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THE LANCET, One of the World’s Most Respected Medical Journals, Launches a Special Israel Issue “Health in Israel: Progress and Challenges in a Region of Conflict”

May. 09, 2017
Dr Richard Horton, Editor in Chief of The Lancet: “Our collaboration began in the aftermath of the tragedy of war between Israel and the Hamas-controlled Gaza Strip in 2014. In July 2014, in the very midst of the conflict The Lancet published a letter that divided medical opinion worldwide.We have learned lessons from this unfortunate episode. Our collaboration seeks to undo the harm and tarnish of this episode by transforming those experiences into constructive practice. We believe that The Lancet's Israel Series could serve as a springboard for increasing not only health and health equity within Israel and between Israel and its closest neighbours, but also offer a platform for greater engagement of Israeli physicians and medical scientists in issues of national and global health.”" 

Above: Third from left Prof. Richard Horton and in front of him Prof. Mark  A. Clarfield (Credit: Pyotr Pliter)

Israel’s health system ensures that a basket of health services is provided for its 8.68 million citizens, mostly free at point of service, which has led to strong progress in the health of the Israeli population, improving life expectancy and reducing infant mortality. 

However, challenges remain – for example, in addressing the health needs of an ageing society and for women and children’s health. Important health inequalities between Israeli Arabs and Israeli Jews and across different regions of the country also persist and must be addressed, according to a new Series in The Lancet examining health in Israel, which began its official launch at a special event in Tel Aviv on Monday. 

Additionally, the Series points to important examples of health care and scientific research crossing political and religious divides, offering opportunities for collaboration in a region of deep conflict. 

Dr Richard Horton, Editor in Chief of The Lancet, says: “This Series was conceived in the aftermath of a tragic conflict in 2014 between Israel and Gaza, and following publication of a letter that divided world medical opinion about that conflict. Through the generous and courageous outreach of the authors of this Series, we have sought to show that medicine and science can be a bridge to a better understanding of complex and seemingly intractable geopolitical challenges. Our future commitment is to work intensively with both our Palestinian and Israeli colleagues to provide the foundations in one aspect of society for peace and justice.” (Background information) 

The Series is part of The Lancet’s programme of country analyses investigating progress towards universal health coverage, and explores the unique aspects of health and health care delivery in Israel. The papers, authored by academics and policy makers in Israel, offer constructive recommendations for strengthening the country’s health care system, improving health, and addressing health inequalities in Israel. 

The Series was led by BGU’s Prof. A. Mark Clarfield (the Series’ guest editor), Israel National Institute for Health Policy and Services Research’s Prof. Orly Manor and Rambam Health Care Campus’s Prof. Zaher Azzam and will be launched at consecutive events in Tel-Aviv, Haifa, Nazareth, Beer Sheva, and Jerusalem during 8-10 May, 2017. 

Healthcare in Israel 

Overall, life expectancy has increased substantially and now stands at 80 years for men and 84 years for women (compared with 75.3 and 79.1 years, respectively, in 1993). Over the same period, infant mortality halved from 7.5 per 1000 live births to 3 per 1000. 

Universal health care insurance – via a landmark National Health Insurance Law - was enacted for all Israeli citizens in 1995, ensuring access to a range of core health services. Reviewed on an annual basis, these services initially included a more limited repertoire of medications, procedures, and tests. But in the past decade, they have expanded to include quality of life and preventive services. 

Although domestic spending on health has increased from 5% of GDP in 1960 to 7.6% in the 2000s, the level of spending has remained relatively constant for the past 20 years. The percentage of funding from public sources has slowly declined from 70% in 1995 to 60% today, with a parallel increase in household expenditure on health. 

Professor A. Mark Clarfield, director of the Medical School for International Health at Ben-Gurion University of the Negev, Beer Sheva, Israel, says: “Israel has made strong progress on health, but challenges remain. The slow, but increasing privatisation of services, and stagnating national expenditure on health must be addressed so as to ensure the country is able to continue providing good quality health care for its citizens. Given that health care delivery and representation in the health professions represent areas of the greatest equality among population sectors in Israel, residual troublesome disparities in health outcomes among population and regional groups reflect inequalities in the socioeconomic underpinnings of health and well-being.” 

Health disparities 

Israel’s population consists of many groups – 74.8% Israeli Jews and 20.8% Israeli Arabs (including Muslim, Druze, and Christian populations). Although there has been progress on health, inequalities persist, often as a result of underlying socioeconomic differences. For example, life expectancy is consistently higher among Israeli Jews compared with Israeli Arabs (80.3 vs 78 for men and 84.1 vs 80.9 for women). 

Smoking prevalence is twice as high among Israeli Arab men (43.9%) compared with Israeli Jewish men (22.1%), and lung cancer is much more common among Israeli Arabs, despite most other cancers being similarly common across both groups. Rates of diabetes and heart disease are also more common among Israeli Arabs. Disparities exist in terms of healthcare too. For example, Israeli Arab women are more likely to be diagnosed at a more advanced stage of breast cancer, and less likely to take part in screening programmes. 

Although progress has been made on reducing infant mortality (now at 3.1 deaths per 1000 live births), it remains twice as high among Israeli Arabs compared with Israeli Jews. Bedouin-Arabs have the highest rates of infant mortality at 11.3 per 1000 live births, which has decreased from 16 per 1000 in 2004. Additionally, about a third of children in Israel live in poverty, and rates are especially high among ultra-Orthodox Jewish communities (67%) and Arab communities (63%), compared with all other Israeli communities (15%). 

Israel is a relatively young country, but the proportion of people over 65 is predicted to rise from 11.1% in 2015 to 14.6% by 2035, putting pressure on health and social care. A unique aspect of Israeli society is the high proportion of immigrants, including from the former Soviet Union and Holocaust survivors who made up a third of the population aged 70 years and older in 2013. 

Dr. Khitam Muhsen, Tel Aviv University, Israel, says: “Overall, health in Israel has improved steadily over recent decades but disparities persist. Life expectancy has remained lower for Israeli Arabs compared to Israeli Jews and this gap has recently widened. Mortality from heart disease, stroke and diabetes remain higher for Israeli Arabs, as does smoking and obesity. All government ministries should make addressing health disparities between rich and poor and Israeli Arabs and Israeli Jews a priority.” 

Recommendations for improving health care in Israel 

The authors make several recommendations to improve health in Israel, including:   

•Increasing spending in the health sector from the current 7.8% of GDP to 9%, consistent with the OECD average. 

•Guaranteeing long-term funding for national health programmes aimed at reducing smoking, lowering sugar and salt content, and encouraging physical activity, especially among disadvantaged groups. 

•Halting the shift from public to private care, and ensuring the Ministry of Health focuses on long-term planning and funding for health care services, and divests itself from providing direct services or operating hospitals. 

•Increasing funding for home and community services to support an ageing population, including support for informal care-givers, as well as increased funding for acute hospital beds. 

•Extending maternity leave from 14 weeks to 6 months, providing contraception under health insurance plans, and introducing a formal government office or department in the Ministry of Health focusing on gender and health. 

•Supporting research through the creation of an Institute of Health Research, under the auspices of the Israel Science Foundation, similar to the National Institutes of Health in the United States or the Medical Research Council in the United Kingdom.  

Collaboration in a region of conflict 

Finally, the Series points to examples of collaboration in the fields of science and health care across historical, demographic, ethnic, political and economic divides. While diplomatic relationships are either non-existent or limited between Israel and its neighbouring countries, shared public health issues such as disease, pathogens or water sources require collaboration between Israel and its neighbours, most especially the Palestinian population. For instance, regional collaboration between Israeli, Jordanian, and Palestinian veterinary and public health services helped contain the outbreak of influenza A H5N1. 

Additionally, an accompanying paper details the medical effort in treating over 2,000 Syrian patients who have made their way over the border and been treated in hospitals in Israel, despite the countries being in a state of war. 

Prof. Karl Skorecki, Rambam Health Care Campus, Haifa, adds: “This Series shows that there is an enormous opportunity 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.  It is especially in those areas of greatest challenge where Israel has shown innovative leadership, that greater mutual engagement in global health forums is most urgently needed.”