Three major agencies are involved in the Israeli health care delivery system. The Ministry of Health is responsible for policy-making; for most of the pre- and post-natal care provided through Mother and Child clinics; for the operation of hospitals under its aegis, which include general, psychiatric, and long-term care institutions; for some aspects of geriatric and psychiatric care; for health education and for partial funding and supervision of the health services provided under the National Health Insurance Law.
Four non-profit sick funds or HMOs (we prefer to call them "health funds") provide curative care through neighborhood primary clinics and regional specialist centers and, in the case of the largest health fund, the former Histadrut Sick Fund, which we will refer to as the General Health Fund, through its own hospitals. The health funds contract with hospitals and other public and private service providers on behalf of their members. At present (1998), the General Health Fund insures about 60% of the Israeli population, the Maccabi Fund, 20%, and the Meuhedet and National Funds about 10% each.
The National Insurance Institute (the Israeli equivalent of the U.S. Social Security Administration) is responsible for home care for the disabled elderly and for the medical care of persons injured in work-related accidents.
In 1995, there were 259 hospitals in Israel, including 48 general hospitals, with 5.91 beds per 1,000 persons, a ratio that is declining. This compares favorably with the average ratio of the countries of the Organization for Economic Cooperation and Development (OECD), to which the U.S. belongs 7.5 per 1,000. The average duration of hospitalization for persons in general care has decreased, from 7.2 days in 1976 to 4.4 in 1996 (CBS, 1997a and 1978). Annual general hospitalization days have been decreasing steadily as well: in 1996, the figure was 793 per 1,000 persons (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 figure for the U.S. was 68.5% (ibid).
In 1996, about 62% of all Israeli hospitals were public and the rest private. Looking at beds rather than hospitals, we find that about 75% of beds are public and 25% private and that the share of private beds has been gradually increasing. Private institutions are concentrated in the fields of psychiatric and geriatric care. The fact that medical institutions are under private ownership does not mean that they practice private medicine: most of the psychiatric and geriatric beds are funded by public agencies mainly the Ministry of Health. One area of health care that is provided mainly by the private market is dental care.
The doctor/population ratio in Israel 461 per 100,000 persons has long been among the highest in the world. Contrary to popular opinion, the latest figures indicate that Israelis do not visit a doctor more often than residents of OECD countries 6.8 times a year on the average (CBS, 1997b) compared with the average of 6.6 visits in OECD countries (calculated from Ben-Nun and Ben-Uri, 1996:18).
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) and slightly lower than that in the U.S. (7.3). Life expectancy at birth is 75.5 for men slightly higher than the average for high-income countries (it is 73.1 in the U.S.), and 79.5 for women somewhat lower than the average for high-income countries (it is 79.1 in the U.S.)(ibid: 18; National Center for Health Statistics web site). 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 diseases 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, albeit, on local rather than national samples) have found about a fourth of subjects to be overweight; 16% of 20-64 year-olds have been found to have high cholesterol levels
It is well known that the health status of a population depends on many factors, including heredity, environment, lifestyle and the health care delivery system itself. One of the most important determinants of health is socio-economic status. As Haines and Smith so succinctly stated in a British Medical Journal editorial, "Firstly, anybody interested in health has to pay attention to wealth. It's the single most important driver of health worldwide . . .." (Haines and Smith, 1997). Indeed, the health profiles of the different groups that make up Israeli society correspond to their socio-economic levels.
Infant Mortality Rates
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 1996, the average rate in Israel was 4.9 for Jews and nearly twice as high for Arabs 9.7 (ICDC, 1997:37). The comparable figures for Whites and Blacks in the U.S. are 6.0 and 14.2 (Federal Interagency Forum, 1998). While infant mortality rates for both Jewish and Arab citizens have been steadily declining, the gap has remained constant. If we take a closer look at the various Jewish communities within Israel, we will find that affluent Jewish communities, which have a majority of residents of Ashkenazi (Europe, the Americas) origin, have lower infant mortality rates than development towns, most of whose residents are of Mizrahi (Asia and Africa) origin.
Standardized Mortality Ratios
Geographical variation has 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). Excess (higher than average) deaths were found in the big cities and in localities with heavy industries (Ginsberg and Tulchinsky, 1992).
In the Negev region of the country Standard Mortality Ratios are 16% above the national average (Tulchinsky and Ginsberg, 1996). Indeed, a health profile of the Negev region shows excess death rates from diabetes, cerebrovascular disease and other ischemic heart disease. Disaggregation of the figures reveals that compared to Jews, Negev Arabs (who are Bedouins) suffer from higher age-adjusted mortality rates from infectious diseases, whereas Negev Jews have higher mortality rates from chronic ischemic heart disease (ibid). Chapter 4 describes a unique research project on genetic diseases carried out with the aid of and for the benefit of Bedouin residents of the Negev.
Research indicates that in Israel as elsewhere, socio-economic status is associated with lifestyle factors like diet, smoking and alcohol consumption (Shuval, 1992). Smoking is considered the single most important behavioral causative factor of morbidity and mortality: a 1996 national telephone survey found that 30% of Israeli men and 25% of women smoked (average in U.S. for men and women combined 25%). These figures are similar to the average for OECD countries (ICDC, 1997: 237-242).
Alcohol consumption is lower in Israel than in European countries an average of 0.9 liters per capita per year, compared to an average of 9.4 liters in the countries of the European Union (ICDC, 1997: 251) and 9.6 for the U.S. (WHO database). In a 1994-95 survey of the adult population of Israel, 50% reported not drinking at all, and less than 2% taking any form of drug other than hashish. Use of hashish was reported by 5% (ibid: 249). Whereas no change was found in the habits of adults over time, the consumption of drugs and alcohol appears to be on the increase among teenagers, though it is still low by international standards.
A Closer Look at the Health of Different Israelis*
This section will take a closer look at the health of special population groups: women, Arab citizens, new immigrants from the former Soviet Union and from Ethiopia, and the elderly.
The life expectancy of women is higher than men throughout the world; however, the gap is smaller in Israel than in other developed countries. While the average gender gap for developed countries is 7 years, the gap in Israel is only 4. Israeli men live longer, on the average, than their counterparts abroad, while Israeli women die earlier. The reasons for these phenomena have not been researched.
The fact that Israeli women live longer, on the average, than Israeli men results in women being dependent on the medical care system for longer periods in their lives. It also increases the likelihood women will be alone in their old age, with no one to care for them when they are ill. Women constitute 57% of the population over 65. By the time women reach the ages of 75-79, only about one-quarter of them live with a partner, compared with more than 80% of men of the same age (Modan et al, 1996).
Age standardized mortality rates for most of the leading causes of death (heart disease, cancer and stroke) are higher among men than among women throughout the developed world. In Israel, however, women are at greater risk of dying of cancer than men for much of the life cycle. While Israeli men exhibit one of the lowest mortality rates for cancer among men in some 20 countries in which cancer registries are kept, Israeli women have among the highest rates in the world higher than the mortality rates from cancer in European countries, though lower than that in the United States (Zadka, 1993). This is due primarily to breast cancer, which in 1994 claimed more than 800 lives. (Chapter 4 describes advances in Bone Marrow Transplantation that may save the lives of numerous women endangered by cancer.)
Women report more ill health than men and suffer more from long-term disability, particularly in old age. Since women are more likely to be living alone, they are also more likely to be placed in institutional care (Stessman et al, 1996). Elderly women report higher rates of hypertension, abdominal problems, muscle or joint pain, chronic fatigue, digestive problems, and respiratory problems than men (ibid; CBS, 1994).
Two diseases that reduce the quality of life and often lead to more serious conditions in women are hypertension and diabetes. Hypertension plays a more important role in the development of congestive heart failure and other coronary problems in women than in men, and it also places women at higher risk of stroke (Strokes et al, 1987; Hoffman, 1995). An estimated 3% of the female population of Israel (compared to 2.7% of males) suffer from diabetes. The disease affects North African Jews and Arabs more than Ashkenazi Jews, and mortality rates are higher for Arab and Mizrahi women than for Ashkenazi ones (ICDC, 1997). For women, diabetes involves higher risks of complications from coronary artery disease than for men. Women with diabetes also experience more severe circulation problems that can lead to limb amputation, and a greater tendency toward auto-immune and reproductive disorders (Hoffman, 1995).
Gender and Medical Practice
Women in Israel are the major consumers in the health care system: they visit doctors more often than men and undergo more laboratory tests, x-rays and other examinations (CBS, 1994). The question is, does more care mean better care?
Israeli medical practice is just beginning to recognize that gender-specific problems are not limited to the reproductive system. A prominent example is heart disease. Because the ruling assumptions were that heart disease is a male malady and that heart disease in women follows patterns similar to those found in men, women's reported symptoms tended to be ignored. The result: Israeli women have been found to fare worse than men during and after acute myocardial infarctions (Ra'anan, 1998, Tzivoni, 1991; Greenland et al, 1991). Additional findings: women have greater impairment of functional status when they are admitted for surgery; they are slower to recover and more likely to die both during hospitalization and in the year following discharge. Increased awareness of gender differences, evidenced in the establishment of a heart clinic for women at the Barzilai hospital in 1998, may improve the prognosis of female patients.
In Israel, as in other developed countries, the fertility rate has decreased in recent decades; nevertheless, it is still higher than that in European countries or the U.S. In 1996, the average number of children for Jewish women was 2.5 and for Muslim women, 4.7. Within the Jewish population, if we look at country-origin groups, we find that women born in Asia or Africa have the highest fertility rates, 3.2, and European or Russian-born the lowest, 2.2 and 1.7, respectively. Israeli-born women have an average fertility rate of 2.6. The social group with the highest fertility rate in Israel is the ultra-Orthodox (Haredi) community, with an average of 7.0 children.
Other fertility trends include a decrease in the number of legal abortions, from 18,000 annually in 1980 to some 16,000 in 1996. Unlike the U.S., teenage pregnancy is not a widespread phenomenon; in fact, it is decreasing. What is growing is the rate of never-married women bearing children (4 per 1,000 in 1995, compared to 3.2 in 1978), though the phenomenon is still much less common than in the U.S., where one-third of live births are out of wedlock (National Center for Health Statistics).
Maternal mortality in Israel is lower than that in many other countries, including the U.S. In 1994 it was 5.2 per 100,000 live births, compared with 7.2 in the U.S. (CBS, 1997; ICDC, 1997).
The dominant national ideology (for Jews only) has always been pro-natal. Among the reflections of this orientation: the creation of a government Center for Demography to look into ways of encouraging fertility among Jewish women, and the fact that Israel has what is probably the highest proportion of in-vitro fertilization centers in the world, 27 centers in 1998. The benefits package under the National Health Insurance Law includes unlimited IVF treatments up to the live birth of two children. Also, Israel is at the forefront of fertility research (see Chapter 4).
Screening for Breast Cancer
Studies have shown that mammography screening reduces mortality in women aged 50-69 by 30 to 40% (Rennert, 1996; Fletcher et al, 1993). In 1994, the Israel Ministry of Health embarked on a National Mammography program, under which health funds are required to invite women over the age of 50 for screening. As a result of this effort, more women are now undergoing checkups: about 30% of Israeli women aged 50-70 invited for screening underwent mammography in 1997 (Miri Ziv, Israel Cancer Society).
Although hormone therapy during menopause is still controversial, Israeli doctors tend to be enthusiastic advocates of the treatment, which is included in the benefits package under the National Health Insurance Law. Notably, alternative therapies are also included in the benefits package.
Arab citizens constitute one-fifth of the population of Israel, and 90% of them were born, raised and educated in Israel. Still, their localities remain underdeveloped and their socioeconomic status is below that of most Jewish groups. As health status is closely tied to socioeconomic indicators, like income and educational level, the health status of Arab citizens of Israel is lower than that of Jewish ones.
Health Status Indicators
Among Arab citizens of Israel, infant mortality has been consistently double that of Jews; it lags behind the Jewish rate by 10-20 years.
In 1995, life expectancy was 2.3 years shorter for Arabs than for Jews (CBS, 1997); the difference was due mainly to excess deaths in infancy and early life. The Standardized Mortality Ratios for all causes of death combined are 20% higher for Arabs than for Jews. The discrepancy holds for two out of the three leading causes of death in Israel heart disease and cerebrovascular events (but not for cancer). It also holds for deaths from external causes, birth defects, hypertension, diabetes mellitus and infectious diseases. Standardized Mortality Ratios for all external causes of death are 30% higher among Arabs than Jews; the ratio for mortality resulting from auto crashes and collisions is 2.1.
Between 1989 and 1998, some 775,000 immigrants came to Israel from the former Soviet Union and about 35,700 from Ethiopia (CBS, 1997: Table 2.22). As recent Soviet immigrants now comprise about 10% of the Israeli population, any special health needs they may have are likely to impact on the health care delivery system. And while Ethiopian immigrants constitute a much smaller minority, they come from an area of the world in which diseases that are relatively rare in Israel, like malaria, AIDS and tuberculosis, are endemic (tuberculosis is also found in higher proportions among Soviet immigrants), and thus their health needs require special planning and attention. Moreover, the distress of immigration has had negative health effects on both groups, necessitating awareness and outreach on the part of mental health professionals, as well as the provision of culturally appropriate care.
With regard to Soviet immigrants, a recent examination of national survey data found that immigrants up to the age of 64 appear to suffer significantly more than veteran Israelis from heart disease. Reported mental distress was also found at higher rates among immigrants, though a lower proportion reported actually utilizing mental health facilities. Immigrants over the age of 50 also reported suffering from more handicaps than veteran Israelis. Some of the differences between immigrants and veteran Israelis may be connected with the stresses of immigration (Nirel et al, 1998).
Among immigrants from the former Soviet Union, the proportion of the elderly is higher than in the general population (14%, compared with 9.6%). Elderly immigrants have reported suffering more than veteran Israelis from hypertension, chest pains, shortness of breath and arthritis (Neon et al, 1993). However, a 1998 analysis of data from four national surveys found no significant differences between veterans and new Israelis in either the incidence or types of chronic diseases for which they reported actually receiving treatment (Niral et al, 1998: 104). Thus, either the difference is a subjective one, or elderly immigrants are not receiving (or not reporting on receiving) the treatment they need.
To date, no systematic study has been carried out of the health needs of new immigrants from Ethiopia. Their relatively high rate of infectious diseases has been pointed out by a number of researchers (for example, Epstein, 1996: 70). A higher rate of suicide has been noted among Ethiopian immigrants than among the general population (Arieli et al, 1994; Arieli and Ayche, 1993), as well as a high level of mental distress (in a local study of immigrants in Netanya), attributed to the trauma of immigration and the conflicts and stresses caused by the immigrants' experiences as newcomers in an entirely different culture (Arieli and Ayche, 1993). No data are available on the comparative utilization of services by Ethiopian immigrants, compared to other immigrants or to veteran Israelis.
In 1996, there were 543,300 persons over the age of 65 in Israel, constituting 9.6% of the total population, and 219,300 persons over the age of 75 (3.85% of the total population) (CBS, 1997). In the OECD countries, the average proportion of the 65+ population is 13%. It is well known that health problems increase with age, and that the average per capita outlay on health for persons over the age of 65 is about 4 times that for persons in younger age groups.
What is less well known is the fact that in Israel 70% of elderly inpatients are women. Although Israel's population is young compared to that of the U.S. and of most OECD countries, the 75+ cohort is growing, and, with it, the need for community services for the elderly and long-term geriatric beds.
In Israel, as in the U.S., most geriatric care is provided by female family members. The proportion of elderly persons who receive assistance solely from family members is higher among Asian- and African-born Israelis than among the American and European born Israelis (Walter-Ginzberg et al, 1997:11), among immigrants from the Soviet Union than among non-immigrants, and among Arabs than among Jews (Be'er, 1996). An estimated 70%-75% of the aged who need assistance in carrying out daily functions from agents outside the family obtain it within the community (Swirski, 1997: 16).
The Long Term Care Insurance Benefits Law, which came into effect in 1988, greatly improved home care for elderly citizens (See Chapter 3 below). It provides 10-16 hours of home care a week on a nearly universal basis for senior citizens who have difficulty carrying out daily functions. In June 1998, some 80,500 persons were receiving benefits under this law, 73% of them women (National Insurance Institute, 1998).
The proportion of senior citizens receiving home care in Israel is high relative to that in other countries 10.7 percent in 1998 due probably to the 1988 law. In the U.S., only about 4% receive home help. In contrast, the proportion of senior citizens receiving long term institutional care is somewhat lower in Israel than the average in OECD countries. Assuming that in 1994 all existing beds were occupied (which they were not), 4.5% of Israelis aged 65 and over were receiving institutional care compared to the average rate of 5.5% in twenty OECD countries and 5.4% in the U.S. (in 1990) (Swirski, 1997).
*The section, "A Closer Look at the Health of Different Israelis," is based on Swirski, Barbara, Hatim Kanaaneh and Amy Avgar, 1998, "Health Care in Israel," Issue No. 9 of The Israel Equality Monitor, Tel Aviv: Adva Center.