Focus on Israel- Progress in Public Health Promotes the Health of the Population

by Simon Griver

Increasing life expectancy

Israel has been a pioneer in the contemporary concept and practice of Public Health and as a result has one of the worlds healthiest populations. The country's success in pursuing effective Public Health policies is reflected in the fact that a nation of immigrants, who have arrived during the past 54 years principally from North Africa, the former Soviet Union and Central Europe, has one of the highest average life expectancies in the world.

This has been accomplished despite the fact that Israel has absorbed Holocaust survivors and a large proportion of immigrants suffering from tuberculosis, malnutrition, heart disease and every type of cancer. At present, 25% of all cancer patients in Israel are newcomers from the former Soviet Union including tens of thousands from parts of the Ukraine and Belorussia who were exposed to radiation from the Chernobyl nuclear plant melt-down in 1987.

According to the Ministry of Health yearbook for 2001, the life expectancy for males (76.6) years) was topped only in Japan. Israeli women live longer than men, but do not fare as well in international statistical comparisons.

What is public health?

Whereas medicine treats the health needs of an individual, public health (a discipline also known as public medicine or social medicine) deals with the health requirements of society as a whole. In fact, public health was a more popular concept in the 19th century when physicians realized that matters such as sewage amenities, cleanliness and a balanced diet would improve the health of the population . But as sanitary and dietary conditions improved and with such medical. discoveries as penicillin in the 20th century, much less emphaisis was placed on public health.

International community acknowledges importance of public health

Public health returned to the global agenda in 1975 at the WHO meeting in Alma Ata, Kazakhstan, in the former Soviet Union. Leading health officials from every country in the world signed a covenant proclaiming that the health of the people and the provision of medical services must be the responsibility of national governments. Only the United States refused to sign the covenant, insisting that individuals rather than their governments must be responsible for the provision of health services for themselves and their families.

Of course most nations simply do not have the necessary resources to offer their citizens adequate health services. Even in developed and relatively affluent countries like Israel, the essential challenge facing public health policy is effective distribution of limited resources.

Israel emphasizes public health

The Zionist Movement in pre-state Israel, which combined the traditional Jewish concern for all people with an emphasis on societal needs, regarded public health as a top social, political and economic priority. By the time Israel declared its independence in 1948, a national health infrastructure was already in place. Mother-and-child care centers (Tipot Halav) administered the necessary vaccinations to new-born babies and advised parents on proper care of infants. Health insurance funds (Kupot Holim) offered day-to-day consultations with doctors and specialists, and insured members for hospitalization.

The National Health Insurance Law

Despite Israel's commitment to providing health services for all of its citizens, by the early 90's some six percent of Israelis were not insured through one of the four existing health funds - Kupat Holim Clalit, Maccabi, Me'uhedet and Le'umit. In 1994, the National Health Insurance Law was enacted and it was implemented the following year, rectifying this situation. Since then, all citizens have their health insurance paid by a tax on income (up to 4.8%) while their employer's portion is collected by the National Insurance Institute, and passed on to the health insurance fund of the individual's choice.

National expenditure

Israel's national expenditure on health is typical for a western country. In 1999, the country spent 8.3% of its Gross Domestic Product (GDP) on health, down from a peak of 8.8% in 1994; the United States spent13.6% of its GDP on health care, Canada 9.5%, Japan 6.9% and the UK 7.6%. Of the Israeli expenditure, 41% was for hospitals and research, 39% for public clinics and preventive medicine and 9% for dental care. Israel spent $1,555 per capita on medicine.

Public health as an academic discipline

The discipline of Public Health is responsible for promoting the health of the population - by planned prevention of disease, by early diagnosis of ill health and by provision of accessible health care for those in need. This population orientation brings with it the requirement to define health priorities and allocation of the appropriate, though usually scarce, resources.

The academic study of the discipline of public health was spearheaded by the Hebrew University-Hadassah Braun School of Public and Community Medicine and its predecessor departments. The major framework is the Master of Public Health (MPH) Course, which provides academic training for public health practitioners and researchers. The School has developed two MPH programs: one for Israeli students, whose graduates form the cadre of public health professionals in the country; the second is a unique international MPH program, which, since 1971, has graduated over 600 students from 80 countries. They have become the mainstay of health care systems in many parts of the developing world.

A central feature of the training program is planning health care for the community, based on the assessed needs for primary health care services. Known as Community Oriented Primary Care (COPC), its concepts and practice have been taken to the corners of the world by the School's faculty and graduates. It embodies a planned link between the clinical responsibility for the individual patient with the public health responsibility for the whole population.

Successes in Israel

University research results are put into practice by the public health system, while the Israel Council for Public Health runs campaigns to raise public awareness of relevant issues. In addition to increasing longevity and reducing infant mortality, Israel has completely eradicated a range of diseases, such as malaria, polio and diphtheria, which had plagued the country in its formative years. Other diseases such as tuberculosis have been virtually eliminated but sporadically reappear, brought in by waves of new immigrants.

Source: Statistical Abstract of Israel

Successful educational campaigns have greatly reduced the level of smoking and the incidence of skin cancer caused by the sun's rays. Israel has the lowest percentage of new HIV positive victims in the western world with just a few hundred new cases each year. This is largely attributed to comprehensive sex education programs offered in the country's high schools. Annual traffic accident fatalities have been reduced from 750 in 1974 to 476 in 1999, despite the fact that there are four times as many vehicles on the roads. As in most western countries, heart disease and cancer are the biggest killers.

The country has also made significant strides in combating nutritional deficiencies. Nowadays the diet of Israelis favors vitamin-rich fresh fruit and vegetables. In the early years of the State, even the country's agricultural infrastructure was, in part, planned in conjunction with the Ministry of Health's nutritional recommendations.

Benefiting the developing world

In the late 1950's, Israel, a small and still developing country, made it a policy to share its developmental experience, including the field of public health, with other developing nations in Asia, Africa and Latin America. In many areas, such as mother and child health, the reduction of infant mortality, the prevention and reduction of communicable diseases and the eradication of endemic diseases like malaria, Israel shared its achievements and solutions with newly developing countries.

MASHAV - The Center for International Cooperation

Israel's main conduit for sharing its public health successes and experiences with health care workers around the world is MASHAV - the Center for International Cooperation of the Ministry of Foreign Affairs. Professionals from every continent, especially the developing world, receive training from MASHAV to enable them to deal more effectively with public health problems in their own countries.

Israel and the PA have been working together in Public Health since the signing of the Declaration of Principles in 1993. Jordan, too, has bilateral ties with Israel in this field, and a proposal for a Multilateral Regional Program on Medicine and Public Health, which has been on hold because of the security situation, is expected to be renewed.

Good public health decision-making is imperative if nations are to use the full potential of their medical resources. The International Masters of Public Health Program (MPH) of the Hebrew University-Hadassah Braun School of Public and Community Medicine, under the auspices of MASHAV, is now being held for the 27th time, and has played a key role in helping medical professionals in the developing world to tackle the enormous problems facing their countries.

Moreover, students who have graduated from MPH have made significant contributions in many countries and have had an enormous impact worldwide. Many graduates have become senior administrators and in several cases even Ministers of Health in their countries and have played a pivotal role in formulating public health policies.

At the same time, MASHAV runs shorter public health courses for an average of 250 professionals each year and teaches on-the-spot public health courses in 12 countries.

Advising From Experience

Israeli experts in a wide variety of fields are able to share their professional knowledge and experience through short-term consultancies. Examples include: a delegation to the island of Zanzibar off the eastern coast of Africa which was able to draw from Israel's experience of draining the Hula swamp (formerly infested with malaria-carrying mosquitoes); and experts who set up community health services for nomads in Eritrea, replicating the type of services designed for the Bedouin in Israel's Negev desert.

Contemporary trends

Israeli experts have identified two contemporary trends, which substantially affect public health. The first trend is the aging of the population and the second is the steeply rising cost of equipment now available to health services.

The Aging of the Population

This phenomenon is placing much strain on health services worldwide. In Israel people aged 65 and over represent 10%, while those aged 75 and over represent 4.3% of the country's population (compared to 8.8% and 3.5% respectively a decade ago). By the year 2003, Health Ministry officials forecast that the proportion of Israelis over 65 will rise to 11% and those over 75 will reach 4.5%.

Still, Israel is a young country by western standards. Children up to the age of 14 comprise 29% of the total population. Despite the aging of the population in Israel, the dependency ratio (which compares the proportion of children under age 14 and senior citizens over 65 to the population as a whole), has decreased from 70% to 64% over the past decade, due to falling birth rates. However, the percentage of senior citizens could rise to over 25% in the first half of the coming century, both in Israel and in other western countries.

Source: Statistical Abstract of Israel

Israeli researchers have noted that the dependency ratio in the developing world is increasing due to decreased infant mortality (but not falling birth rates) and increased longevity. At the same time, to some extent communities in developing nations, where the extended family remains intact, are better suited to cope with aging because the elderly are cared for by the family. In developed countries, where the extended family and community structure have often disappeared, health services must cope with fundamental welfare problems such as loneliness, as well as the illnesses associated with old age.

In Israel, public health efforts in geriatrics encompass both the sociological aspects - attempting to preserve extended family and community structures - as well as the need to combat geriatric-related illnesses such as Alzheimer's and senile dementia.

The Cost of Medical Technology

The introduction of increasingly expensive equipment for diagnosis and treatment as well as costly innovative medications, poses one of the greatest challenges to public health policy. Doctors and health officials are finding that they must now choose between life and death for population groups suffering from various diseases. The economics of health care are further complicated by the fact that research and development of such equipment and medication are inordinately expensive. Thus health care professionals must choose between allocating funds for short term medical needs, or for investing in R&D for long term benefits.

Public health research and policy can help optimize ways to lengthen life and alleviate suffering. Israel is pioneering a reduction in hospital beds as a result of research showing that patients recover more quickly when treated as out-patients. New surgical techniques such as laparoscopy have also helped shorten hospital stays. The hospitalization rate has fallen 24%, from 1,037 days annually per thousand people in 1975 to 785 days, and the average stay over that period has been halved (from 8.7 days to 4.3 days

Source: Ministry of Health Yearbook, 2001

In the new millennium

At the beginning of the new millennium, Israel's public health policy confidently faces the many challenges that lie ahead including improvement of the quality of life for an aging population as medical expenses seem to increase on a par with medical advances.