The hospital ward at Rambam Medical Center in Haifa, the largest in Israel’s north, was relatively “empty” on a Tuesday last month during the Passover holiday: All of the rooms were fully occupied and there were “only” two patients in the corridor waiting for a bed to free up.
“Today things are very quiet,” said the head nurse of the ward, who preferred not to be identified. “Normally this corridor is crowded, with six or seven patients lying on their beds waiting for a room.”
One of the patients in the corridor was an 82-year-old woman who had come to the hospital at 2 a.m. A makeshift curtain divider was draped around her bed for a modicum of privacy as a doctor performed tests. Even so, the woman was visible through one of the openings, a grimace of pain on her face, and the doctor quickly covered up the patient’s bare breast as visitors passed by.
The patient’s son, 51-year-old Fiasl, complained that his mother had not eaten or taken medication since she had arrived at the hospital that morning. “She’s waiting in this corridor because there are no free beds inside the rooms,” he said.
Further down the corridor, another woman was asleep on a bed with a blanket covering most of her thin, hospital-nightgown-clad frame. Her gray hair drooped and her mouth sagged open. She lay there alone.
Inside the intensive care unit, the children of a 94-year-old man gathered around their father’s bed, their faces worried and tired.
“My father came here about 10 days ago in a very bad state; he was sedated and on a respirator. It was a huge mess,” said his son, Moshe Dabah, 49. “They didn’t have a room for him and he was stuck in the corridor. Imagine, sedated and on a respirator — and he was in a corridor!” he said, the hint of a tremor in his voice.
“The emergency room had to negotiate with the ward to take him, and the ward was not ready for him initially, it didn’t have the necessary equipment. But once the decision was made to bring him to this ward, they got their act together very quickly.”
Mohammed, a nurse working in the ward who did not want his surname disclosed, said the hospital wards are hugely understaffed. The intensive care unit, for example, should have one nurse for every two acute-care patients. “In our case, we have one nurse looking after six patients per shift. You can miss things, and families complain and sometimes they get violent.”
During night shifts there are just five nurses for a ward that on a good day has “just” 44 patients, he said. “Someone needs to speak to Netanyahu,” he said cynically, referring to Prime Minister Benjamin Netanyahu, who has led the country for the past 10 years and who was also its health minister, at least nominally, in the last government.
Israel is known globally as the Startup Nation. It has 6,600 startups in its small and connected economy, 14 times the concentration of startups per capita in Europe, and ranks number one globally for R&D expenditure as a percentage of gross domestic product (GDP). The nation is also seeking to become a leader in digital health, leveraging its prowess in software, artificial intelligence and big data to find innovative health solutions for the world.
Last year the government approved a National Digital Health plan to create a digital database of the country’s 9 million residents’ medical files and make them available to researchers and enterprises. Investment in Israeli healthcare technologies has soared, with digital health startups raising $511 million in 2018, up from $389 million in 2017, according to data compiled by Start-Up Nation Central. Hospitals in Israel and HMOs have set up innovation centers to tap into the latest technologies.
But if you are in need of hospital care in Israel, you may end up, like 94-year-old Mr. Dabah or Fiasl’s mother, parked for days in a ward corridor, or waiting for hours in an emergency room.
That is because for the past 20 years healthcare has not been a priority for Israel’s governments, experts say, with funds being channeled to other needs whose advocates are more vocal, and to defense.
Israeli hospitals are “chronically” short of beds and staff, said Dr. Aziz Darawsha, the director of emergency and urgent care at Rambam. “Our population has grown and grown older,” he said. But the number of available beds has not increased over the years, and has actually declined, he said. “We have not prepared enough.”
The occupancy rate of Israeli hospitals, he said, is 100% to 120%.
Israel’s healthcare expenditure as a share of GDP has remained relatively stagnant in the past 20 years, despite the country’s economic growth and the growth of its population.
The share of national expenditure on health as a portion of GDP was about 7.4% in 2017, compared to an average of nearly 9% in the OECD, a group of leading Western nations, and 11% in European countries with health systems similar to Israel’s, according to a report by the Taub Center for Social Policy Studies in Israel.
According to a 2018 Health Ministry presentation based on OECD figures, Israel spent a total of $2,725 per capita on health in 2016, compared to an OECD average of $3,936. In 2016, there were just three hospital beds per 1,000 inhabitants in Israel, compared to an OECD average of 4.7.
Is there a doctor in the house?
Startup Nation also lacks doctors and nurses. In Israel in 2016 there were 3.1 practicing physicians per 1,000 inhabitants, compared to an OECD average of 3.3. Austria, which topped the list, had 5.1 physicians per 1,000 inhabitants. There were five practicing nurses per 1,000 inhabitants that year in Israel, compared to an OECD average of 9.3, with Israel ranking among the bottom four countries, just above Latvia, with 4.6 nurses, and below Poland, with 5.2.
Israel was second to last in the ranking for the number of medical students who have completed basic medical education in a given year — 6.8 per 100,000 inhabitants, well below the OECD average of 12.1.
In 2016, the ministry presentation showed, there were just 4.9 magnetic resonance imaging (MRI) units per million inhabitants, positioning Israel at the third lowest in the list, compared to 15.8 for the OECD average. And there were just 9.7 computed tomography (CT) scanners per 1 million inhabitants, compared to 24.7 for the OECD average.
The lack of resources is “a big part of the problem,” said Dr. Michael Halbertal, director-general of Rambam Medical Center, in a phone interview. Expenditure in health is “not keeping up” with need.
Israel’s population is relatively young, because of both immigration and high fertility rates, and only about 10% of the population is aged 65 and above, compared with almost double that share in the US, Europe and Japan, according to the Taub Center.
Even so, the nation’s population “is rapidly aging,” with the number of seniors in Israel aged 70 and older “projected to double by 2035.” Moreover, about a fifth of senior citizens in Israel live under the poverty line, the Taub Center said.
‘Health is not sexy enough’
Because health is not high on the list of governmental priorities, Rambam’s Halbertal added, the result is “people in the corridors.”
“Somehow the health system has lost priority on our political agenda, unfortunately so, and this is the result,” agreed Prof. Dov Chernichovski, chair of the Taub Center’s Health Program.
As Israel forms its new government and its health and finance ministers take up their posts, they will have to grapple with the huge demand for hospital beds and staff alongside lower national economic growth and a growing budget deficit, which will make it harder for the government to increase spending.
The government may be able to continue spending the same amount on health as it does currently, said Yaniv Pagot, an economist and head of strategy for the Ayalon Group, an Israeli institutional investor, in a phone interview. “But we know it is not enough.
“It is all a matter of priorities and of lobbies and which groups are the most vocal. Health is not sexy enough. Being a health minister is like being a defensive player in a football team. There is no glory in that role, and no one wants to be health minister. You need a lot of money and there are always a lot of complaints.”
Israel spends most of its budget on issues espoused by “the lobby groups that make the most noise,” he said. That includes, besides defense: a pet project of outgoing Finance Minister Moshe Kahlon, who set out a plan to cut the price of housing by giving government-owned land to residential developers almost for free; higher salaries for policemen, prison wardens and firefighters; and bigger payments for people with disabilities, Pagot said.
“These are all important issues, but the question is, are they more important than the health system?” Pagot asked. “All of this comes at the cost of the health system. In the end the pocket is just that one pocket.”
Israel’s health system
Healthcare in Israel is universal and medical insurance payments are compulsory. All Israeli inhabitants are entitled to basic health care, as defined by the National Health Insurance Law of 1995, which dictates that all residents pay medical insurance and join one of the four official health insurance organizations, called kupot holim (patient funds or HMOs). These are run as nonprofits and are not allowed to deny coverage to any resident. In addition, Israelis can increase their health coverage with private health insurance, which more and more people are using.
The share of public expenditure out of total expenditure on health is around 63% in Israel, compared to 73.5% for the OECD average, and 78% among countries with health systems similar to that of Israel, such as Germany and Belgium, according to the Taub report. Meanwhile, the share of healthcare spending out of household disposable income rose from 3.9% in 1997 to 5.9% in 2016, the Taub report said, as more people pay for private health programs.
The fact that private medicine is gaining ground in Israel is a sign of health inequality, said Prof. Dov Chernichovski, chair of the Health Program at the Taub Center, in a phone interview.
“Access to medical care is becoming increasingly dependent on our ability to pay,” he said. And the hospital sector is where this disparity is most clearly manifested.
The 1995 health law transferred most of the responsibility for the care of patients — primary care as well as some specialized care — to the HMOs. So unless patients need to be hospitalized, they are dealt with by the HMOs.
These HMOs are funded by the taxpayer in accordance with the number of people they care for, their gender and where they live — in the center of the country or its less advantaged periphery. The HMOs decide whom to treat and when a patient should be sent to the hospital, and it is they who then need to pay the hospitals for their services, explained Prof. Arnon Afek, associate director general of Sheba Medical Center and acting director of Sheba General Hospital. And when these HMOs pay the hospitals, they negotiate and demand discounts.
This creates a problem for the hospitals, he said, because they are in the “second line” of financial payments: they get less than they need and run huge deficits. In addition, because of strict regulation, hospitals are not allowed to allocate new beds or buy new CT or MRI machines without permits from the Health Ministry and the Finance Ministry.
The health paradox
It is this setup — in which hospitals play a secondary role in the healthcare system — that creates Israel’s health paradox. Because even with the low spending on health, Israelis are actually very healthy.
Israel was ranked the tenth-healthiest country in the world, according to an assessment published by Bloomberg in February, one spot lower than its 2017 position. And with an average life expectancy of 84.4, Israelis will be ranked seventh in the world in longevity in 2040, a University of Washington study showed.
According to OECD data, Israel ranked fourth-highest in life expectancy in 2016, an average of 82.5 years, in line with Norway and just above Sweden, whose population had an average age of 82.4 years. Infant mortality in Israel is also low, at around 3.1 percent per thousand births, in line with Denmark and just above Belgium, at 3.2%, the data shows.
In March, Newsweek ranked Sheba Medical Center, in Ramat Gan, among the top 10 hospitals worldwide for leadership in medical science and biotechnical innovation.
Israel has attained “all of these huge achievements” even as its expenditure on health as a percentage of GDP has remained static for the past 20 years, said Sheba’s Afek.
This is due to a number of factors, he explained: a large part of patient care is provided by the HMOs, which provide effective and efficient services; some 82% of citizens have private insurance, so they can access private medicine when in need; and the health system and the hospitals have become very efficient, making the most of every shekel they have.
Because the system is so lean and efficient, said Afek, “we are paying the price of success. Because we are so good, they [the government ministries] are saying make do with what you have, you manage fine with what you have.”
But the system cannot continue without more funds, Afek, a former director general at the Health Ministry, said. “Without any doubt billions [of shekels] need to be injected into the health system.”
“Whereas once we postponed and avoided [expansion], today we have reached a stage where there is no choice. We have to open new beds, not only physical beds but also manpower to run that bed,” Afek said.
Despite their efficiency, Israeli hospitals are overextended, said Rambam’s Halbertal. “There is no particular day that is harder than others. It is hard all the time,” he said. “We invest a lot of effort to squeeze the most out of each shekel we get to the hospital. We are constantly lacking, the whole system is starved economically.”
Taub’s Chernichovski said the healthcare paradox is a “misconception.” It is true that Israel has a good life expectancy record, he said. “But the roots of this record are in the past — my health, and yours in some ways, depends on what was invested in us 20, 30, even 50 years ago. So, my longevity depends on that. What people tend to do is to compare the current health record with the current situation — and this is a misconception.
“The results of what we are experiencing now will show up in the future generations,” he warned.
New tech will keep hospitals ‘relevant’
Developing and adopting new technologies is one key way to improve hospital revenues, through the automation of processes and the sale of intellectual property, the experts said. But in today’s situation even technology is not enough to get the hospital system out of the woods. Simply put, more money is desperately needed, they said.
“If we want to move on from the situation in which a woman is hospitalized in the corridor, then we must make sure we advance medicine for our citizens and to do that we must innovate. Otherwise we won’t be relevant at all,” said Rambam’s Halbertal.
“Medical institutions, even in the most optimal scenario, will always be short of funds,” he added. “Medicine and health are always a bottomless pit.” That being the case, technology must be adopted and developed to generate added revenues for the hospitals.
The direction for Israel’s health system will eventually be toward caring for patients in their homes, using advanced technologies, said Sheba’s Afek. But that does not obviate the current pressing need for more beds, he said. It is crucial to raise health spending as a percentage of GDP, he urged. “Otherwise we won’t be able to meet the needs.” Technology alone “won’t help in this case,” he insisted.
The Health Ministry is already working toward increasing the number of beds, and has forecast that from 2017 to 2022 some 1,350 new hospital beds would be added to the system, according to the 2018 presentation.
However, even if Israel increases the amount of money it spends on health as a percentage of its GDP, it still must institute major structural changes in the way the health system is run, said Taub’s Chernichovski, who is working with the center on a paper regarding the hospital sector in Israel, to be published shortly.
“It is very fashionable and popular to say we need more beds and more money, but my take on that is that unless we do some structural and other changes before adding the beds, it would be a waste,” he said.
Additional hospitals and hospital beds must be in line with where they are needed most, he said, and with the right incentives. “If you add beds for political reasons… without having an overall strategy, which aligns the increase of beds where the needs are and with the right incentives, then it is really a waste.”
Ayalon Group’s Pagot concurs. “What the government must do is to sit down with private companies and the private sector and think out of the box, and find innovative solutions and set up joint projects on how to solve this problem. But nobody is doing this today.”
In an emailed comment, the Health Ministry pointed to “digital health solutions” as a potential savior.
“Health systems in Israel and around the world “face significant challenges, including the proliferation of chronic diseases, the aging of the population and changes in the Western lifestyle that lead to increased demand for health care in a situation of limited resources.
“In the macro forecasts published by the Health Ministry, we see that in the ‘business-as-usual’ scenario, the additional resources required in the coming decades are enormous in order to preserve the quality of the existing medical services.”
“The development and promotion of digital health solutions has the potential to use novel and groundbreaking ways to deal with these challenges and the potential for advancing the quality of health services in Israel and around the world.”
Meanwhile, at the Rambam Medical Center in Haifa, 61-year old Raya was watching over her 88-year old father, a Holocaust survivor from Ukraine, who spent a whole day in the emergency room the previous day before making his way to the ward. When she came to visit late that morning, he had complained that nobody had yet come to wash him.
“I lost my mother here, in this ward, a year ago,” Raya said. “She was in the hospital more than a month. There is not enough staff here, and the nurses and doctors work under a lot of pressure. It takes a long time to find a doctor, but once they come to you the treatment is good. But because they are constantly in a rush, you feel they want to get rid of you as soon as they can, so they can move on to the next patient.”
“How can someone make life and death decisions under these conditions?” asked Dabah, the son of the 94-year old man in intensive care. “Our decision makers should come and spend a day here and see what is going on.”