Feature

Health for all in a divided land

Israel has committed itself to Health for All, but faces major political and practical hurdles in reducing health inequalities. Jayne Thompson reports

Israel joined the European region of the World Health Organisation in 1985 to increase opportunities for participation in international initiatives and co-operation. In doing so it signed up to the commitment of Health For All by the Year 2000 (HFA), adopting the main principles of the European strategy and undertaking to realign policies affecting health closer to those in Europe.

One of the main themes of HFA is equality in health care and health status: everyone should be able to attain a basic standard of health, and inequalities between population groups should be reduced. The strategy also calls for a reorientation of national policies and systems affecting health. So how far has Israel gone towards equality and necessary changes in structure?

Israel has a public (ie non-profit) health care system, with two key players: the Ministry of Health and the major health insurance organisation, Kupat Holim Clalit (KHC), which insures approximately 70 per cent of the population. The system is one of voluntary health insurance, whereby individuals insured with KHC pay 4.5 per cent of their salary to the General Federation of Labour, the Histadrut, which then passes on 70 per cent of its income to its health fund, KHC. Under a law of ‘parallel dues’, the employer matches employee contributions.

KHC has a strong background of socialist principles and a philosophy of mutual support, but how does this work in practice, and how does the Ministry of Health work towards equality in health? Approximately 80 per cent of the population of Israel is Jewish and 20 per cent Arab, yet while approximately 25 per cent of the total Arab population is uninsured, only two per cent of Jews have no health insurance.¹ While KHC insures the majority of the population, including new immigrants, the elderly, and those receiving welfare benefits, only a very small number of Arabs undertake military service or go on to higher education, both systems which contribute either fully or in part towards health insurance.

Although the health status of the Israeli population compares well with other western developed countries, when the figures are broken down between population groups, gaps start to appear.

In addition to the inequalities in the system of voluntary health insurance discussed above, access to services and sanitary conditions is by no means guaranteed to all. Although Jewish kibbutzim and moshavim in rural areas enjoy excellent standards of healthcare, some rural Arab villages lack proper environmental standards and suffer from sanitation problems. Five per cent of the population lack access to sanitary facilities.²

Several Arab villages are not officially recognised by the Israeli government, resulting in a lack of services including sewerage facilities and a clean water supply.

Health service premises in such villages are small or non-existent, and some Arab villages of the north must rely on neighbouring Jewish settlements or charitable ventures for care.

Many non-governmental organisations (NGOs) provide health facilities in Israel, either on a charitable or private basis. But the majority of these are Jewish/Zionist organisations, many international, which specify that funds must be channelled to poorer, deprived areas of the Jewish community. NGOs working in the Arab sector are sometimes viewed with suspicion and are monitored very carefully by the authorities.

A recent major review of health services in Israel recommended a package of reforms including the introduction of a national mandatory health insurance law. This would ensure complete coverage of the population with one of four sick funds. The system would be one of payroll tax collected and distributed by the government according to a capitation formula; none of the funds would be able to refuse membership, as presently happens in the smaller sick funds.

Introduction of a national health insurance law is a major political issue. Depending upon which form is adopted, it could result in major upheavals not only in the health system but also the political and social maps of Israel.

The current exclusivity of some of the sick funds and their membership would be radically altered as more members would bring more revenue. KHC, currently suffering a financial deficit of NIS2.6bn (about £650m) would benefit under such a system as it has a larger, poorer and more elderly population than the other funds which can refuse membership. Some of the powers of the major trade union, the Histadrut, are being challenged and could be damaged as a result of introduction of such a law, under which individuals would no longer be required to join the union in order to be a member of KHC.

Under the recent change of government, an Arab was named deputy health minister. A committee has recently been convened to address the health needs of the Arab community and had to report to the government by this summer. It remains to be seen whether action will be taken to tackle the needs which the report will highlight, but this is nevertheless a positive sign that Israel is committed to achieving equality in health.

Primary care is accepted as being a major vehicle for change; reorientation of systems and increased funding for primary care are major issues in all countries. An advisor in family medicine has recently been appointed to the health minister and is in a prime position to inform and influence healthcare policy at the highest level.

Israel faces a major task in achieving equality in health for its citizens by the year 2000. The drafting of a national health insurance law, discussion of health needs of the more deprived sectors of the population, and the key position of a specialist in family medicine at the highest level are three significant steps in the right direction.

The healthcare system is highly politicised and it remains to be seen whether the health insurance law will be adopted. Arab-Jewish relations are as tense as ever, but this must not be allowed to hinder government efforts to improve the health status of both its Jewish and Arab citizens.

Several positive steps have been taken along the path to health equality. Review and consultation are the first phase. The next steps must be acknowledgement, action, and implementation if the goal is to be achieved.