This section begins with an introduction to the overall framework of the Israeli Government in terms of health care in the country, and continues with a description of the organization of the Ministry of Health and the health care system.
Israel is a parliamentary democracy and it is the Knesset that ultimately determines laws and budgets. Since the mid-1990s, the Knesset has been very active in health-related legislation, passing such laws as the NHI Law of 1995 and the Patients’ Rights Law of 1996. The key Knesset committees relating to health are the Finance Committee, which prepares the annual budget for votes in the plenum, and the Labour, Social Affairs and Health Committee, which is formally charged with the leading role on health issues.
It is important to note that since the mid-1990s much use has been made of the annual Budget Arrangements Bill, which accompanies the national budget, to move health and other social policy matters quickly through the Knesset in late December as part of the annual budgeting process. This Bill is handled by the Finance Committee rather than by the Labour, Social Affairs and Health Committee, and its use for substantive issues has come under increasing criticism on the part of Israel’s social lobby (a loose network of Knesset members and nongovernmental organizations (NGOs) that seeks to advance legislation to promote equality and the well-being of low-income groups).
Executive power is in the hands of the government. After each round of parliamentary elections, the president (whose role is primarily ceremonial) asks the leader of the largest party to try to assemble a government (cabinet), which must secure and maintain majority support in the Knesset. This is done through the distribution of cabinet portfolios among the various coalition parties. Until the 1990s, the health portfolio was given to one of the smaller, less powerful parties, with the major parties preferring the more visible and powerful portfolios such as Foreign Affairs, Finance, Defence and Education. The period from 1990 to 1994 was unique, as the Ministry of Health was held by major players: first by one of the rising stars of the Likud Party and then by a rising star of the Labor Party. This was a reflection of the growing salience of health care issues in Israel. Between 1995 and 2013, there were 12 ministers of health, some from the smaller parties and some second-tier figures from the dominant parties.
The government plays a role in health care at several critical junctures. First, while the Knesset ultimately must vote on the annual budget, it is the government that prepares and submits the budget. The Ministry of Finance and its powerful Budget Division play a critical role in drafting the budget. However, the government ultimately determines what is proposed in the budget sent to the Knesset, and the political balance of power, as well as the policy priorities of the government as a whole, invariably affect allocations to health care.
Similarly, the government plays an important role in the legislative process. While the Knesset will entertain private members’ bills, in practice most legislation – and almost all major legislation – is submitted by the government. While the relevant ministry prepares the bill concerned, the government’s Ministerial Committee on Legislation plays an important role. For example, in the case of the NHI Law, this was the place where a crucial compromise was reached whereby the Minister of Finance agreed to support the bill on the condition that the Minister of Health would agree to various measures that would serve to control NHI expenditure.
In some cases, elected officials need to decide whether to introduce major health reforms via legislation (which can only be enacted by the Knesset) or via governmental administrative decrees. This was illustrated by the mental health insurance reform (see section 6.1.2), where, after numerous failed attempts to pass legislation enacting the reform, in 2012 the government gave up on the legislative route and introduced the reform via administrative decree.
The Ministry of Health has overall responsibility for the health of the population and the effective functioning of the health care system. The Ministry is headed by the Minister of Health, who is a member of the government (cabinet) and appoints a physician as Director-General, the Ministry’s senior health care professional.
Key functions of the Ministry of Health include:
In addition to all the usual planning, public health, regulatory and stewardship functions, Israel’s Ministry of Health also plays a major role in the direct provision of care. It owns and operates almost half of the nation’s acute hospital beds, approximately two thirds of the psychiatric hospital beds and less than 10% of the chronic disease beds. In addition, it operates many of the nation’s mother and child preventive health centres. This multiplicity of Ministry roles has long been recognized[5] as one of the problems of the Israeli health care system, and it is an issue that is discussed further in section 5.1.
The Ministry of Health receives important input from various advisory bodies. These include the National Health Council, a statutory body established to advise the Minister of Health on implementation of the NHI Law, and a series of standing national councils on, for example, community medicine, oncology, cardiovascular diseases and women’s health; these are appointed to advise the Director-General on both long-term goals and pressing issues requiring immediate policy response.
In the wake of the 2014 report of the German Committee (see section 6.2), steps were initiated to establish a government hospital authority, which would be separate from the Ministry of Health (although still reporting to the Minister of Health).
The Ministry of Finance. As noted above, this is the agency of the executive branch that prepares the budget for approval by the cabinet and Knesset, and monitors its implementation. Historically, its budget division has also been a catalyst for major structural reforms in Israeli health care. In addition, the Ministry’s Wages and Collective Bargaining Division is the lead government actor in negotiations with the health care labour unions. Its Finance and Capital Markets Division plays an important role in regulating the commercial insurance sector. Consequently, the Ministry of Finance has multiple, powerful points of influence over Israeli health care. As in other countries, the Ministry of Finance is the key governmental actor that consistently seeks to limit public spending on health care, to constrain the construction of new health care facilities and to limit the number of employed physicians.
The National Insurance Institute (NII). This collects the health tax that plays a major role in the financing of the NHI system (see Chapter 3 for further details).
The Israel Defence Force (IDF). The Medical Corps of the IDF provides basic and emergency care for military personnel directly and purchases tertiary services from the civilian sector.
The Israel Prison Service. This has its own system for providing medical services to prisoners.
HPs. HPs are voluntary, non-profit-making organizations, obliged to ensure that their members have access to a benefits package, as specified in the NHI Law. In return, the HPs receive an annual capitation fee per member from the government. At the time of writing, there are four HPs and their market shares at the end of 2013 were as follows: Clalit, 52%; Maccabi, 25%; Meuhedet, 14%; and Leumit, 9%. The HPs are governed by boards of directors. In some HPs the members are chosen by parent organizations (labour federations), while in other cases they are indirectly elected by the members of the plan.
Hospitals. While the government owns approximately half of the acute beds, Clalit owns one third of the acute beds and the remaining beds are owned by various non-profit-making and profit-making entities.
Magen David Adom (“Red Star of David”). Israel’s equivalent of the Red Cross operates ambulances and other emergency services.
Pharmaceutical companies. The major international pharmaceutical companies are active in Israel, both in terms of marketing their products and in trying to influence public policy through their industry association Pharma.
Health care unions. Most notable in this regard are the IMA and the Israel Nurses Association (see section 3.7.2).
Universities. Israel has seven research universities and numerous colleges, and they play a pivotal role in training health care professionals.
Research centres. Centres such as the Myers-JDC-Brookdale (MJB) Institute and the Gertner Center, along with various university-based research units, play a pivotal role in the monitoring and evaluation of health care services. In the past decade, the two largest HPs have also established research institutes. The National Institute for Health Policy and Health Services Research plays an important coordinating role.
Advocacy groups and patient organizations. Many of these are organized around specific diseases, health risks (such as accidents) or health care services.
It is worth noting that the category “employers” does not appear on this list. Employers used to play an important role in health care financing, but they no longer do so (see Chapter 3 for further details).
In theory, citizens can influence Israeli health policy through several major channels. The first is the political parties’ primary elections and the Knesset elections themselves (for other methods of citizen participation, see section 2.9.5). However, throughout the history of the State of Israel, domestic issues in general and health care in particular have not figured prominently in election campaigns. One important exception was the 1992 general election campaign in which the introduction of NHI and, to an even greater extent, reduction of corruption in the Histadrut and its separation from Clalit constituted central campaign issues for both main parties.
It should be noted that the political parties had a substantial impact on health policy even during periods when health policy was not a central campaign issue.[6] For many years, the Labor Party resisted efforts to eliminate the HP system in favour of a unitary, government-run NHI system. It also successfully fought for government subsidies of the Histadrut-affiliated HP. Conversely, for decades the revisionist parties, predecessors of the current Likud, used their political power to block any NHI legislation that would preserve the dominance of the Histadrut-affiliated HP. The religious parties used their pivotal role in the political balance of power both to influence NHI legislation and to influence legislation on sensitive issues such as abortion and autopsies.
In recent years, while the political parties per se have not sought to advance particular health policy issues, the policy agendas of the ministers of health appear to have been influenced, at least in part, by their party affiliations. For example, the minister who served from 2013 to 2014 was particularly attuned to middle class concerns, which is not surprising as the middle class is the core constituency of her party. Similarly, the current minister appeared to be particularly attuned to the needs of his party’s core constituency – low income ultra-Orthodox Jews.