The Health Ministry budget that Israel's cabinet approved Monday morning brings some good news, particularly for resident doctors and mental health patients. However, there are noticeable gaps in some of the health system's biggest problems: service availability, the gaps between the country's center and outskirts, and ward overcrowding.
Health Minister Nitzan Horowitz received his requested boost of two billion shekels ($621 million) for the Health Ministry budget, amounting to a total of 45 billion shekels ($13.9 billion) next year. But the health system has a long list of needs due to years of cutbacks and a crumbling infrastructure, and the additional funds aren’t enough to bridge the gaps that became even more obvious during the COVID-19 pandemic.
1. Mental health
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This area of health has been suffering for years from underfunding that has seriously affected its infrastructure, availability, as well as the conditions in psychiatric hospital wards. The good news is 400 million shekels will be dedicated to the construction and renovation of mental health centers and psychiatric hospitals.
The renovations are part of a more comprehensive program under which 400 chronic patients will be transferred from psychiatric hospitals to community frameworks. These are patients who have been institutionalized for years, sometimes for their whole lives, in psychiatric wards since there is no suitable accommodation for them within communities. There is also a plan of building additional "balancing houses," another alternative to hospitalization. There are currently only twelve such houses, and the relevant population needs 130 in order to meet its needs.
Another plan that will receive funding is the formation of crisis teams that will visit patients' homes, an idea which has been lobbied for by different organizations, parents, and patients. Horowitz is planning that the health maintenance organizations (HMOs) will set up and operate such teams. There is also agreement on a comprehensive plan to shorten the wait times for psychotherapy appointments for HMO members, who often wait more than a year for treatment.
Despite these welcome changes, the mental health system's rehabilitation will take years and require billions of more shekels. Before that, awareness needs to be raised that mental distress and illness are widespread, and can be found in every stratum of society, and that people’s suffering can be alleviated.
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The stigma attached to mental health treatment has left the field without a strong lobby for years. This has also had an effect on the availability and quality of therapy: Medical students are overall less keen to specialize in psychiatry and work in psychiatric hospitals.
2. Shortening resident doctors' shifts
The additional funding will allow for the launch of a multiyear program to reduce the length of a resident’s shift from 26 hours to 16 hours in emergency rooms, internal medicine, pediatric, gynecology, neurology, and radiology departments.
The struggle to shorten these shifts has been waged for years and got reinvigorated during the COVID-19 pandemic. The move had been discussed and was included in the 2011 wage agreement with physicians, which called for a pilot project to advance the issue, but nothing materialized from those efforts. After a long struggle by residents, it seems that the move will go forward. However, implementation was never just a budgetary matter, as it also involved considerations about the training quality that residents would receive if their shifts were shortened.
It's unclear how many years this program will take. During the budget discussions, residents protested upon learning that the treasury wanted the program implemented over a duration of 10 years. Residents also protested that the plan would be implemented for only a few specialties. “We will not hesitate to strike, and even resign, if a plan isn’t approved to shorten shifts for all residents in all specialties immediately, and will be implemented over two years at the most,” said a statement by Mirsham, the medical residents’ association.
3. Hospitals in Israel's peripheral communities
The Health Ministry boasted its allocation of six new MRI machines to Israel's peripheral communities, where for the first time they will be operated there by HMOs. But this is merely a symbolic gesture that doesn’t solve the shortage of MRI machines and medical care in general in Israel's outskirts. This allocation shows that the Health Ministry is aware of the inequality, but is far from resolving it. Essentially, as far as health services are concerned, there are two states within Israel: one in its center and one in the periphery. Anyone moving from the center of the country to a more outlying town must take into account that the quality and availability of health services will decrease.
These gaps are evident by any measure: in the number of doctors and personnel per thousand people, the number of hospital beds, waiting times for medical consultations, child development services, and surgeries, as well as the physical distance from dialysis machines for kidney patients, and even emergency rooms. Because of this, many patients outside the big cities must spend hours on the roads to get decent medical care in the country’s center. This inequality will be difficult to change in the upcoming years with the current budget.
It was also decided to increase the public hospitals budget by 500 million shekels, and that these hospitals will be able to keep the personnel slots that were added during the pandemic – a total of 600 doctors, 1,550 nurses and 700 other workers. It was also decided to expand admission to medical education; the goal is to add annually 270 new slots for medical students and 1,500 for nursing students in Israeli medical schools.
Currently, 60 percent of all new Israeli doctors were trained abroad, and their relative size in hospital staffs increases as you get farther from the country's center. Over the past few years some 300 slots for medical students have been added; in 2020 there were 825 students who began studying medicine in Israel. The Health Ministry one thousand new students within the upcoming years.
4. Changes to the Healthcare Services Basket
The new budget also increases funding for the so-called Healthcare Services Basket, the list of subsidized medication and treatments, in the public health system. In recent years, the addition to the budget was 500 million shekels annually, but in the coming years it will grow to 600 million shekels annually, of which 50 million shekels will be allocated to a national program for preventive medicine.
This will make it easier for the Healthcare Services Basket committee, which every year must exclude vital drugs because of budget limitations. But, it still cannot supply all of Israel’s needs. Experts believe that Israel must add 2 percent to the health budget basket annually i.e. 900 million shekels, but past efforts to increase it to even 700 million have failed.
5. Despite the new funding for fields that were glossed over for years, the health budget doesn't do nearly enough to improve the system. “I’m pleased that 2 billion shekels are coming into the system, but the health system has so many holes, so it’s not enough,” said Prof. Gabi Bin Nun, of the Department of Health Systems Management at Ben-Gurion University of the Negev. “It’s particularly disappointing because one of the most important conclusions from the coronavirus crisis is that we must strengthen the public health system.
“Although the health system was funded with a special budget to cope with the coronavirus, it relied to a great extent on the sacrifice and dedication of its medical staffs. There’s a limit to sacrifice, and Israel needs a strong health system,” he said.
The budget increase will not bring Israel’s health system in line with that of the OECD countries. “The cost per capita for health in Israel in 2020 was $3,260, compared to an average $4,540 in the OECD,” Bin Nun said. “Public funding in those countries comes to 80 percent of expenditure, while here in the past year it was 70 percent. It’s true that in the past year there was an increase in public spending on health, but like everywhere in the world, it was to cope with the coronavirus.”
Israel will probably remain near the bottom of the rankings in terms of physicians and nurses per capita even after the budget is approved, and the overcrowded wards and lack of appointments will remain. “The waiting lists here are at such a level that I think patients are paying with their lives,” said Bin Nun. “There has been a fundamental neglect of the system, which to correct will require an additional 5 billion shekels to the budget base.”
After the budget's approval was announced, the Israel Society of Internal Medicine sent a letter to Health Ministry director-general Nachman Ash that said that "once again, internal medicine was left out of the Health Ministry's budget."