The healthcare system in Israel has been in severe crisis for some time. The persistent shortage of resources, hospital beds, training vacancies for students, medical personnel and physical infrastructures, harms thousands of patients on a daily basis. The shortage has even led to increasing numbers of physicians choosing to leave the public healthcare system in favor of private practice, or worse – to work abroad.

Critical medical specialties that are particularly affected by lack of manpower and insufficient remuneration are experiencing a heightened crisis, since many doctors have no desire to engage in these fields.

Consequently, the Israeli healthcare system crisis overshadows the achievements it has recorded over the years as a leader in quality medical care and scientific and technological advancement. Instead, it now faces the threat of becoming one the most unfit and unequal systems in the West.

A typical example of the crisis in the healthcare system relates to the shortage of hospital beds. In January 2011, the Ministry of Health published a report that indicated the persisting downward trend in the number of hospital beds, and the worrisome indicators concerning Israel’s position compared to the OECD countries with regard to the number of beds, hospital occupancy, and the average length of stay for patients receiving medical treatment. ¹ Upon implementation of the National Health Insurance Law in 1995, there were 2.3 beds per 1,000 persons. Since then, the number has consistently declined, reaching 1.94 at the start of 2010 (14,599 beds). During these years, the number of beds in general hospitals increased by only 11%, compared to an approximate 35% population increase.²

Number of General Hospital Beds per 1,000 People in Israel in the Last Decade

In 2008 Israel held a negative record among the OECD countries, with regard to hospital occupancy (96.2% in Israel compared to less than 90% in the OECD countries). In 2008, the average duration of patient hospitalization was four days, the shortest in the OECD (besides Mexico). In this same year, the average number of patients per bed in a specific period (“bed turnover”) was the highest among the organization's countries, at 88 patients per bed.

The comparison with international assessments emphasizes not only the grave situation of the Israeli hospitalization system, but also points to a hospitalization crisis in the peripheral regions. The general number of beds in the northern and southern regions is significantly lower than in the other regions, and this persistent shortage of beds has remained unchanged over the last decade.⁴

These unfortunate statistics are not surprising when we examine Israel’s investment in health compared to Western countries. Israel’s investment in health is reflected in the miserable state of the hospitalization infrastructures, as apparent in the following diagrams:


National Health Expenditure for Hospitalization as a Percentage of the GDP – International Comparison (2008)

In 2008, Israel’s national health expenditure was 7.8% – among the lowest in the Western world.

Health Expenditure Per Capita – International Comparison (2008)
 

In 2008, the health expenditure in Israel was $2,244 per capita – among the lowest of European countries.

These data are not at all surprising. Already in 1995, the State Comptroller cautioned that “overcrowding existing infrastructures with additional beds makes it difficult to treat patients, increases contagion, and is likely to hurt patients’ comfort and wellbeing ….”⁵ Since then, physicians and other authorities in the healthcare system have repeatedly warned that the overload in the hospitals – especially in the internal medicine and intensive care units – has become unbearable.

An increasing number of patients are hospitalized in the hallways, suffer from long waiting periods, and receive inadequate care as a result of poor hospitalization conditions. Naturally, the overload causes heavy burnout among the physicians, who are expected to provide the best medical care despite the lack of necessary conditions. The first objective is to upgrade the medical manpower standardization, which must be adapted to the real needs of the population in 2011 (the current standardization is based on calculations from the 1970s and 1980s).

In light of these trends, it is especially worrisome that in the past decade, the Israeli government has done nothing to allay the ever-increasing hospitalization crisis. Furthermore, the plan for “Reinforcing the Healthcare System,” which the government announced in February 2011, testifies above all that the Ministry of Finance has invested nothing; the government’s response to the crisis in the healthcare system is merely cosmetic.

The shortage of hospital beds and healthcare positions primarily affects the disadvantaged populations. As evidenced this past winter, hospitals in the periphery are the first to suffer from the crisis; patients are forced to wait longer and receive inferior medical care. The internal medicine wards – the first to suffer from the bed shortage – serve these disadvantaged populations, which include the elderly and the poor, who suffer from the shortage more than any other group. Consequently, the strain on the public healthcare system increasingly prompts patients who can afford it to pursue treatment on the private market. This intensifies societal gaps, while the public system deteriorates.

Other factors in the widening of societal gaps include increasing privatization and the rise in health insurance rates. The most prominent example is co-payments, the share patients are required to pay for treatments and medications. These payments have gone from serving as a tool to prevent the overuse of health services, to an instrument of privatization that reduces the government's responsibility to finance the healthcare system. As such, co-payments are primarily used to balance the budget of the health funds at the patients’ expense. This is done to the backdrop of a sharp increase in the private health expenditure, which, according to data of the Central Bureau of Statistics, increased by 34% since the implementation of the National Health Insurance Law.⁶ The private health expenditure rose to 23 billion shekels, which the public pays for out of its own pockets every year. This amount is infinitely higher than the accepted amount in most developed countries (including European members of the OECD, which Israel recently joined).

This burdening of the patients – who are required to pay for an increasing number of health services independently – damages the equity that is the goal of the National Health Insurance Law. According to data of the IMA and the Geocartography Institute’s 2010 annual survey on the subject of inequity, about one tenth of the Israeli public is forced to forgo a doctor’s visit due to the associated cost. Among disadvantaged populations, the percentage of people who forgo a doctor’s visit – up to 19% – is twice as high as the average number of those who forgo a doctor’s visit among the general population. Likewise, the percentage of people among the disadvantaged population who forgo pediatric care is up to 14%, three times higher than the average in the general population (5%). In recent years, interviewees from disadvantaged populations reported an increase in their sense of insecurity vis a vis their ability for pay for medications and medical care not included in the healthcare basket.

To this backdrop, there is an increasingly severe shortage of physicians in Israel. In the following chapters, we will examine the current data on this shortage and its ramifications on the crisis in the healthcare system. 

__________________________________________________________ 

1. Ministry of Health, Inpatient Institutions and Day Hospital Units in Israel, January 2011.
2. Knesset Research and Information Centre, The General System of Hospitalization in the 2011-2012 Proposed Budget, November 2010.               
3. Ibid.
4. Ministry of Health,Dealing with the Inequity in Health, November 2010, p. 89.
5. State Comptroller,Annual Report 45 for the 1994 Fiscal Year and Accounts for the 1993 Fiscal Year, April 1995, p. 180.
6. entral Bureau of Statistics,The National Health Expenditure – 1962-2007, 2009.