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Good Medicine : Chapter 1 - The Development of Health Care in Israel

The Ottoman Period

During the period when Palestine was part of the Ottoman empire (16th century to 1917), the public health service of the Ottoman government consisted mainly of quarantine activities and licensing for physicians. Government hospitals were set up only toward the end of the period. In the 1800s, Jewish philanthropists and some European Jewish communities sent physicians and medications to Palestine in order to protect Jewish colonists from the Christian missions, which established hospitals and offered medical services to locals. The first Jewish hospital (Rothschild Hospital) was set up in 1854 in the old city of Jerusalem, followed by two others, also in Jerusalem - Bikur Holim and Misgav Ladach. Later another Rothschild-funded hospital was set up in Zichron Yaakov for farmers and laborers in the area. This hospital treated Arabs and Jews alike.

The years 1911-1913 marked several beginnings: the creation of the first sick fund (HMO) in Palestine, by workers employed in the Judean colonies and in the town of Jaffa; the organization of the Hebrew Medical Association, by 12 physicians from the new Jewish town of Tel Aviv; and the first public health nurse service in Jerusalem, by the predecessor of the Hadassah women's organization. The service was modeled after the well-baby centers set up for immigrants in urban neighborhoods in the United States, and it was to become the pride and joy of the Israel public health system: a nationwide network of preventive health care stations for pregnant women and infants, known as Tipat Halav (Hebrew for "drop of milk").

The British Mandate Period

Following World War I, Palestine was ruled by the British Mandate government, which in 1920 set up a Government Health Service. A Sanitation Department was responsible for the quality of drinking water, modern house sanitation was introduced, inoculations against typhoid, cholera and smallpox were made compulsory, clinics for the treatment of eye diseases, rampant among both Jewish and Arab children, were set up, and an anti-malaria campaign that included draining swamps and covering wells was carried out. A school medical service was established, along with well-baby and outpatient curative clinics in some Arab towns. Indeed, government activities were concentrated primarily in Arab towns, as the Jewish community in Palestine had already developed institutions of its own, and these were left to develop largely under their own devices.

During the British Mandate period (1918-1948), the health care delivery system of the future state of Israel came into being. It was characterized by a combination of public and private provision of services, and it included activities by the Mandatory government; the Christian missions; Jewish and Arab institutions of self-government; the Hadassah Medical Organization; the Histadrut Sick Fund and other voluntary sick funds, each of which belonged to a different ideological stream; some Jewish, Christian and Arab charitable societies; private physicians and hospitals and traditional practitioners.

The Histadrut (General Federation of Hebrew Workers) was established in 1920, and its cooperative efforts included the Histadrut Sick Fund. This Fund insured workers and provided preventive, curative and rehabilitative care. Its first hospitals were set up in Kibbutz Ein Harod in 1923 (transferred to Afula in 1930) and near Petah Tiqwa in the mid-1930s. By 1946, the Histadrut Sick Fund had two hospitals, 274 clinics and additional health stations in scattered Jewish cities, towns and rural settlements.

Another very active force in the Jewish community was the Hadassah Medical Organization. A 1918 visit by the Hadassah medical mission, recruited by Henrietta Szold, was followed by the establishment of the Hadassah hospital in Jerusalem in 1922. Hadassah established additional hospitals in other urban centers. Hadassah engaged in a broad range of activities: sanitary and anti-malaria work, programs against tuberculosis and trachoma, the operation of 6 hospitals (two in Jerusalem and one in Tel Aviv, Haifa, Safed and Tiberias), laboratories and pharmacies in various locations, and the sponsorship of dental clinics. It focused especially on children: in 1927 Hadassah was operating 17 well-baby clinics; by 1946, their numbers had grown to 90. In cooperation with the Jewish Farmers' Association, Hadassah founded a rural People's Sick Fund in 1931 and set up curative clinics, parallel to those of the Histadrut Sick Fund. Hadassah facilities served mostly the middle class (both Arabs and Jews), while the Histadrut Sick Fund served primarily the labor movement of which it was an integral part.

In 1933, the National Sick Fund was created by the workers' organization of the Right that was opposed to the Histadrut while the Center Sick Fund (which in 1974 amalgamated with another fund to create the present-day Meuhedet Fund.) was established by the General Zionists, who also had their own workers' organization. In addition to these funds set up by partisan organizations, the Maccabi Sick Fund was established by unemployed immigrant physicians from Germany; and two private insurance plans, the Physicians' Fund and Assaf, were also created.

After the Creation of the State in 1948

With the founding of the State of Israel, responsibility for health care was invested in the Israel Ministry of Health, while the Histadrut Sick Fund continued to operate as a mini-ministry with an expanding array of services that made it eligible for extensive government funding. During the first two decades of statehood, the major challenges to the health care delivery system were (1) to extend medical services to Arab communities, especially rural ones, and (2) to provide medical services for the masses of Jewish immigrants who came to the country.

The Ministry of Health took over responsibility for preventive care, and with it, eventually, operation of most of the well-baby clinics, subsequently referred to as Mother and Child clinics.

The 1970s were characterized by the construction of new government hospitals; the Israel Ministry of Health became, more than anything else, the Ministry of Hospitals. With the advance of medical technology, health care costs increased considerably. The 1980s were marked by budget cuts and attempts to increase the share of the private sector in the private-public mix of service provision, and, with the rising standard of living, increased consumer demands for more and better health services. The major developments of the 1990s include two opposing trends: increasing privatization, on the one hand, and implementation of the National Health Insurance Law, on the other.

For the Israeli health care delivery system, the challenge of the coming decade is to increase the equity of health services in Israel against the background of growing demands for privatization and small government, and as income disparities widen and the disadvantaged sectors of the population place increasing demands on the system. Another formidable challenge will be to keep costs down in the face of sharply increasing expenses for medical services.

*The following account is based on Nira Reiss, The Health Care of the Arabs in Israel, 1991, Westview Press; and the Majority Report of the Netanyahu Commission of Inquiry into the Health Care System. Both are recommended reading.