In Israel there exists a disparity between the scope of healthcare services available in the periphery compared to central Israel. This is part of the general inequity and imparity that exists between central Israel and the periphery with respect to other areas of life, including employment, education, welfare and transportation. The periphery is occupied by a population that is disadvantaged in a wide range of areas, and the field of healthcare reflects the social and general level of the population and is influenced by it. Many studies have found a direct proportional relationship between socioeconomic status, particularly level of income and education, and the standard of health. Thus, those who are most severely in need of healthcare services have a narrower scope of medical services available to them.¹  

Life Expectancy and Infant Mortality, by Region

Standardized Mortality Rate from Heart Disease, by District4

The above tables illustrate the considerable disparity between the results of the healthcare system in some areas of the country vs. others. While Jerusalem and central Israel boasted the highest life expectancy, the periphery regions – northern and southern Israel – had the lowest life expectancy. The differences between central Israel and the periphery are also evident in infant mortality: While central Israel has the lowest percentage of infant mortality, the southern and northern regions have the highest incidence, significantly higher than even the national average. Similarly, in the northern districts the percentage of standardized mortality from heart disease exceeds the national average. The southern districts correspond with the north, and the central districts and Jerusalem rank below it. The State of Israel’s obligation to provide its population with healthcare services is a central component of a broader worldview of social justice – a social-democratic worldview that upholds social solidarity and mutual responsibility. The goal is to achieve an equal level of services and welfare for the entire population in all areas of social services – and not just healthcare – and certainly not to discriminate against a substantial part of the population due to its geographic location. On the contrary, the social support should be increased in those areas and settlements whose population is particularly vulnerable due to relatively inferior economic and social conditions.

All the more so must this policy be upheld in the field of healthcare – where the inequity is acute – as this field decisively impacts on the residents’ quality of life, and its consequences may even involve life and death. The State of Israel’s obligation to provide respectable universal health services to the whole population is anchored in the National Health Insurance Law5 In practice, however, the spirit of the law is one thing, while the reality is quite another. The legislator’s intent is far from becoming realized in practice, as proven by the data presented later on.

One of the most complex problems with the health services in the periphery is the difficulty in attracting medical and nursing manpower from central Israel. Central Israel offers physicians – both young and senior – economic, social, cultural and educational opportunities unavailable in the periphery. Therefore, many doctors prefer to have their practice in central Israel as opposed to the peripheral areas.

A physician trains for seven years before receiving his medical license, and there are an additional 4-7 years before he receives his specialist certificate. Becoming a physician is a prolonged process, occurring in the doctors’ 20’s or 30’s, a period during which they form their professional preferences, build a family, develop a social circle, and basically establish their lives; this generally occurs in the same place that they acquired their education. Sometimes a country’s desire to ensure satisfactory distribution of medical manpower throughout the various parts of the country is not in sync with the desires of the individuals whom it seeks to draw to the periphery, and practically speaking, it must form varied and diverse solutions to attract these doctors to the periphery.6

The Number and Percentage of Doctors Employed, by Region7

Among the practicing physicians, approximately 40% (12,192 physicians) are employed in the community, and approximately 60% (12,536 doctors) are employed in hospitals. Below is the number of doctors employed in the community and their percentage per 1,000 persons, by region. The following table shows that in this area too, the percentage of doctors employed in the community in northern and southern Israel – is the lowest.

The Number and Percentage of Doctors Employed, by Region⁸

In the northern and southern regions, not only is the percentage of doctors lower compared to the other regions, but the percentage of medical specialists is also lower. A study conducted by the Ministry of Health based on data from 2003–2004 regarding community medicine, found the percentage of medical community specialists in the north and south to be the lowest in Israel.⁹ 

The Percentage of Medical Specialists, by Region

As shown in Chapter 1, the hospital bed crisis in Israel is severe. The low percentage of beds naturally affects the scope of positions allocated to physicians and specialists in the hospitals’ various wards, and thus creates an overload of work in the hospitals. The staffing ratios, regulated in the 70’s, have not been updated and do not account for, among other things, the following parameters: the technological changes in the realm of medicine, the population increase and population aging, the scope of medical activity, the development of clinical fields and subfields, changes in manpower quota which enable more women to join the profession. Failure to consider the above factors has serious ramifications, including a shortage of medical manpower, and in recent years the situation has become most acute. Due to the low staffing ratio, doctors are forced to work many additional shipfts and on-call shifts, up to 15 a month¹⁰ This intolerable situation may impair the quality of medical care, and endanger the patients. 

In the periphery, it is difficult to recruit high-quality and professional medical manpower, especially in the hospitals, and to preserve existent staff members especially in managerial positions. Several causes can be noted:¹¹
 

• Low remuneration and limited opportunities to supplement income outside the public system: the population in the periphery generally does not resort to private healthcare services, as is common in areas with a higher standard of living.
• The periphery doctors are professionally isolated, and their opportunities for professional development are limited.
• Hospitals in the periphery are not affiliated with university centers to the same extent as hospitals in central Israel. Therefore, the possibilities for engaging in research or taking advanced professional courses are limited, as is the availability of university teaching positions.
• Familial and social drawbacks – the difficulty for the physician’s partner to find suitable work in these areas; social isolation and adjustment issues – the social life, culture and level of children’s education does not always match the level to which the doctor’s children were accustomed when living in Central Israel.

In the periphery, it is sometimes difficult to recruit quality residents, as they prefer to do their residency at hospitals in central Israel, where there are more opportunities for professional development. Likewise, the general medical and nursing manpower crisis in particular fields of medicine, as well as the failure to update the physician-to-patient staffing ratio in hospitals, affect the periphery more than central Israel, impairing the possibility to recruit quality manpower in the periphery. The difficulty in recruiting and preserving healthcare manpower in the periphery – and particularly physicians – is quite common in other countries as well. Documents of the Ministry of Health show that states like Australia, New Zealand, Canada and the US have enacted a compensation system for those who work in the periphery – higher pay and special grants to cover moving expenses. These documents also show that “periphery healthcare” is considered a specialty field studied in medical faculties, and special scholarships are granted to students who choose this as their specialty. Moreover, in some countries it is compulsory to undergo medical training in the periphery. The documents also show that there is high probability that physicians from the periphery will return to their place of origin upon completion of their studies, and one of the ways recommended to recruit doctors to the periphery is by establishing a medical school there.¹²

Already in 1977, as part of the Kibbutz wage agreements, the State of Israel recognized the need to give doctors in the periphery the special incentive of supplemental salary. However, according to the IMA, this supplement amounts to NIS 1,400 at the most for a director, about NIS 1,040 for a specialist who is not a director after two years as a specialist, and NIS 110 for an intern. As such, this supplement does little to draw doctors to the periphery. Similarly, in 2007 it was decided to establish another medical school in the Galilee in order to draw medical manpower to the periphery. In December of that year, the director general of the Ministry of Health appointed a “Committee for Healthcare in the Periphery.” According to the letter of appointment, the committee’s mandate was to “recommend methods to minimize the disparity between central Israel and the periphery in the realm of healthcare, addressing the following dimensions:¹³

1. Imparity in available manpower, hospital beds, equipment, and other resources.
2. Imparity in the population's health profile.
3. Imparity in usage patterns of the available healthcare services.

The director of the Rivka Ziv hospital in Safed headed the committee, and the members were representatives of the Health Funds (Kupot Cholim), the Ministry of Health, the IMA, and some of the government hospitals. In the report that the committee submitted to the Ministry’s director general at the end of December 2008, the committee recommended offering substantial incentives to doctors, nurses and paramedics in the community and the hospitals, who were already working in the periphery or planning to do so.  The committee also suggested adding standardized manpower positions in all the various fields of medicine, in the hospitals and the community. In 2001, the Ministry of Health, together with the IMA and the Council for Higher Education, began to examine strategies to draw doctors to the periphery. However, according to the State Comptroller: “As of November 2008 (the summation of this investigation) nothing has been done about this, and even the doctors’ arbitration ruling regarding the wage agreement, failed to address the topic of  incentive bonuses to draw doctors to the periphery.”¹⁴

To sum up this subchapter: the State of Israel’s obligation to provide its population with healthcare services is a central component of a broader worldview of social justice – a social-democratic worldview that upholds social solidarity and mutual responsibility. In all areas of social service, not only in healthcare, the goal is an equal level of services and welfare for the entire population, and it is clearly unacceptable to discriminate against large sections of the population due to their geographical location. On the contrary, the periphery’s population is disadvantaged in many areas of life, and healthcare both reflects and is influenced by the social and general level of the population. In many studies, a direct correlation is found between socioeconomic status, especially the level of income and education, and the level of health. Thus, although these regions are the ones most in need of the healthcare services, their healthcare system is the most limited. Instead of increasing the social support in those areas inhabited by the most vulnerable population, the population in the periphery suffers from an ongoing and severe shortage of medical infrastructures in general, and of doctors in particular.

In other countries, a number of solutions have been adopted to overcome this problem, such as higher salaries for doctors in the periphery, and grants to cover moving expenses. To draw medical manpower to the periphery, it was decided in 2007 to set up another medical school in the Galilee. A professional committee appointed by the Ministry of Health also recommended offering significant incentives to doctors, nurses, and paramedics in hospitals and the community, who were already working in the periphery or planning to do so. It likewise recommended adding more regularized positions for healthcare personnel in all the fields of healthcare in hospitals and the community, but the Israeli government has thus far done nothing in this regard. The problem of the physician shortage in Israel is far from being resolved, and continues to adversely affect the health of many of Israel’s citizens and to endanger their well-being.

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¹ The Knesset Research and Information Center, The Challenges in Expanding Medical Manpower in the Periphery, by Shelly Levy, 2011, page 2.

² The Ministry of Health and CBS, Social and Wellness Profile of the Settlements in Israel 1998-2002. This publication has not been updated frequently and the Ministry is currently updating it, according to the Ministry’s publication, Dealing with the Inequity in Healthcare, 2010, page 34 

³ From the CBS website

⁴ The Ministry of Health, Dealing with the Inequity in Healthcare, 2010, page 37.

⁵ The National Health Insurance Law, 5754 – 1994.

⁶ The Research and Information Center, ibid.

⁷ The Ministry of Health, Practicing Physicians – Administrative Information, 2010, page 201. 1,938 doctors were practicing in more than one region.

⁸ Ibid, 203

⁹ The Knesset Research and Information Center, ibid, pages 6-7. Excerpted from: The Ministry of Health, the Healthcare Financing Division, Planning and Evaluating Surveys, The Community Doctor: Socio-demographic and Professional Characteristic, August 2007.

¹⁰ State Comptroller, Annual report – 59(b), The Ministry of Health, 2009.

¹¹ Ibid

¹² ibid

¹³ ibid

¹⁴ ibid