demonstrates the fact that infant mortality in a number of Jewish development towns is much higher -- 50% than the national average. Although there are exceptions, most affluent communities are at the bottom, most development towns cluster around the middle and all Arab communities are near the top of the infant mortality graph.

Infant mortality is relatively low in Jewish rural communities: in 1987, the rate was 4.8 m kibbutzim and 7.5 in moshavim. (13)

Standardized Mortality Ratios

Geographical variations have 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 populations). A comparison between mortality ratios for Jews during 1968-78 and those during 1983-86 found significant increases in the Ramla, Tel Aviv, Asbkelon and Beer Sheba districts, and significant decreases in the Jerusalem and Rehovot districts.

Among the suggested, but untested hypotheses concerning the factors contributing to higher rates of mortality are the presence of cement and building construction industries (connected with stomach and lung cancer and leukemia) in the Ramla district and the low standards of care and surgery (associated with septicemia) in the Beer Sheba district. (14)

Health-Promoting Behaviors

Research indicates that socio-economic status is associated with factors like diet, smoking and alcohol consumption.(15) While about 113 of the Israeli population smokes, (16) smoking is more prevalent among Arabs than among Jews, and more common among Mizrahim than among Ashkenazim (see table at top right).

A 1985 survey of smokers aged 60 and over found that the percentage of heavy smokers (20 cigarettes or more per day) was highest among Arabs and lowest among Ashkenazim (see table at bottom right).

Moreover, more Ashkenazim (28.2%) than Mizrahim (20.1%) had quit smoking. The lowest percentage of persons who had quit smoking was found among Arabs (11.4%), (17) pointing, perhaps, to differential stress levels or disparities in access to health education resources.

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 and Jerusalem, and the suburban ring of Tel Aviv. Half of the physicians are located in the Tel Aviv region and in Jerusalem, and 90% of the dentists practice in the three big cities and the suburbs of Tel Aviv (the central district). (19) Residents of the central district and of the big cities have more health care workers of every kind than persons living in the North or South, and there are more hospital beds per 1,000 population in the suburban ring of Tel Aviv than in any other area. (20) With regard to hospital beds (see table below), the inner city of Tel Aviv is slightly better off than the northern and southern districts, but worse off than Haifa and Jerusalem; however, in some cases, residents of Tel Aviv may also utilize services located in the suburban ring.

The central district and Jerusalem have the most psychiatric and nursing care beds; the South, North and central city of Tel Aviv, the least. Again...

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