For the south, the numbers are grim. Israelis there have to suffice with 2.1 doctors per thousand people, compared with 5.3 in Tel Aviv. Only 18 percent of the pediatricians in the Negev are graduates of Israeli medical schools.
And of the physicians who began practicing in the south in 2019, 56 percent were trained in countries whose medical schools, starting in 2026, won't be recognized if their graduates want to become doctors in Israel.
Moreover, those numbers in the south, the worst in Israel, reflect a national trend expected to worsen in the next decade and a half, with all outlying areas the laggards, a new study shows.
Currently 29,700 doctors are active in Israel, or 3.19 per thousand people. This number has actually risen over the past decade but is still lower than the 3.5 average in the Organization of Economic Cooperation and Development, of which Israel is a member.
The Health Ministry predicts that the number will rise to 3.3 by 2025 before falling in the following decade and by 2035 reaching only 3.22 doctors per thousand people. But when factoring in the aging population, the number will stand at only 3.02.
A new report by the ministry’s Financial and Strategic Planning Administration reveals the difficulties in increasing doctor numbers without compromising on the quality of health care.
“At this time of the coronavirus pandemic, claims have often been heard that the shortage of physicians and other medical personnel is the main source of the health care system’s limitations,” the report states. “People who work in the field say that this difficulty is felt not only during a global pandemic but also clearly every winter.”
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Israelis’ longer lives are definitely having an effect. According to the Central Bureau of Statistics, at the end of 2018, people 75 and older made up 4.8 percent of the population, while by 2035 this figure will climb to 7.1 percent and by 2050 to 8 percent.
Another factor is the retirement of physicians, many of whom emigrated from the former Soviet Union in the 1990s. But the key element appears to be the difficulty in expanding training for doctors at a rate matching the population’s needs.
Physician training is a complex matter. It usually takes from seven to 12 years including theoretical studies, clinical studies that includes hands-on experience, an internship and a residency. The clinical part is key, but departments only have so many positions.
“Only a thin layer of excellent achievers make it into medical school,” the report states. For example, in 2017, the average standardized-test score of students who didn’t make it into medical school was 711 out of 800; for students who were accepted, it was 735.
In recent years, the Health Ministry and the Council for Higher Education have strived to increase the number of medical students. In 2019, there were about 4,700 med students, compared with 3,500 in 2009. In 2020, 825 students began medical school, compared with 694 in 2011.
As a result, doctor numbers have risen, but the biggest increase has been that of Israeli students trained abroad, now at 60 percent of Israel’s new doctors.
“The dramatic increase in the number of Israeli medical students trained abroad stems from the relatively easy conditions for obtaining a medical license abroad,” the report states.
With these schools’ academic and clinical levels lower, sometimes very low, “this is a worrisome phenomenon that could eventually seriously impact the quality of medicine in Israel,” the report adds.
In 2019, the Health Ministry thus began to toughen its conditions for obtaining a doctor’s license in Israel, which is expected to significantly reduce the number of graduates of foreign medical schools working as doctors here.
The past decade has indeed seen an increase in the number of students trained in Israel, says Rachel Brenner Shalem, a senior strategic and economic planning official at the Health Ministry. But Brenner Shalem, one of the authors of the report, says there has been a much greater increase in the number of students studying abroad.
“Three years ago the licensing department began to receive complaints about the low level of interns. These were extreme complaints – a person who hadn’t seen a patient at any time during his studies or doctors who couldn’t be trusted to care for patients,” she said.
“The department checked and found that the worse the foreign school was, the more Israelis attended it. Many students who weren’t accepted to medical school in Israel looked for alternatives and got to these places.”
Still, up to 25 percent of graduates of medical schools abroad – for example, in Ukraine, Georgia and Moldavia – pass Israel’s licensing exams.
Meanwhile, strong hospitals in the center of the country are in demand among graduates, with hospitals in outlying areas making do mainly with graduates from abroad. Of residents at Barzilai Medical Center in Ashkelon, 91 percent are graduates of foreign schools. This number is 98 percent at Nazareth Hospital, 82 percent at Ziv Medical Center in Safed and Poriya Hospital in Tiberias, 78 percent at Laniado Hospital in Netanya, 30 percent at Sheba Medical Center in Tel Hashomer, 24 percent at Ichilov Hospital in Tel Aviv and only 10 percent at Beilinson Hospital in Petah Tikva, a Tel Aviv suburb.
The Health Ministry aims for at least 60 percent of new doctors to be graduates of Israeli medical schools; it would achieve this by increasing the number of slots at these schools. The ministry also wants to raise the game of physicians from abroad. All told, it hopes to see around 2,000 new doctors a year, 1,200 of them graduates of Israeli schools.
But Israel’s medical schools aren’t equipped to increase student numbers by a third. A key effort will therefore be increasing the number of clinical training spots, developing new spots in the community, and adding on simulations and other learning methods. Brenner Shalem says the Council for Higher Education’s medical committee is trying to improve the clinical training system, while giving incentives to medical schools.
But even if all this succeeds, it’s not clear that the problem of the gaps will be solved. According to Prof. Ehud Grossman, dean of Tel Aviv University’s medical faculty, “When you take Israel and do an average, you conclude that physicians are lacking, but if you try to get accepted into a desirable specialty, there are no slots.
“As long as the state doesn’t create a situation where people are required to work in specialties where there’s a shortage, increasing the number of doctors won’t solve the problem,” said Grossman, who also heads the Internal Medicine Department at Sheba Medical Center east of Tel Aviv.
“In specialties like geriatrics and pathology, where there’s a shortage in the center of the country as well, increasing the number of graduates won’t help.”
In fact, the figure of 3.19 doctors per thousand people in Israel conceals huge gaps, as seen in those 2.1 doctors per thousand people in the south (and north) compared with the 5.3 in Tel Aviv. For the center the number is 3.4, for Haifa 3.8, and for the Jerusalem area 3.9.
The grassroots method
According to Brenner Shalem, the Health Ministry is well aware of the dearth of doctors in outlying areas. “When there are too few doctors, they naturally go to the attractive areas that offer them more. There are no magic solutions, and so our policy in the first phase is to find ways of increasing the number of doctors in general, with the goal of directing more doctors to the outlying areas and to specializing in the needed fields,” she said.
The gaps between the center and the periphery are seen in almost every aspect, from the number of doctors and nurses per capita to the availability of appointments for specialists and surgery. Attempts to overcome the gaps, including an agreement between doctors and the government a decade ago – grants that would encourage doctors to move to outlying regions – didn’t change much.
“This problem requires a deep solution. Grants can’t be its main element,” Brenner Shalem said, adding that countries like Australia, Canada, France and Japan have made progress grappling with the same problem.
“We’ve found that the best solution is to cultivate doctors from the outlying areas and not import them from other parts of the country. The odds that a doctor who grew up and lives in a distant town will stay there are three times greater than for someone who comes from the center.”
The number of students from outlying areas in medical schools is very low, usually due to gaps in education and equal opportunities. “Out of 120 students starting their medical studies at Ben-Gurion University of the Negev, only seven are from the Negev,” Brenner Shalem said. “Many young people are rejected because of the entrance requirements, even though there are great people who could be excellent doctors.”
Next year a new program will start, aiming to help young people from the south and north qualify for medical school. In its first year, the program will have 30 participants from the Negev and 30 from the Galilee, and is set to expand.
The program is led by Alexey Belinsky, head of human resources strategic planning at the Health Ministry, in cooperation with the Prime Minister’s Office, mayors and academic institutions in outlying areas. The program will be held at Ben-Gurion University in Be’er Sheva and Bar-Ilan University’s medical faculty in Safed.
Participants will receive training to the end of their residency. They will receive tuition help if they pledge to work as residents at hospitals and health maintenance organizations in the outlying area where they studied.
This isn’t just an academic program, Brenner Shalem says. “We’ll train them as medical leaders in the outlying areas, out of a desire to generate broader change in the level of medicine there. So the plan will include getting to know the region’s deeper medical needs and character,” she said.
“We’re introducing them to leading doctors in the periphery and acquainting them with the special problems of the region and rural medicine, and involving them in the work while they’re still students. Hospital directors are very enthusiastic about the idea because they feel the difficulty as well.”