Labriut!* What We Can Learn from Israel
Elliot Bidgood, 5 March 2013
*That roughly means “good health” in Hebrew, if the web does not mislead me
British coverage of the Israeli elections held back in January often focused on the international and security implications of the vote, as reporting in that region so often does. Therefore, we tend to remain ill-informed about Israel’s domestic policy debates. This is perhaps a shame, as it means that while we are used to looking to North America and the European continent for potential policy transfers and case studies, we may sometimes forget that Israel, another comparable nation with often-similar domestic issues to ours, can also offer similar inspiration. An example of this is healthcare.
In a list of what they felt were the ten most pressing domestic issues facing the new prime minister, the Israeli broadsheet Haaretz listed the health system fourth, with only the housing market, broader public services reform and cost of living ahead. They said the following:
“The quality of healthcare in Israel is relatively high, but the system’s structure poses problems. Expanding private medicine needs to be closely monitored and steps need to be taken to ensure that people who can’t afford private insurance still receive adequate care. The long queues at hospital emergency rooms and the long waits for appointments with specialists attest to a problem that could get worse as deficits of health maintenance organizations rise, and these organizations find themselves at odds with the hospitals.”
The Israeli Labour Party created Israel’s comprehensive system of universal health insurance in 1994, part of the wave of social reforms brought about by the Rabin-Peres government of the era. Labour’s 2013 platform (translator tool available here) stressed concerns about what they see as a gradual slide toward privatisation and marketisation threatening “social cohesion” in the public health system. However, while such rhetoric is similar to what we hear in our own health policy debates and while the principles of social solidarity celebrated by Israeli Labour are the same ones it’s UK sister party (and all Brits, for that matter) stress about our healthcare, the basic structure Israeli Labour put in place in 1994 and are now passionately defending is somewhat different to what we know in the NHS. Under Israel’s National Health Insurance (NHI) system, Israelis sign up with one of four kupat cholim, or sickness funds, which contract with providers on behalf of their members and are comparable to those that underpin several statutory healthcare systems in continental Europe or to American Health Maintenance Organisations (HMOs).
The largest sickness fund, Clalit (‘general’), has over half the population enrolled, was established in 1911 as a socialist mutual aid society and has historical ties with the Histadrut, the Israeli equivalent of the TUC. While non-governmental, the funds are non-profit and are strictly mandated by the government to accept any applicant and to provide a certain package of guaranteed benefits under the 1994 law. The NHI is primarily financed by a payroll ‘health tax’ set at two levels of income to ensure progressivity, but even those without an income still receive treatment, keeping coverage universal. General revenue also supplements the system, especially after the abolition of a planned employer tax stream by Likud in 1997. Israel also maintains agreements with the Palestinian Authority under which the PA reimburses Israeli hospitals for treating Gaza residents.
On the provision side, hospitals are often publicly-run by the Ministry of Health, but many are run privately on a non-profit basis. For example, while it contracts with the government hospitals, the Clalit fund also runs 14 hospitals of its own for its members and over a 1,000 clinics. However, the mix of public and independent institutions and diverse funding appears to create genuine patient choice and competition within the system and patient satisfaction is around 80%, somewhat higher than in the UK. Israel has also been praised for its strong primary care structures, early prevention focus and electronic record-keeping. In 2012 US Republican presidential candidate Mitt Romney raised eyebrows when he appeared to praise the system during a visit to Jerusalem, as although the system would indeed make a good model for America it is strongly ‘socialised’ by American standards, arguably more so than the Obamacare reforms to which Romney was strongly opposed.
An OECD health team that visited Israel late last year noted many of these strengths. The Israeli NHI also more than holds its own in international health rankings. Israel is slightly above the OECD average for the number of practicing physicians. While the number of hospital beds per 1,000 population is low, this has coincided with reduced average hospital stays and more day surgery. Life expectancy is the sixth highest in the OECD (the UK in 18th) and mortality amenable to healthcare is slightly better too. Today, a Lancet study (UK health performance: findings of the Global Burden of Disease Study 2010) found that Britain underperforms much of Europe on health outcomes, but for some time available data has also placed Israel ahead of the UK and some other developed nations on similar measures. Israel also boasts a good medical research sector.
As with all national health systems, the Israeli NHI has some drawbacks. Israel only spends 7.5% of its GDP on health, significantly below the OECD average of 9.5% and our spending of 9.6%. While this has earned Israel well-deserved praise for its remarkable cost-control (the result of strict controls and price-setting by the Ministry of Health) and apparent bang for buck in light of high satisfaction and outcomes, there are some indications that the system could benefit from being better funded. Per head expenditure is low and Israel has significantly fewer nurses per person than the NHS. 27% of health expenditure is out-of-pocket (one of the highest in the OECD), the result of certain upfront charges that have been imposed by the sickness funds to make up for the current lack of central revenue. Despite a reputation for good technological uptake, Israel sits next to the UK for access to CT scanners and below us for number of MRI machines. Finally, health inequalities across geographic areas and ethnic and immigrant groups have also been cited as an issue. Nevertheless, as the OECD researchers noted last year, overall Israel remains an interesting case study for us and other nations to look at, as in the main it performs well, it evolved from a tradition of worker’s organisations and it largely manages to simultaneously prize social solidarity, provision diversity, high outcomes and patient focus.
For more of our work on health, including books and research papers, visit our website here.