How health services are organised and funded in Israel
From my perspective, the health service in Israel appears mid-way between the NHS and American healthcare services. For example, similar to the NHS, there is universal healthcare coverage for all citizens. However, similar to the USA, citizens have to pay forat least some of the cost of their healthcare. This is done via a compulsory insurance system; Israeli citizens must sign up to one of four health insurance companies called “Kuppot” and they then have the option to purchase wider coverage within these in addition to the basic plan they sign up for. The different companies offer variations of a basic plan. For example, one offers two free x-rays per year whereas another may offer particular types of cancer medication or free healthcare of children under 18. This creates a competitive element amongst the Kuppot as they try to attract more citizens to their plans.
One particularly interesting fact about the Israeli healthcare system that I came across during my elective is how emergency services are financed. If a patient arrives at an Emergency Department (ED) without prior referral from a general practitioner they must pay for their treatment. Additionally, if a patient calls an ambulance without a doctor’s referral, or they do not have a referral, but they are not admitted to hospital from the ED, they have to pay for the ambulance journey. This system presumably decreases unnecessary attendances at the ED and nonessential ambulance trips. Conversely, it may also mean unwell patients avoid seeking help due to monetary constraints. However, Israel has consistently scored very highly in terms of healthcare system efficiency and overall population health on a global level.
An overview of the main causes of morbidity and mortality affecting the population and challenges to health from social determinants perspective
In Israel causes of morbidity and mortality overall follow trends similar to Western European countries, with the top cause being malignancy followed by heart disease and cerebrovascular disease.
The next cause of death, however, is diabetes, which is ranked higher than in most European countries. This may relate to rising levels of obesity in Israel, particularly in children from less developed parts of the country. Nonetheless overall obesity is much lower than in other economically developed countries such as the USA and UK.
Less widespread but nonetheless interesting causes of morbidity particular to Israel are a wide variety of genetically associated diseases, such as BRCA linked to breast cancer and Crohn’s disease, both of which are more prominent in Ashkenazi Jewish communities. Furthermore, high rates of consanguinity in Israel-Arab and religious Jewish communities have lead to higher incidence of genetic conditions, some of which I came across in the paediatric cardiology clinics I attended. In developed cities in Israel genetic testing is widely available, but this is not the case in many of the Arab territories where consanguinity is extremely common.
What you did during your elective
I spent my Elective at Wolfson Medical Centre with the Paediatric Cardiology team.
The work week was very varied, I observed clinics, ward rounds, catheterisations and surgeries. Additionally, I had the opportunity to attend teaching sessions given to the Paediatric Cardiology Department and to local Israel medical students. I was also able – , together with two other elective students from Nottingham University – to present one of these weekly teaching sessions, on the subject of Respiratory Syncytial Virus and its relationship to Paediatric Cardiology. The feedback we received indicated it was very well received. This gave us an opportunity to formally introduce ourselves to the whole department, and there was a tangible difference in how people related to us afterwards – we felt far less invisible.
We spent an afternoon visiting the Children’s Home where children from abroad who have come to receive cardiac care (via the NGO Save a Child’s Heart) in Israel live before and after treatment. This was a very gratifying experience as we could see the children as children, playing, dancing and crafting, and not just patients in a hospital bed.
Reflections
One of my biggest reservations before going on elective was that I would be the only medical student on elective with the team. In fact, the secretary organising my elective repeatedly told me I would be the only one. Imagine my surprise to find two students from Nottingham sitting in on a clinic during my first day! Their presence greatly improved my experience, particularly as I could learn about the differences and similarities in our medical schools and training hospitals. I also found it gratifying to translate from Hebrew to English for them when doctors spoke in Hebrew (quite often!), as I am a native speaker and they only knew some basic words.
During the elective I noticed some crucial differences in relationships between doctors and their colleagues and between doctors and patients. Overall, professional relationships are a lot less formal than in the UK, with doctors often talking about their personal lives and talking loudly with family etc. on the phone in the office and even on the wards. On one hand I appreciated the relaxed, welcoming atmosphere; however at times it felt like boundaries were pushed and some jokes or conversations may not have been so appropriate for the workplace.
Patients also had less boundaries with doctors, particularly in clinics where they often came knocking on doors or even opening doors because they felt they had been waiting too long or had another question to ask. This open relationship was positive in some ways as patients (or parents of patients) seemed very comfortable and confident with their doctors and felt they could ask questions freely.
The most unique aspect of my elective was the involvement of Save a Child’s Heart. SACH is a charity that brings children from the Palestinian Authorities and over 40 countries all over the world such as Zanzibar, Ethiopia and Romania for cardiac care in Israel. Seeing these children being treated alongside local Israeli children was very inspiring, particularly as there was no discrimination from any of the healthcare professionals treating them. A child from Gaza or Zanzibar received exactly the same medical care as a local one and this showed me a side of Israel that not many people manage to see in media coverage of this contentious country. It was also inspiring to see the children from abroad who have come as a group with one carer going through open heart surgery thousands of miles from home comforts. Within days they would be up and about and playing again, and time and time again I was surprised by the dramatic difference before and after heart surgery for congenital disorders such as Tetralogy of Fallot.
Overall my elective was a fantastic experience which taught me a lot about how I relate to patients and colleagues as well as about the globalisation of healthcare.
Shier Ziser
UCL