1. Prepared by:
Iyad Ibrahim Shaqura
Supervised by:
Dr. Radwan Baroud
School of Public Health
2013-2014
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2.  Introduction
 Organizational Structure
 Health care Financing and Expenditure
 Physical and Human Resources
 Provision of care
 Health care Reforms
 Summary
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3.  Geography and socio-demography
 Economic context
 Political context
 Health status
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4.  The State of Israel was established in 1948; it is a
democratic state with a parliamentary, multi-party
system. It is a small country at the eastern end of the
Mediterranean Sea.
 At the end of 2007, it had an estimated population of
7.2 million, of whom 76% were Jewish and 17% were
Muslim Arabs, with other minority groups including
Christians (3%) and Druze (2%) (Central Bureau of
Statistics, 2008a).
 Population density is among the highest in the
Western world.
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6.  Israel is a relatively young society; 28% of the
population are under 15 years old and only 10%
are over 64 years. Its total fertility rate (2.88 per
woman) is higher than most developed countries.
 Immigration has played a critical role in the
demographics of Israel. The period 1990–2000 saw
the arrival of almost 1 million new immigrants,
the vast majority of whom arrived from Former
Soviet Union (FSU) countries.
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7.  Throughout the country’s history, armed conflict with
neighboring Arab countries and large-scale immigration
have resulted in heavy burdens on the Israeli economy,
creating the need for loans and extensive foreign support.
 Despite these challenges, Israel is a developed,
industrialized country with a substantial high-tech sector,
a growing service sector and a small, technologically
advanced agricultural sector. The 2005 GDP per capita
income (with purchasing power parity (PPP)) was US$ PPP
26 054, similar to that of New Zealand, Spain and Italy.
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8.  In 2006, life expectancy at birth was 78.5 years for
males and 82.2 for females (CBS, 2007).
 Life expectancy for Israeli males is among the highest
for OECD countries and that for women is in the lower
range.
 The infant mortality rate in 2006 was 3.9 per 1000
live births (CBS, 2007); it has declined by 38%
over the previous 10 years.
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11.  Overview of the health care system
 Historical background
 Organizational overview
 Decentralization and centralization
 Patient empowerment
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12.  Israel has an NHI system that provides for
universal coverage. Every citizen or permanent
resident of Israel is free to choose from among four
competing, nonprofit-making health plans (Clalit
53%, Maccabi 24%, Meuhedet 13% & Leumit 10%).
 The health plans must provide their members with
access to a benefits package that is specified within
the NHI Law (Gross 2003).
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13.  The system is financed primarily through
taxation linked to income (through a combination
of earmarked taxes and general revenue).
 The Government distributes the NHI funds
among the health plans according to a capitation
formula which takes into account the number of
members within each plan and their age mix.
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14.  The Ministry of Health has overall responsibility for the
health of the population and the effective functioning of
the health care system.
 In recent years, the Ministry has developed strong
capabilities in the areas of : health technology assessment
(HTA), the prioritization of new technologies, health plan
regulation, quality monitoring for community-based care,
and strategic planning to set goals for population health,
along with strategies for achieving them.
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15.  In addition to its regulatory, planning and policy-
making roles, the Ministry of Health also owns
and operates about half of the nation’s acute care
hospital beds.
 The largest health plan operates another third of
the beds, and the remainder are operated by
means of a mix of non-profit-making and profit-
making organizations.
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16.  The Ministry of Finance has multiple points of significant
influence over Israeli health care, which it uses to try to contain
health care spending, improve the services and increase the
efficiency of the system.
 The largest health plan, Clalit, has a market share of 53%. It
provides community-based services, primarily via salaried
physicians working in clinics that it owns and operates.
 The next largest plan, Maccabi, has a market share of 24% and
provides care primarily through a network of independent
physicians (IPs).
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17.  Although the Ministry of Health’s Public Health
Division operates through regional and district
offices, which have some leeway in responding to
local conditions, the ultimate source of authority is
the national office.
 The regional and district offices serve primarily: to
implement the policies and strategies developed at the
national level, both in the public health field and in
terms of the regulation of long-term and psychiatric
care.
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19.  Overview
 Health expenditure
 Population coverage and basis for entitlement
 Revenue collection/sources of funds
 Pooling of funds
 Purchasing and purchaser–provider relations
 Payment mechanisms
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21.  Health care accounts for approximately 8% of GDP.
 Hospitals and public clinics each account for
approximately 40% of national health expenditure, and
dental care accounts for a further 10%.
 There is universal coverage of the population via an NHI
system, providing access to a broad benefits package
including physician services, hospitalization, medication
and so on.
 Long-term care services and psychiatric services are
currently not included within the NHI but some public
funds are available for partial coverage of these services
through other mechanisms.
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22.  The NHI system is financed primarily from public
sources – a mixed system of payroll tax and general
tax revenue.
 These public funds are distributed among the health
plans according to a capitation formula that, as
mentioned earlier, primarily reflects: 1- the number of
members in each plan and 2- their age mix.
 Cost sharing for: pharmaceuticals, physician visits
and certain diagnostic tests also plays a role in
financing the NHI system.
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23.  Services outside the NHI system are financed via voluntary
health insurance (VHI) and direct out-of-pocket payments
for private sector services.
 There are two forms of VHI available in Israel: supplementary
VHI, offered by the health plans; and commercial VHI,
offered by commercial insurance companies.
 In recent years, the share of public financing has declined
to 64% of total health system financing, while the share of
private financing, especially VHI and co-payments, has
increased to 36%.
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24.  Hospital revenue derives primarily from the sale
of services, with approximately 80% coming from
the sale of services to health plans.
 Currently, the reimbursement of public hospitals
in Israel takes the form of fee-for-service
payments, per diem fees and case payments, and
is subject to a revenue cap.
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25.  Salaries constitute the primary component of compensation
for most hospitals and health plan physicians, and salaried
physicians were recently granted a 25% wage increase by an
arbitrator brought in to resolve an impasse in collective
bargaining between the Israel Medical Association (IMA) and
the country’s major employers.
 Capitation payments are an important form of compensation
for primary care physicians in some of the health plans, and
fee-for-service payments play a significant role in the
compensation of many community-based specialists.
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26.  Physical resources
 Human resources
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27.  In comparison with the OECD, Israel is
parsimonious when it comes to many of the
physical and workforce inputs to health care.
 For example, the Israeli supply of acute care beds
per 1000 population is just over half of the OECD
average (2.1 and 3.9, respectively).
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30.  While the supply of physicians is relatively abundant
(3.5 per 1000 and 3.1 per 1000 population, in the
OECD and Israel, respectively) at the time of writing,
the number of physicians in Israel is growing much
more slowly than in other countries, and a physician
shortage is being projected.
 Until recently, the Israeli physician supply relied
heavily on physicians trained in other countries –
primarily immigrants from the FSU and eastern
Europe.
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31.  However, as the massive immigration of the early
1990s dramatically decreased the FSU’s reservoir
of potential Jewish immigrants departing for
Israel, that source is now drying up.
 To address the projected shortage, Israel is in the
process of expanding its four existing medical
schools and is considering opening an additional
medical school.
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33.  Israel has far fewer nurses per 1000 population than
the OECD average (5.8 and 9.6, respectively) and is
facing a considerable – and growing – nursing
shortage (in part due to the drop-off in immigration
from the FSU).
 Efforts to address this shortage include: 1- expanding
academic frameworks for the training of nurses, 2-
encouraging more young people to enroll in nursing
programmes, and 3- developing programmes for
professionals in other fields to retrain as nurses.
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34.  Israeli nurses are increasingly well trained.
 In 2006, Registered Nurses (RNs) constituted 74%
of the total, up from 58% in 1995.
 RNs now account for almost 90% of new licenses
and approximately half of the RNs have received
advanced specialist training.
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36.  Critical components of the Israeli health system
include: 1- a sophisticated public health effort run by
the Ministry of Health, 2- high-level primary care
services provided by the health plans throughout the
country, and 3- highly sophisticated hospital care.
 Israel also has a strong system of emergency care
delivery that was developed to address its needs both
in times of peace and in times of war or terrorism.
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37.  Israelis have access to a secure, safe and stable
supply of pharmaceuticals at reasonable prices,
due in part to governmental regulation and the
roles of hospitals and health plans as the
principal and bulk purchasers.
 Israel also has an extensive and successful
pharmaceutical industry.
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40.  The system of health and welfare services for the
elderly with disabilities in Israel has developed
enormously since the mid-1980s, particularly with
regard to home care and other community services.
 The passage of the Community Long-term Care
Insurance Law in 1986 contributed greatly to the
development of these services.
 In recent years, palliative care services are also
becoming increasingly available.
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41.  Rehabilitation services are provided within the framework of
the NHI, but mental health care, institutional long-term care
and dental care are not.
 Other sources of public funding provide partial coverage for
long-term care and support for a system of Ministry of Health
community mental health clinics.
 Utilization of complementary and alternative health care is
increasing, both within the publicly funded health care system
and alongside it.
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42.  Primary care is highly accessible in Israel.
 In three of the four health plans, the cost of
primary care visits is fully covered by NHI, and
co-payments are limited to specialist visits.
 The Maccabi health plan charges a small co-
payment for primary care visits.
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43.  The most significant reform in Israeli health care since
1990 took place in 1995, when the law on NHI came
into effect.
 Other important changes include: the introduction of a
law on patients’ rights, the development of a system
for prioritizing new technologies, and the upgrading
of the national emergency response system.
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44.  Several reform efforts, such as the initiative to
transfer responsibility for mental health care
and well-baby care from the Government to the
health plans, have not been successful at the
time of writing.
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45.  The effort to change the legal status of the
government hospitals to independent non-profit
making trusts has also been unsuccessful, but the
government hospitals have gradually become more
independent in practice.
 It should also be noted that, in addition to the
government-initiated major structural reforms, the
Israeli health system has benefited greatly from a large
number of mid-level evolutionary changes.
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46.  Many of these were initiated by the health plans,
hospitals, universities and other nongovernmental
actors.
 In contrast to the government-initiated reforms,
which focused on: financing issues and the issues
surrounding who should provide the services,
these evolutionary changes focused on how
services would be delivered.
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47.  The Israeli health system provides a high standard of
care to the population as a whole, which is particularly
impressive in light of the relatively moderate level of
overall resources allocated to health care.
 Factors accounting for this strong performance include:
1- universal health care coverage.
2- a relatively young population.
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48. 3- good access to high-level primary care
services throughout the country.
4- the development of a national health care
system that is: a) predominantly publicly
financed and b) government regulated,
combined with the c) existence of competition
among providers.
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49.  Important challenges remain:
1- These include the lack of public insurance through
the NHI system for dental care.
2- long-term care and mental health care.
3- a growing reliance on private financing sources.
4- disparities among population subgroups.
 In addition, 1- the unique health needs of the
economically disadvantaged, 2- Ethiopian
immigrants & 3- Israel’s Arab minority population
pose a continuing challenge to the health care system.
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