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30 July 2025 | Policy Analysis
Strengthening existing and establishing new health units at the local level to improve health promotion among Arabs -
27 September 2019 | Policy Analysis
Publication of waiting times for specialists in the community -
16 January 2018 | Policy Analysis
Mapping gaps in availability of community care
User experience and equity of access to health care
In 2014, the Ministry of Health carried out a national survey of patients in general hospitals, the first such survey in over two decades: 75% of respondents indicated that they were satisfied with the hospital care overall and over 80% were satisfied with the care received from both the physicians and the nurses. A lower rate of satisfaction (73%) was found for receipt of information and explanations (Ekke-Zohar et al., 2015).
Over the two decades since the launch of NHI, the MJB Institute has been carrying out a biannual survey of the public’s experience with the health care system, with a particular focus on services provided by the HPs. In 2014, 89% of Israelis were satisfied or very satisfied with their HPs overall, and 61% felt that way about the health system overall; 55% of respondents indicated that they were able to see a specialist within two weeks (Brammli-Greenberg & Medina-Artom, 2015). However, 37% of respondents in the survey were unable to choose their providers for specialized services (such as hospital care), 22% experienced difficulties in securing HP authorizations for such services, and 18% experienced difficulty in accessing care in the evening or on weekends and holidays. In terms of not accessing care, 9% reported foregoing medical care because of distance for themselves or a family member over the past year and 12% reported having foregone care because of the waiting time involved. The financial burden of paying for health care was great or very great for 25%.
In another MJB Institute survey from 2012, patients reported good access to secondary care in the community (non-urgent), with average waiting times of three weeks to see a specialist. There are wide variations among specialties and place of residence. Patients living in the periphery waited longer to see a non-common specialist than patients in the centre; in the periphery, 56% waited more than a month compared with 38% in the centre. In general, half of the patients were satisfied with their waiting times and said they were “reasonable”. Those who said that they were not reasonable would have preferred to wait no more than one and a half weeks (Brammli-Greenberg, Waitzberg & Guberman, 2015).
In its report on the 2009 survey, the MJB Institute team included an in-depth analysis of the survey findings for various vulnerable populations: low income persons, Arabs, immigrants from the former USSR, the elderly and the seriously ill (Brammli-Greenberg & Medina-Artom, 2015). Not surprisingly, the financial burden and the likelihood of foregoing services are generally somewhat greater than average for most of these groups. The situation regarding satisfaction is complex, varying by aspect of care and population group. Moreover, it is important to keep in mind that satisfaction is affected by the interplay of expectations and experience, and expectations may well be below average for some of the vulnerable populations.
In recent years, there have been important improvements in several of the survey findings for some of the vulnerable populations. For example, several years ago the survey pointed to low mammography rates among the Arab population in some of the HPs, and this was subsequently corroborated by data from the national quality indicators programme. The HPs then undertook intensive remedial action and the next round of the survey found a significant improvement in the mammography rates. Similarly, the 2014 survey found substantial improvements in peripheral regions along a variety of indicators, which was consistent with recent governmental and HP initiatives to improve services in those areas.
Context
The Arab minority in Israel have faced significant health disparities compared with Jews, including lower life expectancy, higher chronic illness rates, and elevated infant mortality. Also, Arabs reside primarily in geographically peripheral and socioeconomically disadvantaged areas, where access to health workforce and infrastructure is more limited.
Recognizing these disparities, the Ministry of Health identified the need to strengthen the health system’s response to the needs of the Arab population. To this end, it conducted research to assess community needs and define appropriate intervention programs. As a result, priority was given to the most prevalent health issues in Arab communities, which include diabetes, obesity, genetic diseases, early childhood development, and mental health, with the goal of preventing disease and improving the quality of care.
Impetus for the reform
Israel’s healthcare system has long faced Arab-Jewish health disparities. The COVID-19 pandemic, followed by the war initiated in October 2023, highlighted the urgent need for a more resilient and equitable health system. In response and based on Government Resolution No. 550 “The Economic Program to Reduce Gaps in Arab Society by 2026”, the Ministry of Health launched a targeted initiative to improve health access and outcomes of the Arab population (see https://www.gov.il/he/pages/dec550_2021 for the text of the resolution).
Main purpose of the reform
The reform seeks to build sustainable, community-rooted health ecosystems that are responsive to local Arab needs.
Content and characteristics
The reform builds on local health governance units (health units) that have been established in several local authorities prior to the reform, operating at varying levels of capacity and scope. These units enable local authorities to take a proactive role in promoting health, preventing disease, and addressing social determinants of health. The health units operate as part of the local authority and focus on identified priority areas to promote the health of residents.
In the Arab population, where local authorities often enjoy high levels of trust, these units are seen as key agents of change. As part of the reform new health units have been established in 18 Arab local authorities and three additional units are currently being developed. The reform also supports existing health units in local authorities whose intervention programs meet the required criteria, enabling them to expand their activities.
The local health units promote disease prevention and bring health to the forefront of the local agenda. They work to encourage healthy lifestyles in the community through awareness days (for example, nutrition workshop for diabetes prevention), improving accessibility to health services (for example, child development services), and create infrastructure to support physical activity (for example, walking paths and exercise spaces were developed in 10 Arab towns).
Implementation steps taken
Health units are performing the following activities:
- Employing staff to promote residents’ health, often local residents familiar with the community’s needs;
- Training staff for strategic planning and community engagement;
- Creating operational work plans for 2025;
- Health campaigns, workshops, and organized community health days were held to promote healthy lifestyles and encourage behaviour changes. For example, obesity prevention programs were implemented, including among children.
Outcomes to date and evaluation
- A measurement and evaluation program was developed to assess progress in reducing disparities.
- A national dashboard of health indicators is under development to support long-term monitoring and transparency.
Authors
References
Waiting times are one of the main issues publicly discussed in Israel. Long waiting times in the public system, particularly for specialist care and elective procedures, are one of the main reasons why citizens purchase voluntary health insurance and turn to privately-funded providers. However, until now, data on waiting times were not publicly available apart from a few general surveys, and neither citizens nor the regulator knew how long waiting times were and to what extent they represent a barrier for access to health care.
As a result, the MoH decided to establish a national system for measuring and reporting on public waiting times for specialists, part of the “national program for strengthening the public health care system”. In June, 2019 the MoH published waiting times for specialists in the community by region on an interactive map of Israel (GIS-based) on its website. This is the first time that the MoH has collected and published data on waiting times from health plans (HPs). The map reports on median waiting times for non-emergency appointments by all HPs (aggregated) and refers to “waiting for a specific doctor” (this refers to a physician in a given speciality selected by the patient by name). Other measures can also be selected, such as averages and standard deviation. Data refer to five common specialties: orthopaedics, gynaecology, dermatology, ophthalmology, and otolaryngology, which represent roughly 70% of all specialist visits in the community each year. The map presents national data refined into 52 geographical areas.
These data will enable both the MoH and HPs to detect problems of availability of health care services and disparities between regions, and to plan actions to shorten waiting times. The idea is to publish up-to-date data, but it is too early to know how often the maps will be updated. It is also not known if data will be published by HP. Regarding waiting times for inpatient care, the MoH published data for the main elective procedures by hospital at the national level in 2015, but did not keep updating it.
The MoH is planning a second policy to tackle waiting times. In August 2019, the MoH approached the HPs and required them to publish their goals for maximum waiting times for a list of health services. These health services include: primary care physicians (e.g. family physicians, paediatricians), secondary care physicians (e.g. orthopaedics, dermatology), non-physician services (e.g. physical therapy, mammography) and psychiatry. The aim of this policy is to increase competition between HPs in terms of availability of care. Although the MoH has never defined maximum waiting times for health care services, by requiring HPs to define and publish maximum waiting times provides a step forward in this area. Despite these efforts, it remains unclear whether there are any standards for these waiting times. Although the MoH plans to set maximum waiting times at some point, the policy change is in its early stages and it remains unclear how and when these will be implemented.
Authors
References
MoH. Waiting times map web site. Available at: https://gis.health.gov.il/waitingtime/ (in Hebrew)
The MoH has begun to collect data on the availability of community care measured as physicians’ hours by specialty, region, and health plan (HP). These data were published in the MoH’s 2017 annual report on the reduction of gaps in health, and with the intention to continue publishing these data annually.
Data on service availability were obtained by scanning information from HPs’ websites, for a list of specialties: dermatology, family medicine, gynaecology, ophthalmology, orthopaedics, ENT, and paediatrics. “Availability” was measured as weekly hours of service per specialty per 1,000 population in each HP per region. The information was presented on maps, such that Israel was divided into about 50 areas and the rate of available physician hours per population was colour-coded.
Results show that there are substantial gaps in availability of services by HP and by region. As expected, the availability of primary-care physicians (PCP) is greater than for secondary care. However, the availability of PCPs varies among HPs. For example in one HP, PCP availability is similar across the regions, and ranges from 17 to 30 hours per 1,000 persons, while in another HP there are much more significant gaps in availability across regions. As expected, gaps in availability across regions are greater for secondary care than for primary care. In general, the biggest HP is characterized by greater uniformity in availability across regions for most specialties.
Areas found without any services for secondary care are rare, and they are located mainly in the far northern part of Israel (where most people live in small towns or villages). Naturally, there are more areas without specialists than areas without PCPs. For ENT and ophthalmology only, areas without service were identified for all HPs. Interestingly, there is a weak link between socio-economic level and availability of services, and there are specialty-HP combinations for which lower availability was found in central regions.
This mapping is part of a broad spatial analysis of the gaps in health and health services being carried out by the MoH in an effort to identify underserved areas. The NHI law does not determine standards of availability of health services, therefore policymakers are interested in understanding the current situation in order to address inequalities and gaps in availability of services across regions and HPs.
For the first time, the public can compare the availability of HP’s services by area of residence, which represents a new tool for choosing among HPs. This tool may enhance competition, which may lead to improvements in access and quality of care.