Health and health care in Israel: an introduction

Searching the Internet for psychiatric disorders among Arab and Jewish Israelis: insights from a comprehensive infodemiological survey

Israel represents a complex and pluralistic society comprising two major ethno-national groups, Israeli Jews and Israeli Arabs, which differ in terms of religious and cultural values as well as social constructs. According to the so-called “diversification hypothesis”, within the framework of e-health and in the era of new information and communication technologies, seeking online health information could be a channel to increase health literacy, especially among disadvantaged groups. However, little is known concerning digital seeking behavior and, in particular, digital mental health literacy. This study was conducted in order to fill in this gap. Concerning raw figures, unadjusted for confounding variables (time, population size, Internet penetration index, disease rate), “depression” searched in Hebrew was characterized by 1.5 times higher search volumes, slightly declining throughout time, whereas relative search volumes (RSVs) related to “depression” searched in Arabic tended to increase over the years. Similar patterns could be detected for “phobia” (in Hebrew 1.4-fold higher than in Arabic) and for “anxiety” (with the searches performed in Hebrew 2.3 times higher than in Arabic). “Suicide” in Hebrew was searched 2.0-fold more than in Arabic (interestingly for both languages search volumes exhibited seasonal cyclic patterns). Eating disorders were searched more in Hebrew: 8.0-times more for “bulimia”, whilst “anorexia” was searched in Hebrew only. When adjusting for confounding variables, association between digital seeking behavior and ethnicity remained statistically significant (p-value < 0.0001) for all psychiatric disorders considered in the current investigation, except for “bulimia” (p = 0.989). More in details, Israeli Arabs searched for mental health disorders less than Jews, apart from “depression”. Arab and Jewish Israelis, besides differing in terms of language, religion, social and cultural values, have different patterns of usage of healthcare services and provisions, as well as e-healthcare services concerning mental health. Policy- and decision-makers should be aware of this and make their best efforts to promote digital health literacy among the Arab population in Israel.

Expanding Canadian Medicare to include a national pharmaceutical benefit while controlling expenditures: possible lessons from Israel

In Canada, there is an ongoing debate about whether to expand Medicare to include a national pharmaceutical benefit on a universal basis. The potential health benefits are understood to be significant, but there are ongoing concerns about affordability. In Israel, the National Health Insurance benefits package includes a comprehensive pharmaceutical benefit. Nonetheless, per capita pharmaceutical spending is well below that of Canada and the Organization for Economic Co-operation and Development average. This paper highlights seven strategies that Israel has employed to constrain pharmaceutical spending: (1) prioritizing new technologies, subject to a global budget constraint; (2) using regulations and market power to secure fair and reasonable prices; (3) establishing an efficient pharmaceutical distribution system; (4) promoting effective prescribing behavior; (5) avoiding artificial inflation of consumer demand; (6) striking an appropriate balance between respect for IP rights, access and cost containment; and (7) developing a shared societal understanding about the value and limits of pharmaceutical spending. Some of these strategies are already in place in some parts of Canada. Others could be introduced into Canada, and might contribute to the affordability of a national pharmaceutical benefit, but substantial adaptation would be needed. For example, in Israel the health maintenance organizations (HMOs) play a central role in promoting effective prescribing behavior, whereas in HMO-free Canada other mechanisms are needed to advance this important goal.

Bismarck and the Long Road to Universal Health Coverage

The 2015 Sustainable Development Goals (SDGs) state that All United Nations Member States have agreed to try to achieve Universal Health Coverage by 2030. This includes financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Universal health coverage (UHC) means inclusion and empowerment for all people to access medical care, including treatment and prevention services. UHC exists in all the industrial nations except the US, which has a mixed public-private system and struggles with closing the gap between the insured and the uninsured population. Middle- and low-income countries face many challenges for UHC achievement, including low levels of funding, lack of personnel, weak health management, and issues of availability of services favoring middle- and upper-class communities. Community health services for preventive and curative health services for needs in populations at risk for poor health in low-income countries must be addressed with proactive health promotion initiatives for the double burden of infectious and noncommunicable diseases. Each nation will develop its own unique approach to national health systems, but there are models used by a number of countries based on principles of national responsibility for health, social solidarity for providing funding, and for effective ways of providing care with comprehensiveness, efficiency, quality, and cost containment. Universal access does not eliminate social inequalities in health by itself, including a wide context of reducing social inequities. Understanding national health systems requires examining representative models of different systems.

Health reform is necessarily a continuing process as all countries must adapt to face challenges of cost constraints, inequalities in access to care, aging populations, emergence of new disease conditions and advancing technology including the growing capacity of medicine, public health and health promotion. The growing stress of increasing obesity, diabetes, and other chronic diseases, requires nations to modify their health care systems. Learning from the systems developed in different countries helps to learn from the processes of change in other countries.

From Population Databases to Research and Informed Health Decisions and Policy

Background

In the era of big data, the medical community is inspired to maximize the utilization and processing of the rapidly expanding medical datasets for clinical-related and policy-driven research. This requires a medical database that can be aggregated, interpreted, and integrated at both the individual and population levels. Policymakers seek data as a lever for wise, evidence-based decision-making and information-driven policy. Yet, bridging the gap between data collection, research, and policymaking, is a major challenge.

The model

To bridge this gap, we propose a four-step model: (A) creating a conjoined task force of all relevant parties to declare a national program to promote collaborations; (B) promoting a national digital records project, or at least a network of synchronized and integrated databases, in an accessible transparent manner; (C) creating an interoperative national research environment to enable the analysis of the organized and integrated data and to generate evidence; and (D) utilizing the evidence to improve decision-making, to support a wisely chosen national policy. For the latter purpose, we also developed a novel multidimensional set of criteria to illuminate insights and estimate the risk for future morbidity based on current medical conditions.

Conclusion

Used by policymakers, providers of health plans, caregivers, and health organizations, we presume this model will assist transforming evidence generation to support the design of health policy and programs, as well as improved decision-making about health and health care, at all levels: individual, communal, organizational, and national.

Social considerations of inflammatory bowel disease in Southern Israel

Chronic diseases pose unique social challenges beyond traditional health considerations that require specific attention. In this report, we examine the case of a middle-aged woman with ulcerative colitis, living in Southern Israel. Trust between the patient and physician is shown to positively influence a variety of therapeutic outcomes and should be considered a fundamental component of successful care. In context of the military conflict between Israel and Gaza, the needs of patients with chronic diseases cannot be forgotten. The work environment is also identified as an area of particular concern, as a supportive work environment is essential in order to maintain satisfaction in the workplace and sustain a high quality of life. Out-of-pocket costs for medications are confirmed to be a significant barrier to adherence. Better understanding of patients’ financial capabilities, along with affordable therapeutic interventions, will alleviate healthcare-related financial burdens and improve health outcomes.

Inequalities in non-communicable diseases between the major population groups in Israel: achievements and challenges

Israel is a high-income country with an advanced health system and universal health-care insurance. Overall, the health status has improved steadily over recent decades. We examined differences in morbidity, mortality, and risk factors for selected non-communicable diseases (NCDs) between subpopulation groups. Between 1975 and 2014, life expectancy in Israel steadily increased and is currently above the average life expectancy for the Organisation for Economic Co-operation and Development countries. Nevertheless, life expectancy has remained lower among Israeli Arabs than Israeli Jews, and this gap has recently widened. Age-adjusted mortality as a result of heart disease, stroke, or diabetes remains higher in Arabs, whereas age-adjusted incidence and mortality of cancer were higher among Jews. The prevalence of obesity and low physical activity in Israel is considerably higher among Arabs than Jews. Smoking prevalence is highest for Arab men and lowest for Arab women. Health inequalities are also evident by the indicators of socioeconomic position and in subpopulations, such as immigrants from the former Soviet Union, ultra-Orthodox Jews, and Bedouin Arabs. Despite universal health coverage and substantial improvements in the overall health of the Israeli population, substantial inequalities in NCDs persist. These differences might be explained, at least in part, by gaps in social determinants of health. The Ministry of Health has developed comprehensive programmes to reduce these inequalities between the major population groups. Sustained coordinated multisectoral efforts are needed to achieve a greater impact and to address other social inequalities.

Israel: health and beyond

The principle that global human identity and dignity supersede other values is a broadly accepted conviction that guides practice and policies in the realm of human health in most of the world. An assessment of the level of success that Israel has achieved in health, in the face of formidable challenges, including rapid population growth, diverse and often divided ethnic affiliations, and existential security threats, leads us to propose that extension of this principle of global human identity and dignity, together with the objective of a decent society, as overriding values beyond health to other domains of human endeavour within Israel and in its relations with neighbouring peoples, represents an entirely achievable imperative. The result will be to further advance Israel's aspiration to serve as a model for societal decency with wide international acceptance and engagement. We have identified several determinants of Israel's advancement in health, including: articulation of a clear vision, national purpose, and long-term commitment that seeks to take the health of its citizens seriously; a multi-ethnic population that brings diversity and energy to national progress; a political democracy, which is characterised by robust debate and discussion about the nation's future; national legislation governing cardinal health-care processes; cultural and religious histories that respect and revere scholarship, learning, research, and charitable donation; an expanding economy, with recent but increasing appreciation of the economic, social, and political underpinnings of health and health inequalities; a strong base of international support from the Diaspora Jewish community; and a strong desire for acceptance by the international community in key arenas, especially science and health. As a result, despite the fewer than seven decades since its establishment, Israel has achieved important milestones in health. Nevertheless, this trajectory of achievement is threatened by several serious challenges, including the capacity to sustain high-quality universal health coverage, especially for an ageing population living with multiple comorbidities in the face of a stagnant level of the percentage of treasury funding to health care at a level that is well below the average of the Organisation for Economic Co-operation and Development; ever-increasing transfer of services and care covered by the mandatory public health services basket to private programmes; insufficient progress in resolving health disparities among and between communities, populations, and regions of the country congruent with disparities in income and employment; gender inequities; a looming increase in the already alarming shortfall in health-care professionals; and failure to match inpatient and acute care facilities to manage growing needs. These challenges within Israel are magnified in the context of health disparities with the neighbouring Palestinian population, a situation in which ongoing-but fragile and limited-health cooperation and training arrangements cannot stand in for a solution that will address Palestinian national aspirations. We come away from this Series with a great sense of optimism, but with specific recommendations that are based on the foregoing challenges. We believe that by increasing the investment in the health sector, which includes investing in the societal, political, educational, and environmental underpinnings of health, far more can be achieved to move Israel to a model international leadership position in health care, education, and research, and turn health into an engine for economic wellbeing and development. Religious leadership in Israel, with its formidable political influence, can be harnessed to promote health initiatives in areas ranging from smoking cessation and healthy diet to organ transplantation, and most of all condemnation of hostility and its replacement by peaceful resolution of even the deepest conflicts. Most of all, this Series showed that there is an enormous opportunity, which Israel can lead, to leverage the universally accepted principles of health as a sanctuary against conflict and inequity, to achieve a brighter future for a deeply troubled region of the world.

Coming of age: health-care challenges of an ageing population in Israel

Although Israel is still young in years, with relatively high birth rates and older people (individuals aged 65 years or older) constituting only about 11% of its population, the absolute number of older people is growing rapidly. Life expectancy is high, and increasing numbers of people are living to advanced old age (older than 85 years). A wide spectrum of geriatric care is provided within a universal system providing health services to all citizens. Community and institutional care is available, and many innovative programmes are being developed. The unique demographic characteristics of the ageing society in Israel reflect cultural and multiethnic diversity, in addition to a high rate of immigration of older people. To meet the growing challenges, address disparities, and search for innovation will require planning and development of adequate services at the highest level.