Healthcare in Israel

Ottoman era

During the Ottoman era, health care in Palestine was poor and underdeveloped. Most medical institutions were run by Christian missionaries, who attracted the indigent by offering free care. In the late nineteenth century, as the Yishuv, the pre-state Jewish community, began to grow in the wake of the First Aliyah, the Jews attempted to establish their own medical system. In 1872, Max Sandreczky, a German Christian physician, settled in Jerusalem and opened the first children's hospital in the country, Marienstift, which admitted children of all faiths. The Jewish agricultural settlements, financially backed by Baron Edmond de Rothschild, hired a physician who traveled between the communities and ran a pharmacy in Jaffa which he visited twice a week.

In 1902, the first Jewish hospital, Shaarei Zedek, opened in the Old City of Jerusalem. Additional Jewish hospitals were built in Jerusalem and Jaffa. In 1911, the Judea Worker's Health Fund, which later evolved into Clalit Health Services, was established as the first Zionist health insurance fund in the country.

During World War I, the Ottoman authorities closed the Jewish hospitals in Jerusalem and Jaffa. The Ottoman Army seized the medical equipment and drafted most of the doctors. With the war's end and the British conquest of Palestine, the Yishuv was left without an effective hospital system. In 1918, the Hadassah Women's Zionist Organization of America established the American Zionist Medical Unit (AZMU) to rebuild the Yishuv's medical system. With assistance from the AZMU and foreign contributions, the Jewish hospitals were reopened, and a new one was established in Jaffa. In 1919, hospitals were opened in Safed and Tiberias, and a hospital was opened in Haifa in 1922. The AZMU was turned into the Hadassah Medical Federation, which oversaw the Yishuv's health system.

British mandate

With the start of British rule, measures were taken to improve public health in the area. They began during British military rule, and continued to grow with the establishment of the British Mandate in 1922. In Jerusalem, accumulated refuse heaps were removed, public rubbish bins were installed; the entire population was vaccinated against smallpox, and pools and cisterns were covered with mosquito repellent as part of the campaign to eradicate malaria. In 1929, the Zionist Commission and the British authorities sent the Jewish epidemiologist Gideon Mer to Rosh Pinna to establish a laboratory for malaria research. Mer's laboratory was instrumental in eradicating the disease. The campaign against malaria was headed by Hadassah until 1927, when the organization turned responsibility over to the authorities. The Mandate administration also operated a Health Department that operated its own hospitals, clinics, and laboratories. The Health Department primarily cared for British personnel stationed in Israel and provided health services to the Arab population. Little was invested in Jewish health, as it was assumed that the Yishuv was capable of managing its own healthcare system. With the expansion of the Yishuv through the Third and Fourth Aliyah, the number of new Jewish medical facilities grew. The number of Hadassah hospital beds tripled. New Jewish hospitals and health insurance funds were also established. The other major provider of healthcare aside from Hadassah was the Histadrut labor federation, which had its own sick fund and by 1946 operated two hospitals and hundreds of clinics and health centers. In addition, some private medical centers and health funds were also established.

State of Israel

The Yishuv's health system formed the basis of the Israeli healthcare system with the establishment of the state of Israel in 1948. The Israeli government replaced the British Mandate's health department with a Ministry of Health, and established regional health bureaus and an epidemiological service. Hospital facilities formerly run by the British authorities were taken over by the state, and new hospitals and clinics were established. At the end of 1948, only 53% of Israel's Jewish population was insured, about 80% of them by Clalit, with a few small health funds insuring the remainder. Throughout the following years, Israel's healthcare system was expanded, and within a decade, about 90% were insured.

Until the enactment of the National Health Insurance Law in 1995, the Israeli healthcare system was based on a series of independent Health Maintenance Organizations (HMOs). The largest was Clalit Health Services, which was owned by the Histadrut. It was also the only HMO to accept people without discriminating based on age or medical history. Histadrut membership was a prerequisite for Clalit membership. There was a series of government-owned hospitals, with 29 hospitals operated by the government in 1987. The government also subsidized Clalit and some other HMOs. Clalit owned a series of hospitals, as well as clinics in virtually every city, town, village, and kibbutz. There were other HMOs - Maccabi, which offered greater freedom of choice and shorter wait times to its client base of largely middle-class professionals, and the National Sick Fund, both of which maintained their own clinics and funded the hospitalization of their clients in government hospitals. Finally, there were some private doctors and very few private hospitals, and some highly expensive HMOs covered private healthcare.

In 1973, a law was enacted which forced all employers to participate in the medical insurance of their workers, by means of a direct payment to the HMO in which the workers were members. The duty of participation was eventually changed and diminished as part of the arrangements law (חוק הסדרים במשק המדינה) of 1991.

In 1988 the government appointed a Commission of Inquiry to examine the effectiveness and efficiency of the Israeli health care system. The commission handed in the final report in 1990. The main recommendation of this report was to enact a National Health Insurance law in Israel. The National Health Insurance Law came into effect in 1995. Prior to the law, the only Health Maintenance Organization to accept members without discrimination based on age or medical situation was the Clalit HMO which was then in the ownership of the Histadrut labor federation, and membership in the Histadrut was a requirement for membership with Clalit. After enactment of the 1995 law, membership in any of the four Health Maintenance Organizations was guaranteed for all citizens, and Israelis were given the right to transfer between Organizations once per year.

In the late 2000s, a future shortage of doctors and nurses became a concern, as the rate of doctors graduating from Israel's medical schools annually had dropped to 300, 200 less than needed, and many Soviet immigrant doctors and nurses began to retire. That number was estimated to eventually rise to 520 with the opening of a fifth medical school, but still below the 900 graduates that will be needed in 2022. This caused concerns of a shortage of medical personnel, which would imperil the quality and speed of medical care in the country. As a result, Israel began offering incentives to Jewish doctors to emigrate from abroad and practice medicine in Israel. Initially, only about 100 doctors from the former Soviet Union immigrated under this program every year, but the program is now attracting doctors from North America and Western Europe. An investigative committee looking into the issue also called for incentives to be offered to Israeli medical students who had not been accepted in Israel and had gone to study medicine abroad to return to Israel, and for a program that involves 150 international students studying medicine in Israel to be shut down. In addition, the Israeli Health Ministry announced the launching of a new nursing assistants' profession, and increased nursing education programs in colleges. Israel has also begun a program under which doctors from Eastern Europe work in Israel in fields such as pediatrics and internal medicine.

National Health Insurance Law

In 1995, the National Health Insurance Law came into effect, which made membership in one of the four existing Health Maintenance Organizations compulsory for all Israeli citizens. The law determined a uniform benefits package (סל בריאות) for all citizens - a list of medical services and treatments which each of the Health Maintenance Organizations is required to fund for its members. Additionally, certain services were brought under the direct administration of the State, usually by means of the Health Ministry. In addition, the law set out a system of public funding for health care services by means of a progressive health tax, administered by Bituah Leumi, or the National Insurance Institute, Israel's social security organization, which transfers funding to the Health Maintenance Organizations according to a certain formula based on the number of members in each fund, the age distribution of members, and a number of other indices. The Health Maintenance Organizations also receive direct government funding. Under the health tax, 5% of every salary is automatically deducted.

The 1995 law also imposed a system of financial and medical oversight of HMOs by the State. In addition to the uniform benefits package provided to all citizens, which provides coverage for basic and essential health care, every HMO fund provides their members with the option to acquire "supplementary insurance" (ביטוח משלים), which includes services and treatments that are not covered by the publicly funded system.

The four HMOs: Clalit (the largest with about 54% of the population belonging to it), Maccabi, Kupat Holim Meuhedet and Leumit.

Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on 1 January 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds. To be eligible, a citizen must pay a health insurance tax. Coverage includes medical diagnosis and treatment, preventive medicine, hospitalization (general, maternity, psychiatric and chronic), surgery and transplants, basic dental care for children up to age 14, first aid and transportation to a hospital or clinic, medical services at the workplace, treatment for drug abuse and alcoholism, medical equipment and appliances, obstetrics and fertility treatment, medication, treatment of chronic diseases and paramedical services such as physiotherapy and occupational therapy.

Participation in a medical insurance plan with one of the four national HMOs is compulsory for all citizens, who can select and participate in any one of them regardless of factors such as age, gender, or pre-existing conditions. All Israeli citizens are entitled to the same Uniform Benefits Package, regardless of which health fund they are a member of, and treatment under this package is government-funded for all citizens regardless of their financial means. The Uniform Benefits Package covers all costs in the areas family medicine, emergency treatment, elective surgery, transplants, and medications for serious illnesses that are part of the official "basket of medications" (which is large and updated regularly). However, availability of services differs by location, as each of these organizations operate their own medical facilities, including private hospitals. In addition, they also operate their own supplementary health insurance programs, under which non-essential health services are funded for an extra fee, though these fees tend to be low. The HMOs are prohibited by law from denying any citizen membership a supplementary health insurance plan, and may not discriminate due to pre-existing conditions. However, premiums are based on age, divided into specified age groups. In addition, non-essential services can also be funded by a citizen sharing the cost with their employer.

Under special circumstances, the HMOs can fund medical treatment abroad. There is a cap of $250,000 without copay to fund medical treatment abroad, though that limit can be waived by the Director-General of the Ministry of Health.

All citizens doing their compulsory military service in the Israel Defense Forces have all their health care costs covered by the military, including up to two free abortions for female soldiers.

Government spending on healthcare is about 60% of the total, considerably below the average for OECD countries of 72%.

Rights under the National Health Insurance Law

Private healthcare

There are private health insurance plans which citizens may participate in addition to the compulsory participation one of four national health insurance institutes. All major Israeli insurance companies offer health insurance plans. These plans provide coverage for additional options for treatments. For example, in the area of elective surgery, a participant in a private insurance plan may choose the surgeon, anesthetist, and hospital anywhere in Israel or around the world. In the area of transplants, unlimited funding is available to ensure a donor is found and the procedure is done without the need for government approval. In the area of medications for serious illnesses, private insurance companies give access to a wider range of than the official "basket of medications", as the Israeli government is not financially capable of covering all medications. In comparison with health insurance in other countries, private health insurance in Israel is considered comparatively cheap, but premiums are based on age, gender, and previous medical history.

There are also a number of private hospitals and clinics throughout the country. Although the healthcare in public and private hospitals is equivalent in quality, private hospitals offer superior patient care and amenities to public hospitals, such as private rooms designed as hotel rooms, Internet and television access, restaurant-quality food, and extra beds for visitors to stay overnight.

Safety and quality

Israel has one of the most technologically advanced and highest-quality healthcare systems in the world. Hospitals in Israel are equipped with modern facilities and high-quality medical technology. Medical personnel are very well-trained.

Healthcare in Israel is also delivered very efficiently - in an August 2014 survey, it was ranked as having the seventh-most efficient healthcare system in the world.

Seven Israeli hospitals have received accreditation from the Joint Commission, an organization that sets safety standards for medical care: Soroka Medical Center in Beersheba, HaEmek Medical Center in Afula, Meir Hospital in Kfar Saba, Rabin Medical Center in Petah Tikva, Kaplan Medical Center in Rehovot, Carmel Medical Center in Haifa and Assuta Medical Center in Tel Aviv.

Health care providers

Providers in the Israeli healthcare system consist of a mixture of private, semi-private and public entities. Generally, family and primary medicine facilities are run directly by Clalit for its members while the other HMOs operate their own family practice clinics in the larger cities and contract with privately operated family practice clinics in smaller communities. As with primary practice, Clalit tends to provide specialty and outpatient care in their own clinics while the other HMOs generally contract with outside, private care physicians and facilities for this sort of service. In addition to these, the ministry of health in conjunction with various local authorities also runs a network of public well care and prenatal and infant care clinics throughout the country.

Physicians

In 2013 there were 3.1 professionally active physicians per 1000 population in Israel, a ratio higher than for countries like the U.S. and Japan. In the end of 2014, there where 34,231 registered physicians in Israel, 25,637 under the age of 65, 30,683 under the age of 75. There are over 10,000 more physicians in Israel who are licensed but not practicing (working in other fields, retired). About forty percent of Israeli physicians are women. Between 2000 and 2009 the OECD reports no growth in the physician per capita ratio in Israel compared to a global average of 1.7% growth in developed countries. There are also severe physician shortages in specific specialties, such as anesthesia, general surgery, geriatrics, and primary care

Israel has five university medical schools, all but one of which follow the European 6-year training model. However, the medical school at Bar-Ilan University follows a four-year program similar to the American system, and there is also a four-year program at Tel Aviv University similar to the American system for students who hold a bachelor's degree in certain biological sciences. The entrance requirements for the various schools of medicine are strict: all students must have a high school matriculation certificate with a grade average above 100 and a psychometric grade over 740.

A large percentage of Israeli doctors were not trained in Israel. In 2008, only 35% of doctors in Israel were born there, and almost 50% were immigrants from South America specially from Argentina and Eastern Europe, particularly the former Soviet Union. In addition, many Israelis study medicine abroad, with Israeli medical students particularly popular with European universities. To practice in Israel, doctors trained abroad must pass a licensing examination to ensure that their medical training is up to Israeli standards. Immigrant doctors who graduated from an American, British, Canadian, French, Australian, New Zealand, or South African medical school are exempt, provided they have 14 years of experience, including residency, and undergo a six-month internship-like "adjustment period" in Israel.

Nurses

As of 2011, there were 37,300 actively practicing nurses in Israel or 4.81 nurses per 1000 population compared to OECD country average of 8.7 nurses per 1000 population, ranking Israel one of the lowest nursing ratio countries in the developed world, after Greece, Mexico, and Turkey. This represents a 14% decrease in Israeli nursing per capita from 2001. Nursing education is similar to that of other developed countries. There are many Registered Nurse programs, Bachelor of nursing academic programs, and several graduate schools for advanced degrees. A Bachelor's degree is a prerequisite for advanced certifications and clinical courses. Licensed practical nurse programs ended, yet were recently re-approved as a solution to the nursing shortage in Israel. Although nurse practitioners were legalized in Israel in November 2013, only Israeli-trained nurse practitioners are authorized to work. Although the law provides for recognition of foreign-trained nurse practitioners, no process is in place for doing so. Only geriatric and palliative nurse practitioners have been allowed to work thus far, although plans for other NP specialties are in place. All NP courses to date have been provided by the Ministry of Health, and are post-Masters certificate courses several months in length. Compared to Western country standards and the International Council of Nursing, Israeli nurse practitioners have relatively limited scopes of practice and independence.

Physician Assistants

One of the well-established solutions to the growing shortage of medical personnel that is experienced also in Israel is the development of mid-level practitioners, e.g., nurse practitioners and physician assistants. The development of Physician Assistants in Israel was in a constant debate for years until a committee appointed by the Ministry of Health Director General recommended on 2013 on the development of an Israeli version of Physician Assistants in five areas that are currently in great need: Internal Medicine, Surgery, Anesthesiology, Emergency Medicine and Pathology. Because of legislative reasons, and in order to implement fast, the Ministry of Health decided not to create a new general profession like in the US but to expand the capabilities and authorities of existing medical professions thus creating new 'roles' for theses professions as Physician Assistants. The first course of Emergency Medicine Physician Assistants started on May 15, 2016, comprising about 35 participants, most of them academic paramedic with substantial experience and very few MDs from international universities (outside Israel) that failed to pass the Israeli government examination so are not licensed to practice medicine in Israel. In the near future the Israeli Ministry of Health intends to open similar courses in the areas of Anesthesiology and Pathology.

Emergency services

Emergency medical services in Israel are provided by the Magen David Adom (MDA) organization, which staffs approximately 1,200 emergency medical technicians, paramedics, and emergency physicians, and 10,000 volunteers. The organizations operates 95 stations and a fleet of over 700 ambulances. The majority of the fleet consists of Basic Life Support ambulances. There are also smaller numbers of Advanced Life Support ambulances and Mobile Intensive Care Units. For air ambulance services, MDA relies primarily on Unit 669 of the Israeli Air Force. There are also four MBB Bo 105 utility helicopters staffed with MDA paramedics owned by Lahak Aviation operating as air ambulances throughout the country. Non-emergency and repatriation air ambulance services are normally provided by private charter carriers.

Magen David Adom is supplemented in some areas by Hatzalah, an emergency ambulance services network serving Jewish communities worldwide, and ZAKA, a series of community emergency response teams staffed by Orthodox Jews, who in addition to providing medical services and evacuation, also aid in the identification of terrorism victims and gather spilled blood and body parts for burial. The Palestine Red Crescent Society also provides services to Arab neighborhoods in Jerusalem. It gained access to Jerusalem after signing a 2005 Memorandum of Understanding with Magen David Adom.

The ambulance system, for the most part, conforms to the Franco-German model of EMS care, and the presence of physicians at high-acuity emergencies is not uncommon. In addition, emergency ambulance services is bolstered by a variety of private carriers tasked with interfacility transfers only.

Medical tourism

Israel is emerging as a popular destination for medical tourists. In 2006, 15,000 foreigners travelled to the country for medical procedures, bringing in $40 million of revenue. As of 2010, up to 30,000 foreigners come to Israel every year for treatment, mostly from Russia.

Some medical tourists come to Israel because the procedures they seek are not available in their home countries. Others, particularly from the US, choose Israel because they can receive quality treatment, such as surgery and in-vitro fertilization at much lower cost. Many medical tourists come to Israel for treatment at the Dead Sea, a world-famous therapeutic resort. The Israel Ministry of Tourism and professional medical services providers are working to promote awareness of this niche in Israel.

According to a report in 2013, the number of patients from Eastern Europe, Cyprus and the United States seeking treatment at Israel's public and private hospitals is growing. Income from medical tourism was assessed at about $140 million in 2012.

Palestinian medical tourism

A significant number of residents of the Palestinian territories seek medical treatment in Israel, often for sophisticated tests or treatments not available at Palestinian hospitals. Their treatment is paid for under a financial arrangement with the Palestinian Authority, or in some cases, at their own expense. Medical treatment for Gaza Strip residents is paid for by the Palestinian Authority or organizations such as the Peres Center for Peace.

Palestinians who apply for medical treatment in Israel must obtain a humanitarian entry permit from Israel, of which thousands are issued annually. In January 2009, during the Gaza War, the Palestinian Authority temporarily canceled financial coverage for all medical care for Palestinians in Israeli hospitals, including coverage for the chronically ill and those in need of complex care not available in the Palestinian territories. Palestinian officials stated that they wished to send the patients to neighboring Arab countries instead, accusing Israeli officials of using Palestinian patients, some injured in Israeli airstrikes, in PR campaigns to improve Israel's tarnished image during the Gaza War. In 2012, The Palestinian Authority's Ministry of Health reported spending approximately $42 million in 2011 to finance medical coverage of Palestinians in Israeli hospitals and the Arab World. Arab citizens of Israel belong to the same health care system as that of all other citizens of the country.

The quality of medical care in Israel is significantly better than anywhere in the West Bank and Gaza. Irwin Mansdorf, a member of Task Force on Medical and Public Health Issues, Scholars for Peace in the Middle East wrote about routine care that Palestinians continue to receive in Israeli hospitals and from Israeli physicians.

Saving Children, established by the Peres Peace Center, enables hundreds of Palestinian children to receive free medical care, in particular cardiac surgery, from Israeli surgeons.

"Save a Child's Heart" is a program in which any child with heart problems can receive free medical attention and surgery from select doctors and hospitals within Israel. From 1996 to 2007, 4,591 children had been examined world wide, of the 1848 children treated 828 (45%) were Palestinian.

Humanitarian aid

As of August 2013, Israeli hospitals have provided treatment to scores of Syrian citizens injured in the Syrian civil war. Since late March, some 100 Syrians have been treated at two hospitals in Galilee. The patients arrive by military ambulance and the hospital calls the army to transport them back when they are released. The Israeli military also operates a field hospital and mobile medical teams along the Syrian frontier.

Uninsured Populations

One of the great achievements of the National Health Insurance Law in 1995 was that practically all the Israeli population was insured and thus entitled to the services included in the 'health basket'. Nevertheless, as of 2016, there are roughly 250,000 non-tourists that stay in Israel for long periods that are not entitled to the benefits of the National Health Insurance Law. About 100,000 of them are foreign workers who entered Israel legally and have a mandatory private health insurance that is paid by their employer. Other 100,000 are people entered Israel legally (as tourists or as foreign workers) but their visa expired so considered to be illegal residents. The remaining 50,000 are work immigrants, asylum seekers and refugees, mainly from Eritrea and Sudan, who entered Israel illegally through the Egyptian border. For those illegal residents that are working full time, there is a mandatory health insurance by the employer. This insurance is limited as it is dependent on the continued work and payments subtracted from salary, thus becoming ineffective and practically expires as the insured is becoming unemployed from health reasons. For those 'illegal residents' that don't have effective health insurance and are protected from deportation to their countries of origin (because of the ongoing conflicts or forced recruitment), few services where developed either by the Israel Ministry of Health or by local NGOs and international aid organizations. The most important services include free access to Emergency Rooms and hospitalization services when needed for urgent care, primary care clinics, and psychiatric clinic.

Hospitals and medical centers

In the end of 2014, there were 85 hospitals in Israel: 44 general hospitals, 12 mental health hospitals, 29 specialized hospitals (geriatric and rehabilitation centers),as well as 278 residential long-term facilities. Only 11 of the general hospitals are government-owned and operated by the Ministry of Health, 9 owned by Clalit Health Services (Israel largest HMO), and the rest are private, such as Herzliya Medical Center. Most of the private hospitals in Israel belong to nonprofit or charitable organizations.

Public satisfaction with hospital care is considerably less than with other aspects of the healthcare system. There are 3.1 beds per 1000 population, compared with an OECD average of 4.8. Occupancy runs at 96%. The average length of stay is 4.3 days, compared with the OECD average of 6.5. There are long waiting lists which has led more than 75% of the population to take out secondary health insurance.

Medical research

Israel is a world leader in medical and paramedical research, and bioengineering capabilities. Biotechnology, medical, and clinical research account for over half of Israel's scientific publications, and the industrial sector uses this extensive knowledge to develop new pharmaceuticals, medical equipment, and treatment therapies. Among other areas of medicine, Israel is a leader in stem cell research, with the largest number of articles, patents and research studies per capita, as well as research into regenerative medicine and medical marijuana.