Israel has been doing comparatively well in the war against COVID-19. In a study done by the Taub Center for Social Policy in Israel, we had predicted that COVID-19 mortality would probably not exceed several hundred people. Simultaneously, there was a concern regarding collateral mortality that could match this figure in a year due to the long-standing weaknesses of the healthcare system that, naturally, have become more apparent during the crisis.
Israel’s 9.136 million residents (2019) are spread out over a relatively small land mass of 8,630 square miles. The population density, 1,070 per sqm, is less than that of Singapore, South Korea, and Taiwan, which have also done relatively well in fighting the virus, so far. Moreover, because of political and security reasons, Israel is a geopolitical island that is probably harder to penetrate than New Zealand that is praised for its relative success in the war. Thus, considering the nature of the spread of the virus, and the area and population to handle, Israel is not a formidable challenge, relatively speaking. The key port of entry that needed effective closure – Ben Gurion International Airport – turned out to be a challenge initially, symptomatic of what was about to come.
In addition, Israel’s population is young; those aged 65 and older make up approximately 10% of the population – whereas in most other developed countries those aged 65 and older make up twice that. The population of Israel is in relatively good health and that, in addition to young age, is associated with comparatively high levels of income and education. Thus, considering the mortality profile of the virus – old age, ill health and low socio-economic status – Israel has been predisposed to lower death rates than other developed countries.
Furthermore, the constant war footing, along with a centralized government and leading technology, prepared Israel to mobilize its resources quickly and efficiently in order to fight the virus; unlike Taiwan, for example, that did not anticipate a battle of this magnitude. This instinctive compliance helped the people to observe social distancing guidelines, and to quickly expand Israel’s capacity to handle potential, asymptomatic and mild cases. Indeed, these measures have been largely overseen and executed by the Defense Ministry, Israel Defense Forces’ Home Front Command, Police, as well as Israel’s Mossad (Secret Intelligence Service) that has quietly secured supplies from overseas for which other countries have competed. In part because of the war footing and despite some “tribalism,” Israel’s society shares a relatively high solidarity sentiment. This has been critical in mobilizing the civil society and in removing, for the time being at least, potential intergenerational strains between the younger “contributors” to the war and the older “beneficiaries.”
The combined factors above have helped Israel first and foremost, protect its weakened health care system thereby, protecting Israelis from the virus, thus far. This system – fortunate to have a highly skilled and motivated staff – suffers from long standing structural deficiencies, an inadequate political-authoritative standing, and lacks resources. Structurally, Israel does not have the clear separation between healthcare administrative roles of, say, the British National Health Service (NHS) and the policymaking, regulatory and supervisory roles of the British Ministry of Health. The State of Israel owns and runs, through the Health Ministry, about half of the acute care beds as well as maternal and child health services. Since 1976, seven state-appointed committees and the State Comptroller have recommended, ineffectively, that the Health Ministry relinquishes its administrative roles in favor of impartial and better policy making and oversight. As we suggest in two additional studies, the Ministry remains a dishonest broker in the system, a poor policy maker, and along with the Treasury, attempts to micro-manage a system the two Ministries barely comprehend.
While rightfully requiring — in time — the relative closure of the country and social distancing – the Health Ministry has not established clear policies due to its innate weak strategic planning capacity. One consequence is the practical absenteeism in the battleground of Israeli Sickness Funds with a vast lab, infrastructure and administrative capacity. Case and (crucial) point, the ministry insisted on – but has failed thus far – to administer testing of the population at large, especially of those high risk elderly living in geriatric facilities and of young people who could possibly be allowed to return to work, if not infected or recovered. This aspect of the war remains wobbly. Initially, the Health Ministry, short-sighted and over-confident in its lacking administrative capacities, even insisted that all the COVID-19 tests be conducted in its own central lab. Predictably overwhelmed, it has finally permitted samples to be tested in dozens of other labs around the country. In fact, the Health Ministry may have subordinated prudent policy to its (in)ability to administer tests.
The botched testing has hit most – again despite predictability, but with no surprise – nursing homes. Long-term care is the soft belly of Israel’s otherwise developed welfare system. In yet another study, we propose a unified authority to oversee long-term care — independent of the Health Ministry. This could have avoided some of the disproportionate mortality in nursing homes.
The consequences of the Health Ministry’s structural weaknesses translate into a weak political-authoritative standing in government and in society, at a time that the Ministry must uphold social distancing, in part to defend a health care system starved for years by the Treasury. While Israel’s medical professionals and technology are among the best in the world, its healthcare infrastructure and recurrent funding have been in a state of neglect for some time, as summarized in the Taub Center Overview from 2019. We have seen that even when adjusting for the young age of the population, the number of beds per 1,000 is 2.5 compared to 3.6 in the OECD. Similarly, the current financing of hospitalization has been comparatively low as well. The relative shortages are more acute in the country’s periphery.
In addition to inadequate infrastructure and funding, Israel suffers from perverse incentives to over-hospitalize. Israeli Sickness Funds reimburse hospitals, below cost, according to a state regulated “cap mechanism.” Consequently, this mechanism increases the Sickness Funds’ and others’ demand for hospitalization. The low bed-to-population ratio combined with those incentives leads to an exceptionally high annual number of patients per bed in Israel: about 66 versus an average of about 41 in the OECD countries. This reflects relatively short length-of-stay – 5.2 days versus 6.7 OECD average – on the one hand, and particularly high bed-occupancy rates – about 94%, versus 75%, on the other. This means that at the outset, Israel has no slack in acute hospitalization. This situation – known to the Ministry of Health – led to the “clearing out” – understandably under the circumstances – of patients from acute care institutions, just in case.
The clearing has been into a weakened community care system that – additionally – cannot sufficiently support those who refrain from approaching hospitals during this time, even for outpatient care. The capping system has minimized the incentive for providing care in the community, whether in health clinics or nursing homes. The capacity to provide medical care in the community has been deteriorating for some time. This clearly further decreased the healthcare system’s ability to deal with the challenge effectively in the community as well. Consequently, as noted above, the fear of peripheral mortality is not lesser in Israel today than the fear of virus mortality.
Israel’s success in the war is thus a combination of favorable geopolitics, demography-cum-health, standards of living, a state under conditions of closure and preparedness for emergencies, the public’s support and mobilization, and perhaps even some luck. If this success holds, many will “claim ownership,” the Health Ministry included. This is dangerous, if the public and politicians buy into it. First, the weaknesses of the system need to be considered now while a justified but risky opening of the economy, and second in anticipation of the ‘day after’ when the system faces collateral damage and routine emergencies.
Rehabilitation of the system requires: adjusting the system’s resources to levels of developed countries in the OECD; removing the Ministry of Health from administrative functions and over-involvement of the state in general in micro-managing the system; establishment of an independent authority for long term care; and the return of community care to the helm of medicine in Israel.
Dov Chernichovsky, Ph.D. is Professor emeritus of Health Economics and Policy, Ben Gurion University of the Negev, and chair of Health Policy Program, The Taub Center for Social Policy Research in Israel. The views are those of the author only.