Israel's high standards of health services, top-quality medical resources and research, modern hospital facilities, and an impressive ratio of physicians and specialists to population are reflected in the country’s low infant mortality rate (3.6 per 1,000 live births in 2010) and long life expectancy (81.5 years, average in 2010). Health care for all, from infancy to old age, is ensured by law and the national expenditure on health compares favorably with that of other developed countries.
In November 2015 Bloomberg ranked Israel the sixth healthiest country in the world, taking into account data from the United Nations, the World Bank and the World Health Organization. Israel was the only Middle-Eastern country to appear in the top 10, and the United States, Australia, Germany, Switzerland, Japan, Sweden, and U.K., all ranked lower than Israel on the list.
In the 19th century, diseases such as dysentery, malaria, typhus and trachoma were rampant in the Land of Israel, then a backward and neglected part of the Ottoman Empire. To provide health services for the Jewish population of the Old City of Jerusalem, a number of clinics, set up by European Jewish communities, extended free medical services for those unable to pay and were famous for their dedicated care under difficult circumstances.
These clinics expanded to become hospitals: Bikur Holim (est. 1843), Misgav Ladach (est. 1888) and Shaare Zedek (est. 1902), which still function today, offering uptodate services with modern medical technology.
The Hadassah Medical Center in Jerusalem, with schools of medicine, nursing and pharmacology and two modern hospitals, traces its beginning to two nurses who were sent to Jerusalem in 1913 by the Hadassah Women's Zionist Organization of America.
Israel's health problems are similar to those prevailing in the Western world. Since heart diseases and cancer account for about two thirds of deaths, the study of these illnesses has become a national priority. Also of great concern are medical care for the aging, problems arising from environmental changes, and conditions emanating from current lifestyles, as well as traffic and occupational accidents.
Health education programs are widely used to inform the public of the need to stop habits such as smoking and overeating, as well as lack of physical exercise, which have proved detrimental to health. Campaigns are also run frequently to increase workers' and drivers' awareness of potential dangers.
Environmental and health hazards have been generated by rapid population growth and steady expansion of agricultural and industrial activities. More than 70 percent of Israel's industry is concentrated along the narrow coastal zone where meteorological conditions are unfavorable for the dispersal of pollutants. To combat pollution of the Mediterranean and Red Sea coastlines, Israel has adopted a multifaceted program of legislation, enforcement, beach and shore clean-up and international activities, primarily within the framework of the Mediterranean Action Plan.
Under conditions of water scarcity and intensive development, the degradation of water quality constitutes a critical problem. The main causes of groundwater pollution are chemical fertilizers, pesticides, seawater intrusion and domestic and industrial wastewater. High priority has been given to wastewater treatment to safeguard environmental and public health and to develop an additional water source for agricultural irrigation. A rehabilitation program for polluted streams has been initiated with the aim of transforming them into vital freshwater resources with ecological and recreational value. Water quality in streams is routinely monitored, while the potability of drinking water is strictly supervised.
Factors affecting air quality include energy production, transportation and industry. In response to alarming levels of pollution in highly industrialized urban areas, primarily along the coastal plain, a comprehensive new program for the management of air resources has been launched, which includes instituting emission standards and expanding the national air monitoring system. The use of low-sulfur coal and oil for energy production has helped reduce concentrations of sulfur oxides considerably, but pollutant emissions linked to increased vehicular traffic have risen significantly. New measures, including lead-free gasoline and catalytic converters, should help combat pollution from this source.
Israel faces an increasing solid waste problem resulting from rapid growth in population, industry and consumption. Hundreds of poorly-operated dumps generate health and environmental hazards. To overcome this problem, Israel is implementing a plan to shut down illegal dumps and replace them with a few environmentally-safe landfills, as well as facilitating a shift to low- and non-waste technology, as stipulated in its recently-enacted recycling law.
Safe management of hazardous substances is spelled out in legislation enacted to provide "cradle to grave" administration, including licensing, regulation and supervision over various aspects of their production, use and handling. Enforcement of the legislation and implementation of Israel's new national contingency plan for dealing with hazardous substances accidents should minimize potential dangers to health and the environment.
In addition to regulatory measures and education as essential components of its environmental policy, Israel now also offers financial grants to companies which invest in monitoring and pollution treatment facilities and in environment-friendly technologies and materials.
On February 23, 2016, Israel became one of the only countries in the world to adopt a groundbreaking pre-exposure prophylaxis treatment program to prevent HIV transmission. The program provides medications that significantly reduce the risk of contracting HIV to healthy but high-risk individuals, and provides HIV carriers with pills to help prevent the spread of the disease. HIV prevention drugs will be available at various HIV centers and hospitals throughout Israel. The program was approved by the Israel Health Ministry after debate in the Knesset Labor, Social Welfare and Health Committee.
The foundation of the health system, including a network of medical services for prevention, diagnosis, and treatment, was laid during the prestate period by the Jewish community and the British Mandate authorities, which administered the country from 1918 to 1948.
Thus, when the State of Israel was established, a well-developed medical infrastructure was already functioning, immunization was standard procedure, and frameworks for improving environmental conditions were operative. However, in the early years of statehood, the health services had to readdress some of the problems previously overcome in order to cope with the health needs of hundreds of thousands of refugees from postwar Europe and from Arab countries. This challenge was met through an intensive national effort involving provision of special services as well as a far-reaching plan of health education and preventive medicine.
The country's population is served by an extensive medical network comprising hospitals, outpatient clinics, and centers for preventive medicine and rehabilitation. Hospital care includes highly advanced procedures and techniques, from in vitro fertilization, MRI scans, and complicated brain surgery to bone marrow and organ transplants.
Mother-and-child care centers, for women during pregnancy and children from birth to early childhood, offer prenatal examinations, early detection of mental and physical handicaps, immunizations, regular pediatric check-ups, and health education.
Administration and Structure
Responsibility for all health services lies with the Ministry of Health, which prepares legislation and oversees its implementation, controls medical standards nationwide, maintains food and drug quality standards, licenses medical personnel, promotes medical research, evaluates health services, and supervises the planning and construction of hospitals. The ministry also acts as a public health agency for environmental and preventive medicine.
Israel's approximately 32,000 physicians, 9,000 dentists, and 6,000 pharmacists pursue their professions as members of hospital staffs and neighborhood clinics as well as in private practice. About 72 percent of the country's 54,000 nurses are registered, while the rest are practical nurses.
Training for medical professions is offered at four medical schools, two schools of dentistry, two of pharmacology, and 15 nursing schools, seven of which grant academic degrees. Courses for physiotherapists, occupational therapists, and nutritionists, as well as for X-ray and laboratory technicians, are available at a number of institutions.
Magen David Adom, Israel's emergency medical service, provides a network of first aid stations, a nationwide blood donor program, blood banks, first aid courses, and a public ambulance service, which includes mobile intensive care units. The organization functions with the help of some 10,000 volunteers, many of them high school students, who serve at 109 stations throughout the country.
The National Insurance Law provides for a standardized basket of medical services, including hospitalization, for all residents of Israel. Medical services are supplied by the country's four comprehensive health insurance schemes, which must accept all applicants regardless of age or state of health.
The main sources of funding are a monthly health insurance tax of up to 4.8 percent of income, collected by the National Insurance Institute, and employer participation in the cost of insurance for their employees. The insurance schemes are reimbursed according to a weighted average number of insured persons, calculated by age, distance of home from a health facility, and other criteria determined by the Ministry of Health.
Whereas medicine treats the health needs of an individual, public health (a discipline also known as public medicine or social medicine) deals with the health requirements of society as a whole. In fact, public health was a more popular concept in the 19th century when physicians realized that matters such as sewage amenities, cleanliness and a balanced diet would improve the health of the population . But as sanitary and dietary conditions improved and with such medical. discoveries as penicillin in the 20th century, much less emphaisis was placed on public health.
Israel has been a pioneer in the contemporary concept and practice of Public Health and as a result has one of the world’s healthiest populations. The country's success in pursuing effective Public Health policies is reflected in the fact that a nation of immigrants, who have arrived during the past 54 years principally from North Africa, the former Soviet Union and Central Europe, has one of the highest average life expectancies in the world.
This has been accomplished despite the fact that Israel has absorbed Holocaust survivors and a large proportion of immigrants suffering from tuberculosis, malnutrition, heart disease and every type of cancer. At present, 25% of all cancer patients in Israel are newcomers from the former Soviet Union including tens of thousands from parts of the Ukraine and Belorussia who were exposed to radiation from the Chernobyl nuclear plant melt-down in 1987.
Public health returned to the global agenda in 1975 at the WHO meeting in Alma Ata, Kazakhstan, in the former Soviet Union. Leading health officials from every country in the world signed a covenant proclaiming that the health of the people and the provision of medical services must be the responsibility of national governments. Only the United States refused to sign the covenant, insisting that individuals rather than their governments must be responsible for the provision of health services for themselves and their families.
Of course most nations simply do not have the necessary resources to offer their citizens adequate health services. Even in developed and relatively affluent countries like Israel, the essential challenge facing public health policy is effective distribution of limited resources.
Israel emphasizes public health
The Zionist Movement in pre-state Israel, which combined the traditional Jewish concern for all people with an emphasis on societal needs, regarded public health as a top social, political and economic priority. By the time Israel declared its independence in 1948, a national health infrastructure was already in place. Mother-and-child care centers (Tipot Halav) administered the necessary vaccinations to new-born babies and advised parents on proper care of infants. Health insurance funds (Kupot Holim) offered day-to-day consultations with doctors and specialists, and insured members for hospitalization.
The National Health Insurance Law
Despite Israel's commitment to providing health services for all of its citizens, by the early 90's some six percent of Israelis were not insured through one of the four existing health funds - Kupat Holim Clalit, Maccabi, Me'uhedet and Le'umit. In 1994, the National Health Insurance Law was enacted and it was implemented the following year, rectifying this situation. Since then, all citizens have their health insurance paid by a tax on income (up to 4.8%) while their employer's portion is collected by the National Insurance Institute, and passed on to the health insurance fund of the individual's choice.
Public health as an academic discipline
The discipline of Public Health is responsible for promoting the health of the population - by planned prevention of disease, by early diagnosis of ill health and by provision of accessible health care for those in need. This population orientation brings with it the requirement to define health priorities and allocation of the appropriate, though usually scarce, resources.
The academic study of the discipline of public health was spearheaded by the Hebrew University-Hadassah Braun School of Public and Community Medicine and its predecessor departments. The major framework is the Master of Public Health (MPH) Course, which provides academic training for public health practitioners and researchers. The School has developed two MPH programs: one for Israeli students, whose graduates form the cadre of public health professionals in the country; the second is a unique international MPH program, which, since 1971, has graduated over 600 students from 80 countries. They have become the mainstay of health care systems in many parts of the developing world.
A central feature of the training program is planning health care for the community, based on the assessed needs for primary health care services. Known as Community Oriented Primary Care (COPC), its concepts and practice have been taken to the corners of the world by the School's faculty and graduates. It embodies a planned link between the clinical responsibility for the individual patient with the public health responsibility for the whole population.
Benefiting the developing world
In the late 1950's, Israel, a small and still developing country, made it a policy to share its developmental experience, including the field of public health, with other developing nations in Asia, Africa and Latin America. In many areas, such as mother and child health, the reduction of infant mortality, the prevention and reduction of communicable diseases and the eradication of endemic diseases like malaria, Israel shared its achievements and solutions with newly developing countries.
Israel's main conduit for sharing its public health successes and experiences with health care workers around the world is MASHAV - the Center for International Cooperation of the Ministry of Foreign Affairs. Professionals from every continent, especially the developing world, receive training from MASHAV to enable them to deal more effectively with public health problems in their own countries.Israel and the PA have been working together in Public Health since the signing of the Declaration of Principles in 1993. Jordan, too, has bilateral ties with Israel in this field, and a proposal for a Multilateral Regional Program on Medicine and Public Health, which has been on hold because of the security situation, is expected to be renewed.
Good public health decision-making is imperative if nations are to use the full potential of their medical resources. The International Masters of Public Health Program (MPH) of the Hebrew University-Hadassah Braun School of Public and Community Medicine, under the auspices of MASHAV, is now being held for the 27th time, and has played a key role in helping medical professionals in the developing world to tackle the enormous problems facing their countries.
Moreover, students who have graduated from MPH have made significant contributions in many countries and have had an enormous impact worldwide. Many graduates have become senior administrators and in several cases even Ministers of Health in their countries and have played a pivotal role in formulating public health policies.
At the same time, MASHAV runs shorter public health courses for an average of 250 professionals each year and teaches on-the-spot public health courses in 12 countries.
The Aging of the Population
This phenomenon is placing much strain on health services worldwide. In Israel people aged 65 and over represent 10%, while those aged 75 and over represent 4.3% of the country's population (compared to 8.8% and 3.5% respectively a decade ago). Still, Israel is a young country by western standards. In 2010, 28% of Israel's population was aged between 0-14, compared to 17% in other Western countries, and about 10% were aged above 65%, compared to 15% in Western countries.
Israel's population is considered young compared to other Western countries -
Israeli researchers have noted that the dependency ratio in the developing world is increasing due to decreased infant mortality (but not falling birth rates) and increased longevity. At the same time, to some extent communities in developing nations, where the extended family remains intact, are better suited to cope with aging because the elderly are cared for by the family. In developed countries, where the extended family and community structure have often disappeared, health services must cope with fundamental welfare problems such as loneliness, as well as the illnesses associated with old age.
In Israel, public health efforts in geriatrics encompass both the sociological aspects - attempting to preserve extended family and community structures - as well as the need to combat geriatric-related illnesses such as Alzheimer's and senile dementia.
The introduction of increasingly expensive equipment for diagnosis and treatment as well as costly innovative medications, poses one of the greatest challenges to public health policy. Doctors and health officials are finding that they must now choose between life and death for population groups suffering from various diseases. The economics of health care are further complicated by the fact that research and development of such equipment and medication are inordinately expensive. Thus health care professionals must choose between allocating funds for short term medical needs, or for investing in R&D for long term benefits.
Israel's comprehensive welfare system is based on legislation which provides for a broad range of national and community services. Care of the elderly, support programs for single parents, children, and youth, prevention and treatment of substance abuse, and assistance for new immigrants comprise a large part of available social services. Correctional services encompass probation frameworks, remedial programs for school dropouts, and residential and observational services for youth in distress. Sheltered workshops and employment counseling are among the rehabilitation services provided for the blind and physically disabled. The developmentally challenged are cared for through various residential and communitybased programs.
Under the Social Welfare Law (1958), municipalities and local authorities are required to maintain a department responsible for social services, 75 percent of whose budget comes from the Ministry of Labor and Social Affairs. Nationwide services such as adoption, probation frameworks and residential institutions for the developmentally challenged are funded and run by the ministry. The ministry determines policy, initiates legislation, enacts regulations for the operation of social services and supervises those offered by public and private organizations.
Social Service Personnel
Schools of social work, available in most universities, offer graduate and postgraduate training, combining theoretical study with field work. Government-operated programs provide training for child care staff and social work aides, as well as in-service training for social work professionals. Community and case workers are employed in various contexts, including social service bureaus, community centers, immigrant absorption facilities, mother-and-child care centers, schools, factories, and hospitals.
Care and services for the elderly have become a major component of Israel's health and social service capabilities. While the total population has increased five-fold since the country's establishment, the number of senior citizens (age 65+) has increased ten-fold, now representing nearly 10 percent of Israel's 7 million inhabitants. Much of this growth has been due to mass immigration, which peaked during the 1950s and the 1990s. Over one million immigrants have arrived since 1989, mainly from the countries of the former Soviet Union, more than 12 percent of them aged 65 and over. Many had neither the time nor the opportunity to learn Hebrew, be absorbed in the workforce or establish a secure economic foundation for their old age. Thus many of Israel's elderly, some 13 percent of whom are disabled, are dependant upon family and community resources.
With planning and supervision under the aegis of the Ministry of Labor and Social Affairs, delivery of services is channeled through the social service departments of the local authorities. Community-based services for senior citizens, which aim to preserve their independence at home, include assessment of needs by a social worker, assisting families caring for an aged person, senior citizens' clubs,meals-on-wheels, sheltered housing, daycare, medical equipment, and transportation. Emphasis is placed on services for high-risk groups, such as people without family or adequate income.