Medical manpower in Israel: Political processes and constraints

Health Policy,15 (1990) 189-214 Elsevier

189

Chapter 8

Medical manpower in Israel: political processes and constraints Judith T. Shuval

Introduction ‘Health manpower development, an interconnected set of activities dealing with planning, production, utilization and support of manpower, transcends all other issues in health development. It is a critical factor for the economic efficiency of the health care system, and an important response mechanism for attaining the goal of health for all through primary health care’ [45]. However, a realistic appraisal indicates that the political reality in most countries has made effective planning in this area rare because of competing interest groups seeking resources and power [31,34]. The Israel case study demonstrates the role of these pressures in determining the training, allocation, utilization and planning of health manpower in a health care system characterized by on-going processes of political compromise among a variety of groups. Perhaps the most distinguishing social facts about Israel are its small size and the heterogeneity of its population. Since its formal establishment in 1948, there has been a constant stream of immigration from a wide variety of countries which has resulted in a mixed ethnic population which is among the most differentiated in the world. In 1985, 40% of the Jewish population was born in other countries, and among the Israel born, only 18.5% are second-generation Israelis. About 18% of the population is not Jewish: 77% of these are Moslems, and the remainder are Christians, Druze and members of other small religious groups. While Israel does not have a nationalized health care system, 94.5% of its population is covered by comprehensive health insurance which includes curative and preventive ambulatory care as well as hospitalization. Regional hospitals are located within no more than 30 kilometers of most communities; primary, curative and preventive services are easily accessible on a neighborhood basis. A strong egalitarian welfare ideology has traditionally provided support for a broad network of health care institutions giving extensive curative and preventive services to the population. Indeed, sensitivity to health needs is widespread in all segments of the population of Israel. 0168-8510/90/So3SOC 1990 Elsevier Science Publishers B.V. (JGmedical

[1151

Division)

190

Selected background data about Israel appear in the Appendix. The health care system in Israel is closely linked to the general political structure. Many of its structural characteristics and its mode of functioning reflect political processes at the macro level of Israel’s political life. At the same time the health care system has developed its own political life as a complex, multi-faceted set of interest groups which interact among and within themselves. Israel is governed by a parliament (Knesset) numbering 120 members. The large number of political parties, many of them small, has always necessitated a coalitiontype government. Since no single party has ever controlled a majority, the smaller coalition partners have wielded power, disproportional to their size. The system is characterized by processes of conflict, bargaining, and compromise over central political issues, ostensibly unrelated to health care. However, the close linkage of the health care system to political interest groups means that these processes spill over to affect that system, particularly with regard to the distribution of resources and power. It is therefore necessary to consider manpower planning within the context of the more general political and power constellation.

Historical roots The roots of the Israeli health care system may be found in the period preceding independence in 1948 when its critical political characteristics were established. Despite many changes in the society, there has been remarkable continuity in certain basic patterns which can be clearly traced over time [1,25]. The British Mandate for Palestine, established in 1920, was responsible for overall administration of the area. The Jewish population (Yishuv) numbered 83790 in 1922 and 649000 by 1948, and was organized as a semi-autonomous community which undertook to provide its members with basic services in terms of self-defined standards and values. Services for the Arab population, which numbered over 650000 in 1922 and 1800000 before partition in 1948, were provided by the Mandate authority [2]. The Yishuv established an autonomous school system, welfare services, land development, immigration and health care services. It comprised a highly politicized population which was divided into several active, ideologically differentiated groups vying with each other for influence and power. These groups were organized as political parties with differing religious, social and economic ideologies, each of which sought to maximize its influence and control in the community. Provision of health care for their members was viewed as an appropriate, essential service of these parties. In 1912 two labor parties (Achdut Ha’avoda and Hapoel Hatzair), each representing somewhat different socialist ideologies, established two sick funds based on the principle of mutual assistance. In 1920 these two sick funds united under the General Federation of Labor (Histadrut) the principal trade union. The Histadrut was initially, and has continued to be, more than a trade union in the usual sense; it has viewed itself as a central institution in the nation-building process, serving the political parties which supported it, the most important of which have 11161

191

been the Labor Party and its affiliates [1,57]. It included among its goals the creation of a classless society and the establishment of agricultural settlements: its institutions included a bank, building companies, an array of cultural institutions and a network of health services. The latter, the General Kupat Holim, was linked from its founding to this body which played a dominant role in the social and economic development of the society during the period preceding and following independence. Over the years the health services provided by the General Kupat Holim became a major resource of the His&hut and served as the principal means of maintaining the loyalty of its membership because membership in Kupat Holim is conditional on membership in the Histadrut. Membership fees are graduated by income and are deducted from monthly wages of salaried persons. Independently employed persons pay their membership fees directly. The socialist ideology of the Histadrut caused it to structure the Kupat Holim health services along egalitarian lines. A network of community clinics was established in all parts of the country, rural and urban, providing comprehensive medical care at no direct cost; hospitals were established as well as dental and optical care at reduced rates and medication was provided without cost, or for a small symbolic fee. Services expanded over the years to include pharmacies, laboratories, X-ray facilities, mother and child care centers, physical and occupational therapy services, rehabilitation centers and rest homes. Membership grew dramatically, largely as the result of mass immigration, from 10200 insured persons in 1922 to 350000 in 1948, and 3 303072 in 1986 [21,26]. The pattern of political linkage of health services is seen with regard to several smaller sick funds which also have their early roots in the period preceding independence [25]. In an effort to offer their members, who did not belong to the Histadrut, health care along the general lines provided by the General Kupat Holim, the right wing Revisionist party established the National Workers’Sick Fund (Kupat Holim Leumit) in 1933. In 1936, an additional small sick fund was founded by the General Zionists, another center-right political party, which continues to provide health care at present with somewhat different sponsorship under the name Kupat Holim Meuchedet (United Sick Fund). The Maccabi Sick Fund, established in 1941, was not formally sponsored by a political party but represented a group more favorable to private medicine and opposing the ideological, socialist stance of the General Kupat Holim. Thus, it may be seen that the tradition of politically-linked sick funds providing comprehensive health insurance started in the 1920s and 1930s. These groups continue to provide services and to reflect the dynamics of the political constellations that developed in the society, although not all have maintained their original political identities. However, the dominance of the Labor party and its control of the government and of the Histadrut until 1977 is reflected in the continuing dominance of the General Kupat Holim [ 16,401. An additional element in the present health care system, the Ministry of Health, also has its roots in the period of the British Mandate. Although the Mandatory authority delegated much of the responsibility for administration and delivery of medical care to the Yishuv, it also established a Department of Health which carried u171

192

overall responsibility for a variety of health-regulation tasks and also for the direct delivery of certain health services, largely to the Arab population. The former included registration of deaths and birth, supervision of veterinary services, sanitary inspection, water control, licensing of certain trades and industries, registration of medical practitioners, inspection of shops and factories, control of infectious diseases, and other public health functions. The direct services provided by the Department of Health included a network of hospitals, pre- and post-natal clinics and school health programs. This pattern, combining administrative and coordinating functions with responsibility for direct delivery of certain types of health care, was inherited by the Israel Ministry of Health in 1948 which took over the role of the Department of Health when the British Mandate ended. The present structure of the health services was established in the early 1950s during a period of economic and political instability when urgent health needs had to be met as a result of mass immigration. Many of its present characteristics were molded by the unique circumstances of the earlier period, and were built into the evolving Israel health care system.

Structure of the health care system: components and their relationship The present structure of the health care services has been described as a pluralistic, politically-linked system in which there is considerable fragmentation and duplication as a result of competition among the unequal components and little coordination among them [16,25]. Table 1 shows the overall picture regarding health manpower in Israel. Table 1 Persons employed

In medical and para-medical

professions,

1972-1983

1972

1983

Physicians

6460

11895

Pharmacists Dentists Registered nurses Practical midwives and nurses Paramedical professions

1780 1990

EE 14 785 12110 11570

El 5770

(Central Bureau of Statistics, 1986; General Kupat Holim, 1987b).

The system may be described in terms of three components: (1) Four voluntary sick funds of which one, the General Kupat Holim, of the Histadrut, has always been dominant in size and influence, as a result of its political affiliation with the powerful Histadrut and Labor Party. In addition there are three small sick funds. Together these sick funds provide pre-paid comprehensive health care, including ambulatory, hospital, drug, convalescent and other services to 95.4% 11181

193 Table 2 Persona insured In the sick funds, 1981 (%)

Total Insured Not-insured Insured in Sick Funds Total General sick fund Maccabi Leumit Meuchedet (Central Bureau of Statistics,

Total population

Jews

Non-Jews

100.0

100.0

100.0

95.4

98.2

74.0

4.6

1.9

26.0

83.0 9.3 4.0 3.6

82.3 9.9

89.9 3.9 3.5 2.7

1984).

of the population through networks of community services spread throughout the country in both rural and urban areas. Table 2 indicates the relative size of the various sick funds. The largest is the General Sick Fund which in 1986 insured 3 303 072 persons or 80% of the insured population. It operates 1282 ambulatory clinics, 15 hospitals, numerous laboratory and convalescent homes as well as other facilities. It employs 27 804 persons of whom 5146 are physicians. These represent half of the doctors in Israel. Table 3 presents the types of manpower employed by the General Kupat Holim [21]. The three smaller sick funds (Leumit, Meuchedet and Maccabi) provide similar services to 17% of the insured population. The largest of these is the Maccabi Sick Fund. Thus far the three smaller sick funds have not built their own hospitals but have reimbursed the General Kupat Holim or the government when their members have been hospitalized. However, some have recently started to plan and establish their own hospitals [29]. (2) The Ministry of Health which has continued to act (a) as a direct provider of health care through its network of hospitals and other direct curative and Table 3 Employees

of the Generel Kupet Hollm, by Gender, 1986

Total Physicians Nurses* Paramedic& Dental occupations Pharmacists and pharmacist Laboratory workers Engineers and technicians Maintenance personnel Administrative personnel

assistants

* Includes nurses with baccalaureate

Total

Males

Females

27 804 5 146 9 181 1888 655 1031 1557 402 3 722 4 222

7 266 3 234 788 338 200 326 211 373 778 1018

20538 1912 8 393 1550 455 705 1346 29 2944 3 204

degrees, diplomas and practical nurses.

HI91

194

preventive services; and (b) as a supervisor and coordinator of health services. Both of these functions have been expanded considerably over the years and the Ministry now runs thirty hospitals and includes a wide range of departments dealing with such public health areas as health education, licensing of health professionals, road safety, sanitation, pest prevention, epidemiology, food control, nutrition, pharmacology, as well as planning and operations research [8,54]. There is widespread consensus that this dual role, in which the Ministry is simultaneously a provider and a supervisor-planner of health services, is an anomaly which carries complicated political overtones. These are most evident in competition for resources among various components of the health care system when political affiliations assume critical importance in the negotiative process. (3) A ‘voluntary’ component which also has its roots in the pre-independence period. It includes a variety of institutions such as Hadassah, religious and missionary hospitals and several small organizations geared to provide care to special groups. There are some private hospitals and nursing homes as well. Shortly after the formal establishment of the State in 1948, the Prime Minister, David Ben Gurion, who was aware of the dangers of a politically fragmented society, sought to strengthen the collective, national identity by abolishing certain politically linked institutions such as independent military factions and politically affiliated school systems. These were placed under one national authority. This process was not applied to the health care system, a major portion of which, the General Kupat Holim, continued in its pre-State status as an affiliate of the Histadrut. Because of its role as a critical political power-base for the Histadrut and for the Labor Party, which controlled the government coalition, the General Kupat Holim retained its traditional autonomy and entered into an on-going process of competition with the newly established Ministry of Health. The three components of the health care system with their entrenched political affiliations and their relative power in the overall society, have made long-term planning for health manpower difficult. A somewhat curious situation prevails: Israel, which has comprehensive health insurance for 94.5% of its population, has no national health insurance system. Proposals for such insurance have been supported by the more conservative, right-wing political parties, while the Labor party and its affiliates have strongly opposed it and in fact have blocked several efforts to pass such a bill in the Knesset. Needless to say, this opposition stems from political considerations relating to the independence of the General Kupat Holim which is unwilling to relinquish its autonomy to control by a national health authority [16,25]. The Labor Party, which served as the principal group in the government coalition until 1977, has been the dominant political force controlling the Histadrut. The Histadrut continued to expand its economic enterprises over the years and acts not only as the most powerful trade union in the country but as an owner and manager of some of the largest industries, construction companies, and marketing enterprises in Israel. Kupat Holim membership continues to be conditional on Histadrut membership; attempts to disengage the two have consistently met with opposition by the Histadrut and Labor Party leadership who fear that membership in

195

the Histadrut would be diminished if its members were not assured health insurance Ul. This political linkage has given the General Kupat Holim direct access to the principal corridors of power through the Labor Party for a period of thirty years. Close control of the General Kupat Holim has been maintained by the Labor Party through political appointments to its boards and governing boards. It has been successful in obtaining major subsidies from the government for ongoing operations and for expansion of its services with few demands for regular accountability. The loss of government control by the Labor Party in 1977 shifted the power balance significantly, although the long earlier period of Labor dominance made it possible for the General Kupat Holim to establish an extensive, strongly entrenched empire. In fact its power and inlluence have been greater than that of the Ministry of Health, which has generally been rated as a junior ministry in the government coalitions [58]. In 1988 there were a total of 21 ministries in the Israel government. As in most coalition governments, priority has been given to the Ministries of Defence, Foreign Affairs, Finance and the Prime Minister’s Office. These have been headed by leadership figures commanding strong political constituencies which have enabled control of the bargaining process determining the distribution of resources. In the political scramble for ministerial posts, the Ministry of Health has frequently been assigned to representatives of the smaller parties in the coalition government whose political influence has been limited. And even when the Minister of Health has been a representative of the Labor Party, he or she has been confronted with the powerfully entrenched General Kupat Holim empire. Since the Ministry of Health is also a provider of services, it has inevitably found itself in competition with the General Kupat Holim for the same government controlled resources. In that process the latter has rarely been the loser.

The politics of supply The supply of physicians stems from two sources: (a) immigration, and (b) graduates of medical schools. Both of these sources are strongly influenced by political processes which determine the quantity, quality, field of practice, and distribution of the physician population. (a) Migration

A major factor determining the supply of medical manpower in Israel has been immigration. The policy toward admission and licensing of immigrant physicians reflects central ideological themes in the Israeli value context which are inherently political but which cut across specific political entities within the society. Israel’s open door policy welcomes virtually all Jewish immigrants. The acceptance and integration of immigrants who may be forced to immigrate or who WI

1%

freely opt to come, continues to represent one of the cardinal values of Israeli society. Pragmatic considerations of economic need or job availability have not served as criteria for admission; the assumption has been that the society and its economic structure must be adapted to the economic and social needs presented by immigrants rather than the reverse. [48]. Jewish immigration before the establishment of the State of Israel brought large numbers of physicians. In the mid-1930s one in every 225 Jews in the country was a physician. During the years 1939-1945, when many German physicians escaped from Nazi Germany, the ratio of physicians among the immigrants was as high as 1:120 [52]. The number of physician immigrants entering the country over the years varied and depended on the countries of origin and on the total number of immigrants arriving (Table 4). These changed periodically in terms of shifting conditions in various countries and in Israel itself. The most dramatic recent source of immigrant physicians has been the Soviet Union which permitted large-scale emigration of Jews in the 1970s. During that decade 288 318 left the Soviet Union and of these 161040 came to Israel. Among these were over 1227 physicians who comprised almost half of the total number of immigrant physicians to Israel during that period [48]. Table 4 shows that 6751 immigrant physicians came to Israel between 1972 and 1987. The open-door policy has meant that the number of immigrant physicians entering the country has been unplanned and has been a function of circumstances which have been largely uncontrolled. Table 4 immigration

of health-care

personnel

Total

to Israel 1972-1987

Physicians

Dentists

1972 1973 1974 1975

2 108 2 242 1451 898

821 835 575 353

142 180 97 80

1977 1976

1068 943

434 405

1::

1979 1978 1980 1981 1982 1983 1984 1985 1986 1987

1942 1353 1045 664 667 813 720 547 610 627

693 536 389 195 229 293 256 226 242 267

202 113 104 82 18266

Total

17 858

6751

Paramedicals 1 145 1227 779 465 E

130

1z 552 367 352 394 334

1: 98

;z 262

1832

9 725

(Ministry of Immigration, 1987).

The licensure procedure in force in Israel for immigrant physicians until 1987 has been different from that used in other Western countries [49]. It has reflected an effort to reconcile two major societal needs which in some cases conflict:

One expresses the ideologically-based concern to accept and integrate immigrant physicians into the health care system while the other expresses a desire to maintain and safeguard the quality of medical care. In an effort to answer both of these needs the process has been differentiated into two levels, the first dealing with licensure for general practice and the second relating to licensure for specialty status. ,The change introduced in 1987 will be discussed below. After demonstrating an acceptable level of competence in the Hebrew language, immigrant physicians were required to demonstrate formal completion of studies at one of the medical schools listed as acceptable by the Ministry of Health which uses the listing of the World Health Organization as its reference. If internship was not included in the course of studies, an immigrant physician is required to complete a year of internship in an appropriate institution in Israel. When the documents were acceptable, the individual was given a one-year license to practice general medicine in one of the medical care organizations. During this period he was supervised and evaluated by a physician supervisor. If the evaluation was satisfactory, a license was granted for general practice. The second stage of licensure concerns specialty status which, in the Israel context of practice, is viewed as a sine qua non by virtually all graduates of Israeli medical schools. The Israel Medical Association through its Scientific Council is responsible for the administration and evaluation of formal written and oral qualifying examinations for medical specializations. These are the same as those required by Israeli-trained physicians. Unless an immigrant physician can demonstrate acceptable training and experience in a recognized medical specialty, he is required to pass the formal specialty examinations in order to qualify as a specialist. Physicians in fields of practice which are already saturated in Israel have been encouraged to participate in one of a number of re-training courses the purpose of which was to promote entry into medical fields in which there was a shortage of practitioners. These have changed over the years but have included such areas as family medicine, geriatrics, anesthesiology, and radiology, all of which fields have been shunned for many years by graduates of Israeli medical schools [47]. Resolution of the two conflicting needs was a functional compromise expressed by the differentiated licensing procedure. Employment has been provided in their profession for virtually all immigrant physicians once their medical school credentials have been accepted. Recognition of specialty status has involved examinations or extra courses thus focusing more on the quality control issue. Several attempts to establish more stringent licensing procedures in the past did not succeed because of the strong political-ideological commitment to an opendoor policy and the need to provide immediate employment for immigrant doctors. But in 1987, more rigorous quality control was formally applied to the first level of licensing, The decline in the total number of immigrants and consequently of immigrant physicians, made it possible for professional pressure groups to express their long felt concern with the uneven level of training among immigrants coming from a wide range of medical schools in different countries [53]. As of 1987, physicians trained outside Israel are required to take formal qualifying examinations

198

administered by the Scientific Council of the Israel Medical Association. This regulation also applies to Israelis who completed their medical training outside Israel. It is estimated that each year about 150 such foreign trained Israelis seek licenses to practice in Israel. This change represents a major compromise with the ideologically-based orientation which was principally concerned with employment and integration of immigrant physicians into the health care system. (b) Medical schools

A major component in the supply of physicians are the four Israeli medical schools which admit secondary school graduates to a seven-year program including a final-year of internship. Each has been established in response to pressure from groups of professionals in the universities and hospitals or other interested parties. As Mahler [31] has noted, ‘educators are not particularly interested in manpower plans, and they give education a life of its own’. The status and prestige attached to a medical school have served as important motives although in each case public support has been sought through affirmations by the interested parties attesting to the unique contribution of each successive school to a health problem or to needs of the population. The arguments surrounding the establishment of each medical school indicate the different themes advanced by the interested groups and the strategy of their utilization. The political processes involved were not anchored in the formal party system but in the balance of power among various interest groups, some of them wielding considerable influence. The first medical school to be established was the Hebrew University-Hadassah Medical School founded in 1949, one year after independence. There was no locally based institution at the time and persons wishing to study medicine generally trained in Europe. Little opposition was voiced especially since health needs were growing rapidly in the period of mass immigration. The joint efforts of the already existing Hadassah Hospital and the professional impetus of the Science Faculty of the Hebrew University were critical to its establishment. Both saw a medical school as a major service to the society, as well as a means of expansion and development ml. From its earliest days the Hebrew University-Hadassah Medical School has been strongly oriented to science, technology and research and has channeled its graduates to specialties reflecting those themes. Its prestige and commitment to high academic and medical standards have made it a powerful model for the other schools that were subsequently founded [39]. In the early 196Os, interest was expressed in Tel Aviv medical circles in establishing an additional medical school to be affiliated to the young and expanding University of Tel Aviv. The strongest supporters of the idea came from the leadership of hospitals in the Tel Aviv area and the Israel Medical Association who argued that such a medical school would raise the level of the region’s hospitals, bring home Israeli students and physicians studying or working abroad, attract foreign students to study in Israel, provide healthy competition between two medical schools, provide channels for advancement for young professionals seeking a 11241

199

teaching career, and serve lower income students from the Tel Aviv area [47]. In the public debate over the establishment of a second medical school, there was less consensus than in the discussions concerning the first. It was noted that there was no shortage of physicians in Israel to meet the needs of a growing population: in 1962 the doctor/population ratio was 1:405, the highest in the world and immigration provided a regular supply of additional medical manpower. Nevertheless the pros won out. The Tel Aviv University Medical School opened in 1964 [35,47]. The third medical school was established in 1969 and was incorporated in 1971 as a regular faculty of the Technion-Israel Institute of Technology, a veteran Institute in Haifa which specializes in mathematics, physics, engineering, architecture, computer sciences, and other technological subjects. This medical school set as its unique purpose to train its graduates for an understanding and appreciation of advanced science, biotechnology, and use of sophisticated medical equipment. Despite some differences of opinion, the establishment of the Haifa Medical School was approved, not least because it was an election year and the political leadership in Haifa was strongly in favor (Ha’aretz, 7 August 1969). The fourth medical school of the Ben Gurion University of the Negev in Beersheba was established in 1974 in the wake of a headlong confrontation between its supporters and its opponents. The latter were led by the deans of the three established medical schools. The supporters attributed little significance to the findings of a special committee established by the Minister of Education to examine the need for additional locally trained physicians. That committee reported that there would be an excess of 5000 physicians within the next decade without the establishment of an additional medical school. The arguments favoring the new school focused on the unsatisfactory quality of the current medical manpower and on the intention to train a new type of doctor who would be skilled to deal with major problems of the health care system. It was claimed that these problems would be reduced by integrating the new medical school into the regional health care system, by exposing all students to an innovative, integrated, community-oriented curriculum throughout the full course of their training, and by using different. personality-related criteria for admission [43]. Despite no small opposition [6], the fourth medical school was established and has graduated over 200 physicians to date. In summary: The on-going establishment of new medical schools has had little relation to the existing manpower available [33]. Each group of interested parties, principally teachers in the science faculties of the local university and clinicians in the relevant hospitals, referred in turn to the currently compelling arguments and all claimed that teaching facilities, both pre-clinical and clinical, were readily available in existing institutions with little need for additional investment of resources. The momentum of expansion in both preclinical and clinical teaching facilities of all four schools clearly indicates the short-lived validity of that argument. The specific claims of the supporters have yet to be scientifically established. However, the prestige gained by the affiliated universities and hospitals has been considerable and the supply of well-trained physicians has been consistently augmented. In the

200

broader context it is worth noting that these processes are not unique to Israel. FUllop and Roemer [19] state that the number of medical schools in the world increased by 85% between 1955 and 1975 while the population grew by only 42%. A career in medicine has been traditionally attractive to Israelis. Over 3000 persons have applied each year during the 1980s to Israeli medical schools. About 400 have been admitted annually. In 1984 there were 2230 students in the four medical schools. Large numbers of those who do not gain admission in Israel go abroad to study, frequently at medical schools where the curriculum does not include the kind of intense laboratory training and bedside teaching that is viewed as essential in Israeli medical schools. Many complete their final clinical years or their internship in Israel. In 1984, 340 physicians completed their studies at the four Israeli medical school and were licensed to practice. In that year an additional 183 Israelis who studied medicine in other countries and 36 young immigrant physicians completed a year of internship in Israeli hospitals and were licensed (Table 5). Furthermore, about 200 experienced immigrant physicians received licenses to practice. Thus, in 1984, approximately 760 physicians were added to the practicing population, an increase of 6.5% in the total physician manpower. While the number of immigrants fluctuates somewhat from year to year, this is a fairly typical picture of the annual entries into the physician manpower pool [53]. Table 5 immigrants

1979 1980 1981 1982 1983 1984 1985

and foreign-trained

israelis who completed

internships

in Israel, 1979-1995

Immigrants

Foreign-trained Israelis

Total

86 70 43 :;

122 107 103 113 179 183 150

208 177 146 157 232 219 183

33:

(State Controller’s Office, 1986).

The politics of abundance and shortages Israel is characterized by one of the highest physician/population ratios in the world: 331:lOOOOO(Table 6) [56]. There is no evidence that this ratio is in any way related to excessive health problems. The reverse is in fact the case: rates of infant mortality, life expectancy at birth and at age 60, as well as most morbidity data show Israel to be characterized by health indicators that are not very different from those in many Western countries [54] (See Appendix). The large supply of physicians was evident well before independence and at that time was a result of immigration of relatively large numbers of refugee doctors. In 1952 the physician to population ratio was l/390. Over the years this high ratio

201 Table 6 Ratio of physicianslpopulation

Israel France Spain Belgium Austria Greece Sweden United Kinadom (World Health Organization,

in selected countries

Physicians/100000

Year

331 303 302 293 287 285 277 164

1985 1985 1983 1984 1985 1984 1986 1981

1988).

has continued, with some fluctuations, as a result of the joint effects of continuing immigration and regular additions to the practicing population of locally trained physicians and of Israelis trained abroad. The annual rate of increase in the number of physicians is three times the rate of growth of the population [53]. An on-going debate has raged for many years regarding the extent to which the apparent abundance of physicians conceals actual shortages. Parties to the debate are politically committed to one interest group or another and their arguments reflect those interests. Several forecasts regarding physician manpower have been published [24]. These have estimated the demand for doctors in the late 1970s and early 1980s and virtually all have predicted an excess of physicians. The general surplus does not prevent shortages in specific specializations [42]. However the excess has already caused, and in all likelihood will continue in the future to cause, emigration of Israel trained physicians to other countries [24]. In 1982, 531 physicians who completed their training in Israel were abroad, half of these for over four years [53]. An additional manpower forecast was published in 1982 with predictions for various occupational groups in 1985 [37]. An annual increase of 3.3% in the number of physicians was predicted while the annual growth in the population during that period was only 1.8%. Proposals to reduce the number of physicians have been put forth by the Ministry of Finance in its efforts to deal with spiralling costs in the health care system. These have included the suggestion to reduce the number of medical students, to retrain some physicians to become dentists [9], to enforce retirement regulations more stringently, and to introduce licensing examinations [16]. As noted, the last of these proposals was in fact adopted in 1987. Assuring full employment has been a dominant goal of Israel governments since 1948. In fact, unemployment has been kept relatively low: In 1985 6.7% of the civilian labor force were unemployed and by 1988 it was 7.0%. Needless to say, unemployment was higher in specific localities and age groups (see Appendix). Major efforts have been invested to find employment for the large physician population and in fact almost all have been employed in the health care system. Even in those cases in which immigrant physicians failed to obtain licences to practise in their specialty, they were virtually all employed as general practitioners, 11271

largely in the primary care system [48]. It has however been noted that there is underemployment of physician manpower which is expressed in a relatively short working day, liberal vacations, and fringe benefits especially for older physicians who are permitted to put in fewer hours, particularly during the summer months [35]. These measures are congruent with the generous welfare benefits offered to most salaried Israelis but in the case of the physicians they reflect a political concern to ensure employment for all and specifically to provide jobs for immigrants. Such underemployment is especially evident among physicians employed in the community clinics of the General Kupat Holim who are older on the average than those in the hospitals and include a high proportion of women. In 1987 it was estimated that 23% of the physicians in the General Kupat Holim community clinics would reach the age of retirement by 1991. The percentage of women physicians in the community clinic population was 48.4% in 1986, and, among the pediatricians this figure reached 72% [22,51]. The Israel Medical Association is both a trade union and a professional association for all physicians. It has played a major role in wage negotiations and demonstrated its power most dramatically in the four-month doctors’ strike in 1983 [23,38]. One of the mechanisms it has used to ensure employment for the large number of physicians has been to minimize the substitution of nurses or other paramedicals for doctors. This has been done by a stringent set of professional requirements which in effect prevent substitution for physicians. The ratio of nurses to doctors is low: 3.3/l [16]. Furthermore, compared to many developed countries, Israel has a low nurse to population ratio: 678:lOOOOO in 1982 [56]. While there are many reasons for the latter phenomenon, job dissatisfaction plays a major role as does the feeling of many nurses that career advancement is limited [571. The large absolute number of physicians (11 895 in 1983) has not prevented certain shortages and maldistributions [4,35]. Some of these patterns are not too different from those seen in other countries, but others reflect unique social and political characteristics of Israel. A recent study compared health manpower ratios in 31 development towns (total population 20201) and 24 veteran towns (total population 52 315). The former are characterized by relatively high proportions of persons with less education, more children per family, denser housing, a high proportion of persons engaged in non-skilled occupations, relatively high unemployment, and more residents of Asian-African origin [ 181. Table 7 presents a comparison of health personnel and facilities in the two types of communities. It may be seen that the ratio of primary care physicians to population is 1:2326 in development towns and 1 :1852 in the older more established veteran communities. The latter also are characterized by a more favorable ratio of specialist physicians. On the other hand, the development towns show a more favorable ratio of pediatricians and of nurses. In smaller development towns, in which physicians attend clinics only a few times a week, much of the day to day primary care is provided by nurses. The State Controller’s Report for 1986 stated

203 Table 7 Health personnel in development and veteran towns: 1981 31 Development Primary care MD/10000 Specialist MD/10000 Pediatrician/10000 under 14 Nurse/l0 000 *Population: 20 201. **Population: 52315. (Ellencweig and G&stein,

l/2326 l/6667 lf2128 l/1471

towns*

24 Veteran towns** l/1852 l/3448 l/2299 l/1695

1986).

that there are physician shortages in the Negev (South) and in the Galilee (North) [531. Rural areas in Israel are not all under-serviced in terms of health care. Kibbutzim, many of which are also located in geographically remote areas, enjoy high quality health services. Because of their relatively high level of education and awareness of health needs, and because most of them are intimately linked to the Histadrut and Labor Party, which increases the accessibility of General Kupat Holim services, kibbutz populations are high utilizers of health services [32]. Many kibbutzim also invest directly in health personnel and facilities over and above those provided by the General Sick Fund [17]. Despite the large number of physicians there is maldistribution regarding the quality of health care. Primary care on the community level is recognized to be the keystone of an acceptable health care system. While the network of primary care facilities in Israel is widespread and generally accessible, it is poorly integrated with the hospital system. The status differential between primary care and hospital practice is reflected in the widespread preference of Israeli medical school graduates for the latter [35,47]. Immigrant physicians have found employment principally in the primary health care system and a considerable proportion of them do not have specialty status [48,53]. The large total number of physicians has not prevented shortages in certain medical specialties. In a small country these are ephemeral and the market can be quickly saturated. However, in 1986 there were shortages in the following specialties: geriatrics, pathology, anesthesiology, radiology and isotopic medicine 1531.

On-going political processes National planning? In 1986 the Annual Report of the State Controller, a non-political, governmental body whose task is to evaluate the functioning of government offices and other public organizations, presented a critical review regarding planning of health manpower [53]. _

11291

204

The report states that the Ministry of Health does not have a unit directly responsible for health manpower planning nor does it maintain an on-going database that could serve as the basis for such planning. In terms of real influence, the annual reports of the State Controller, which focus on different bodies each year, are somewhat limited. The findings are widely respected and generally get broad media coverage but, as with many news items, their viability in the public consciousness is short-lived. The Controller’s disengagement from the political structure acts to limit his inlluence on a highly politicized system in which decisions are most often taken in response to the balance of pressures from powerful interested parties, a situation seen in many countries [34]. In fact there is at present no process of national planning for health manpower. There has been no systematic evaluation of changing levels of need and demand or of the amount and quality of service offered by different types of practitioners [3,27]. This absence of planning applies in other areas as well and is often justified by the contention that frequent emergencies make long-term planning problematic in Israel. Although one cannot deny the existence of such emergencies, in our judgement such contentions frequently serve to advance the interests of the relevant parties and in many cases, the very urgency of a specific situation reflects a lack of overall planning. The on-going unrest and strikes in the health care system clearly reflect the latter situation [4,23,38,41,55]. In the absence of a national planning program, each of the health care organizations has dealt with its own manpower issues. Each determines its manpower structure in terms of its own needs, budgetary constraints and, in large measure, in competition with the others for a share of the resources allocated to health. Each of the bodies maintains its own data base concerning health manpower but there is duplication and weak integration among them [20-22,541. The General Kupat Holim has focused some of its planning efforts on the quality level by launching a major program to train family physicians. The concentration of immigrant physicians with no specialty status in its primary care clinics has heightened the awareness of this organization to the quality issue: 49% of the physicians employed in the primary care clinics of the General Kupat Holim are not licensed specialists 1221. There is evidence that interest in family medicine may be growing. In a study of Israelis who completed medical school between 1980 and 1984, it was found that 7% were actually in family medicine residency programs which are funded for the full four-year training period by the General Kupat Holim [44]. Each of the residents undertakes to work in a primary care clinic for three years after completing the training program. In 1986, 195 specialists in family medicine were employed by the General Kupat Holim in their primary care clinics (Kupat Holim, 1986) and over 200 were in residency programs, of which 75 are graduates of Israeli medical schools and 25% were trained abroad. The growing numbers apparently reflect market constraints in other residency options for recent medical school graduates and possibly a growing awareness on the part of the latter regarding the psycho-social aspects of health. There is no clear evidence to indicate that the Beersheba Medical School, which is specifically geared u301

205

to orient its students to this field, has contributed a higher proportion of students to residency programs in family medicine to date. of the Israeli medical school graduates starting a residency in family medicine in 1986, 15% were trained in Beersheba, 15% in Haifa, 44% in Tel Aviv and 26% in Jerusalem. This distribution corresponds to the proportions of graduates from each of the schools [44]. Health services in the macro-political arena The political affiliations of the various health care organizations have given them different bargaining leverage in the competitive process and this changes in terms of shifting balances in the national political arena. We have noted the political change which took place in 1977 when the right-wing Likud party came into power after a period of more than thirty years during which the national leadership was in the hands of the Labor Party. This shift in the political constellation had major implications for the political leverage of the General Kupat Holim. Membership in the Histadrut has changed recently and at least a third of its membership are currently Likud supporters [57]. The fact that the Ministry of Finance was no longer under Labor Party control after 1977 has limited the latter’s access to resources. The health care system is utilized by the political leadership as a major element in the bargaining process and in the jockeying for power among the parties. In particular, the strength of the General Kupat Holim has continued since its founding to endow its political sponsors with the power that results from dependence of its members on its services. The Labor party has repeatedly resisted efforts to separate Histadrut membership from General Kupat Holim membership. It has also rejected proposals to introduce small fees for clinic visits which have been proposed in an effort to reduce the high utilization rates of primary care services. The average annual number of physician contacts per insured person is 12.3 [lo] and the prescription rate per year is 24. Over and above the high value traditionally placed on health by Jews, there has been some sociological research which has pointed to the importance of certain latent functions of the medical care system which encourage utilization of primary care services in a society characterized by immigration and ethnic heterogeneity as well as by comprehensive health insurance. These latent functions include people’s desire for psychological support, legitimation of failure through the sick role, and formal certification of illness in order to utilize sick leave from work. Physicians participate in decisions concerning distribution of scarce resources such as cars for the disabled, sheltered housing, special jobs, telephones, and other benefits. These functions, which occupy a considerable portion of professional time in primary care settings, have for many years caused young Israeli medical graduates to shun careers in such clinics [35,50]. Despite the widespread consensus that Israelis are excessive utilizers of these services, the Labor Party and the Histadrut have reiterated their ideological stance regarding the right of all insured persons to health care at no direct charge. In the draft national budget for 1988 the Ministry of the Treasury proposed that a symbolic fee of NIS 4 (about $2.50) be charged for clinic visits and NIS 10 (about $6.50) per day for hospitalization for all insured persons except those below a certain income 11311

206

level, chronically ill, pensioners and infants. Despite several compelling reasons to introduce a symbolic charge for clinic visits, the strong opposition of the Histadrut and the Labor party prevented its approval in the Knesset and it was not included in the national budget for 1988, which was an election year.

Competition among sick funds An additional dimension of political conflict may be seen in processes of competition for members and resources among the four sick funds. The overall dominance of the General Kupat Holim has not been seriously contested until recently. However, the health care system has been subject to considerable stress in recent years as a result of spiralling costs and continuing wage disputes which have resulted in major disruptions in its functioning [41]. Most dramatic was a four-month physicians’ strike in 1983 and a 17day strike by the nurses in 1986. In 1987 and 1988 there have been a prolonged series of work stoppages by all types of health personnel in hospitals and in community clinics. Long queues for elective surgery due to part-time use of operating rooms have resulted in widespread dissatisfaction among consumers. Growing dissatisfaction in the General Kupat Holim membership has begun to express itself by members ‘voting with their feet’, i.e., shifting their membership to other sick funds. Table 8 shows a decline in the annual rate of growth in the General Kupat Holim membership from 2.7% between 1984 and 1985 to only 0.7% between 1985 and 1986. Between 1982 and 1985 the growth in membership paralleled or exceeded the growth in the overall population. However, most recently between 1985 and 1986, the total population increased by 1.5% as compared to only 0.7% growth in the General Sick Fund membership. This has caused increasing consternation in the political leadership. Table 8 Growth in Membership

of General Kupat Holim, 1982-1986

Number of insured persons

Increase from previous year

Percentage growth from previous year

1982 1983 1984

3 105 167 3 141765 3 227915

35 598 86 150

:::

1985 1986

3 279 303 072 033

24 039 51118

;:“7

(General Kupat Holim, 1987b).

By way of contrast, during recent years the Maccabi Sick Fund has shown considerable growth. In 1981 it had 310000 members. In the period 1985-86 it grew by 4.5% and between 1986-1987 by 7.4%. [29]. The Maccabi Sick Fund has also expanded its primary health care services in the last few years to twenty-five

11321

2w

development towns which until recently have been serviced largely by the General Kupat Holim. All of the sick funds obtain funds from the government. The basis on which funds are allocated to each of the sick funds has been a subject of intense negotiation since 1950 [25]. The criteria have tended to favor the General Kupat Holim, but in recent years, the smaller sick funds have sought to qualify for such subsidies by establishing clinics in small, outlying settlements often leading to duplication and waste when such parallel services already exist. Possible effects of the private sector An indirect but important factor influencing the distribution of medical manpower has been the recent growth in the private sector of health care. In a society which provides comprehensive health insurance to 94.5% of its population, this phenomenon is viewed with real concern as an indication of certain problems in the operation and quality of service in the public sector. If people can obtain health care at no out-of-pocket cost, why should they opt to pay for it? Documentation regarding change in the relative size of the private sector is incomplete and no major study has yet been undertaken on the topic. Machnes-Caspi [30] reports that in 1968-1969, 6% of those insured by the sick funds purchased services at least once from a private physician while in 1975-1976 this figure rose to 32%. Analysis of the background characteristics of utilizers of the private sector shows them to have a higher family income, higher rent, and more rooms in their dwelling. Another way of estimating the size of the private sector is by examining the consumer’s role in total health expenditures. In 1983-1984 one quarter of the total care expenditures were directed to the private sector, more specifically to dental care, private physicians, medicines and medical equipment purchased by households. There is little evidence for change over time in these data [12]. Almost all physicians are presently employed in salaried positions in one of the health care organizations. Wages are controlled by grades and have been a subject of controversy and unrest. Those who already work on a private basis generally supplement their incomes from such additional practice. Future growth in the private sector, in which income is markedly greater, could cause important changes in the distribution of physician manpower.

Summary and Conclusion The health care system in Israel is intimately linked to the overall political structure. The coalition-type government, composed of numerous parties joined in a tenuous balance, has frequently focused the bargaining process among the partners on the health care system. The latter serves as an important element in the give and take of the macro-political system, so that decisions concerning it have in many cases been completely unrelated to issues of need, demand or supply of u331

208

health manpower. In particular the General Kupat Holim, which provides comprehensive health care to four-fifths of the population has served the political interests of the Histadrut and the Labor party. Decisions relating to its operations have been guided as much by political considerations as by broader health needs of the society. In some cases these are congruent and have resulted in constructive contributions to the society. This is clearly the case with regard to the extensive, widely spread network of health care institutions which literally cover the entire country, including its most remote and deprived areas. The same may be said with regard to the family medicine program. There are many additional examples of important health projects which reflect both sets of needs. At the same time there are examples which reflect dominantly political interests. In playing to its electorate by opposing small fees for clinic visits, the General Kupat Holim may be doing a disservice to the society in terms of the rational use, overall quality and costs of the health care system. The same may be said of its efforts to reduce competition from smaller sick funds by augmenting its own share of government subsidies. The lack of overall national planning with regard to health manpower is a result of the fragmentation of the health care system into several components which compete for resources and influence. The Ministry of Health is actually one of these and it has not had the political leverage to implement a national planning program or to set meaningful priorities in terms of health needs. This impotence is partly the result of historical factors which caused it to have a double role that induces a conflict of interests: it is a provider of health care as well as a coordinator and supervisor of health services. The overall supply of medical manpower is among the highest in the world. The large number of physicians stems from migration and from graduates of local or foreign medical schools. Both of these components of the supply process have been strongly influenced by political factors on the macro and the micro level. The open-door policy has brought thousands of immigrants, among them many physicians. Virtually all have been licensed and employed in the health care system. The establishment of four medical schools since 1949 reflects pressures and political inlluences on a micro, but no less powerful, level. While a variety of rationalizations have been used for each, the bottom line in exercising influence in each case has been the faculty of a specific university, physicians in one or more hospitals and local interest groups. There is little evidence that rational considerations relating to current supply of medical manpower or to needs of the population played a real role in decision-making. However, the schools are all of high quality and turn out extremely well trained physicians. There is widespread agreement that Israel has an excess of physicians and considerable public debate has focused on this issue. As in many countries, the geographic distribution is uneven and certain areas suffer shortages; a number of specialties are in short supply. The quality of medical care is uneven and questions have been raised about the level of practice among physicians trained in a variety of countries. There is a real value conflict in the society surrounding this issue in view of the 11341

209

salience and centrality of immigration. The open-door policy is one of the cardinal values of Israel. At the same time there is deep concern with regard to the quality of health care and spiralling costs. The recently introduced licensing examinations address the quality issue. In an effort to keep employment up, medical manpower is not always utilized to its maximum. Hidden under-employment is widespread in the community clinics where older physicians and women work relatively few hours. Ibis is not the case among hospital physicians. In the long run it is our feeling that decisions concerning medical manpower planning will be determined by two over-riding factors that are as salient in Israel as in other countries. Rapidly increasing costs of running the health care system are likely to introduce constraints regarding the planning process. Israel simply cannot afford to run an inefficient health care system. Duplication, lack of rational distribution of manpower, and under-utilization of staff are ‘luxuries’ that will be less and less acceptable in the future. Growing dissatisfaction of the consumer population, which expects high quality health care, will also induce more rational planning. As consumers become more critical and vocal, their input into the political system will gain in importance on both a national level, by means of support for political parties, and on a more local level in terms of their choice of sick funds. The smaller sick funds are already attracting members away from the traditionally dominant General Kupat Holim in a process that is likely to cause growth in the former groups. Such market mechanisms will make their own contribution to the quality and distribution of medical manpower in future years.

I1351

210

Appendix Selected background data on Israel (Central Bureau of Statistics, 1984,1985

and 1988)

1985

1980

Total % Jews % Non-Jews

4.266.2 82.5 17.5

3.921.7 83.7 16.3

Jews by birthplace % Israel born % Born in Asia-Africa % Born in Europe-America

3,517.2 60.4 17.6 22.0

3.282.7 55.9 19.5 24.6

749.0 77.1 13.3 9.6

639.0 78.0 14.1 7.9

30.0 10.1 44.1 3.2

30.4 9.7 47.4 3.1

73.5 77.1

72.5 76.2

21.6 10.3 2.9

22.0 12.4 2.8

Population

(thousands)

Non-Jews 510Moslems % Christians % Druze and others Population by selected age groups % Jews O-14 % Jews 65+ % Non-Jews O-14 % Non-Jews 65+ Area 21,501 km2 Density: 199.3 per km2 Kid Stalktics Life expectation Males Females

at birth

Jews Births per 1000 population Infant mortality per 1000 live births Total fertility per woman Women born in: Israel Asia-Africa Europe-America Non-Jews Births per 1000 population Infant mortality per 1000 live births Total fertility per woman Moslem Christian Druze

32.; 2:8

2.8 3.0 2.8

32.3

36.5

20.6 t :;

24.4 5.4 6.0

:::

:::

11361

211

Labor Force Percentage of women in labor force: 37.8 Occupational distribution, by sex, (%), 1985 Males Scientific and academic workers Other professional or technical workers Administrators and managers Clerical Sales Service Agricultural Skilled workers (industry, building, transport, etc.) Unskilled workers (industry, transport, building, etc.) Total Percentage

of unemployed

8.5 10.1 7.6 10.7 8.7 8.5 7.0 34.2 1;::

Females 8.6 23.7 1.8 29.6 5.9 18.9 2.3 7.6 1.5 100.0

Total 8.5 15.3 1z 716 12.4 5.2 24.1

1G

in civilian labor force by sex (1983-1987)

1983 1984 1985 1986 1987

4.0 2::

5.3 7.0 7.3

4.5 5.9

6.5 5.3

7.9 7.2

;.: 610

Health System Hospitals, by type (1985) General Care Mental Diseases Chronic Diseases Rehabilitation

42 31 76 2 151

Hospitals

and number of beds, by ownership

(1985) Number of hospitals

Number of beds

Private Government Municipal government local authorities General workers sick fund Hadassah Missions Other non-profit hospitals

6 624 9 476

2 14 1 377

1287 5088 869 3531 636

27511

151

Total Hospital beds per 100 000 population,

60 30

by type of bed (1985)

General Mental diseases Chronic diseases Rehabilitation Other

280 183 169 12 1

Total

645

[1371

beds per 100000

212 Health Insurance: 94.5% cmered by comprehensive

health insurance (1984)

Health Expenses National Expenditure on Health as Percentage of GNP (1984/85) 7.4% Urban Household Expenditure on Health as Percentage of Total Consumption (1979/80): 4.2% of Total Consumption Expenditure

Expenditure

References 1 Arian, A., Health care in Israel: Political and administrative aspects. International Political Science Review. 2 (1981) 43-56. 2 Bachi, R., The population of Israel, The Institute of Contemporary Jewxy, Hebrew University of Jerusalem, 1974. 3 Baruch, N., The institutional organization of health services in Israel. Center for Policy Research, Jerusalem, 1973. 4 Benjamin, Y., Gafni, A. and Blankett, J., Is a physician surplus a mirror image of a shortage? The Israel Institute of Business Research. Working Paper No. 837/84. Tel Aviv University, Tel Aviv, 1984. 5 Benjamin, Y., Gafni, A. and Blankett, J.. The Israeli physicians’ strike: an inevitable outcome of the structure of Israel’s health care system. J. Collective Negotiations. 15 (1986) 21 l-223. 6 Benziman, U., A Fourth Medical School) Ha’aretz. 5th February 1973. (Hebrew). 7 Bergman, R. and Hen, R., Nurse Manpower in Israeli. Bitachon Soziali, July 1976. (Hebrew). 8 Bilski. R., Planning in Israel’s public health services. In: Can Planning Replace Politics? The Israeli Experience, R Bilski (ed.), pp. 217-258, Martinus Nijhoff Publisher, The Hague (1980). 9 Call, R.L., Sgan-Cohen. H.D. and Mann, J., Changing the dental applicant pool in Israel: retraining of physicians, Israel Journal of Dental Sciences, 1 (1985) 149-253. 10 Central Bureau of Statistics. National Expenditure on Health 1983-84 and Preliminary Estimate for 1984-85, Supplement to the Monthly Bulletin of Statistics, Vol. XXXVII, No. 3, 1986. 11 Central Bureau of Statistics. Statistical Abstract of Israel 1987. No. 38, Jerusalem 12 Central Bureau of Statistics. Statistical Abstract of Israel 1986. No. 37, Jerusalem. 13 Central Bureau of Statistics. Statistical Abstract of Israel 1985. No. 36, Jerusalem 14 Central Bureau of Statistics. Statistical Abstract of Israel 1984. No, 35, Jerusalem. 15 Central Bureau of Statistics. Statistical Abstract of Israe. 1983. No. 34, Jerusalem. 16 Cohen, R., The Israeli Health System: Power, Politics and Policies. Ph.D. dissertation. Faculty of Medicine, University of Toronto, 1986. 17 David, I., Panker, G. and Deutsch, H., Health Expenditures in the Kibbutz. Department of Health and Welfare Administration, Ben Gurion University of the Negev 1980 (Hebrew). 18 ElIencweig, A.Y. and Grafstein, O., Inequality in health: a case study. Department of Medical Ecology. Hebrew University. Hadassah Medical School, Jerusalem, 1986 (unpublished). 19 FUlop. T. and Roemer, M.I., International Development of Health Manpower Policy. WHO Offset Publication No. 61. World Health Organization, Geneva, 1982. 20 General Kupat Holim. Planning for Manpower in Kupat Holim Research and Medical Economics Department, Tel Aviv, 1987 (Hebrew). 21 General Kupat Holim. Kupat Holim - Institutions and Services - 1987. Publication No. 125. Research and Medical Economics Departmen Tel Aviv, 1987 (Hebrew). 22 General Kupat Holim. Manpower Planning in Kupat Holim Publication No. 123. Research and Medical Economics Department, Tel Aviv, 1986 (Hebrew). 23 Greenberg, D.S., Health Care in Israel. The New England Journal of Medicine 309 (1983) 681-684. 24 Halevi, H.S., The Next Generation. Harefuah 85 (1973) 384-386. (Hebrew). 25 Halevi, H.S., The bumpy road to national health insurance: the case of Israel. Brookdale Institute of Research on Aging and Adult Human Development, Jerusalem, 1980. 26 Kanev, I., Mutual Aid and Organized Medicine in Israel. Economic and Social Research Institute. General Kupat Holim, Tel Aviv, 1953. [1381

213

27 Kissick, W.L.. Health Manpower in Transition. The Milbank Memorial Fund Quarterly. 46 (1968) 53-90. 28 Levin, M., Balm in G&ad: The Story of Hadassah. Schoken Publications, New York, 1973. 29 Maccabiton Newsletter of the Maccabi Sick Fund, January 1988. (Hebrew). 30 Machnes-Caspi, Y., Consumption of private medical services by Israeli households with full coverage of health insurance. Public Health (London) 94 (1980) 89-94. 31. Mahler. H., Greetings In: Health Manpower Out of Balance. 2. Bankowski and T. Fttllop (eds.), pp. 7-10. Conference sponsored by the Council for International Organizations of Medical Sciences (CIOMS) at Acapulco, Mexico. CIOMS, Paris, 1987. 32 Mao& B., Case study of a psychiatric treatment center. In: Community Mental Health in Israel. A. Aviram and Y. Levav (eds.), pp. 213-222, Cherikover, Tel Aviv. 1981, (Hebrew). 33 Mejia, A., The nature of the challenge, in Health Manpower Out of Balance. Z. Bankowski and T. Ftillop (eds.), pp. 15-40. Conference sponsored by the Council for International Organizations of Medical Sciences (CIOMS) at Acapulco, Mexico. CIOMS, Paris, 1987. 34 Miller, G.E., Early influences, late consequences, possible interventions. In: Health Manpower out of Balance. 2. Bankowski.and T. FUllop (eds.), pp. 67-75 Conference sponsored by the Council for International Organizations of Medical Sciences (CIOMS) at Acapulco, Mexico. CIOMS, Paris, 1987. 35 Ministry of Health. Report of the Commission for Clarifying the Problem of the Shortage of Doctors, 1963-64, Jerusalem, 1964. 36 Ministry of Immigration. Unpublished data, 1987. 37 Ministry of Labor and Social Affairs. Manpower Forecast: 1980-1985. Office of Manpower Planning, Jerusalem, 1982 (Hebrew). 38 Modan, B., Medicine Under Siege, The Doctors’ Strike - The Crisis of Israeli Medicine. Adam Publications, Tel Aviv. 1985 (Hebrew). 39 Niederland, D.. History of the Hebrew University-Hadassah Medical School. Dean’s Office, Hebrew University-Hadassah Medical School (Hebrew, unpublished), 1985. 40 Palley, H.A., Yishai, Y. and Ever-Hadani, P., Pluralist Social Constraints on the Development of a Health Care System: The Case of Israel. Inquiry 20 (1983) 65-75. 41 Pinhas, S., Strikes in the medical sector - past, present and future. Harefuah 112 (1983) 100-102 (Hebrew). 42 Pizam, A., Estimate of the Demand for and Supply of Physicians in 1982. Recanati School of Management, Tel Aviv University, Tel Aviv, 1973 (Hebrew). 43 Prywes, M.. Aims of the medical school in relation to motivation: practice, not preaching, creates motivation. Medical Education 17 (1983) 69-71. 44 Prywes, M. and Biton, I., A survey of medical school graduates in Israel, 1980-1984. Harefuah 110 (1986) 197-199. (Hebrew). 45 Ramalingaswami. V., Statement in Health Manpower out of balance. Z. Bankowski and T. FUllop (eds.), pp. 11-14, Conference sponsored by the Council for International Organizations of Medical Sciences (CIOMS) at Acapulco, Mexico. CIOMS, Paris, 1987. 46 Reports of the Committee to Examine the Health Services of Kiryat Shmona, 1981 (Hebrew, unpublished). 47 Shuval, J.T.. Entering Medicine: The Dynamics of Transition. A Seven-Year Study of Medical Education in Israel. Pergamon Press, London, 1980. 48 Shuval, J.T.. Newcomers and Colleagues: Soviet Immigrant Physicians in Israel. Cap and Gown Press, Houston, 1983. 49 ShuvaI, J.T., Social functions of medical licensing: a case study of Soviet immigrant physicians in Israel. Social Science and Medicine 20 (1985) 901-909. 50 Shuval, J.T.. Antonovsky, A. and Davies, A.M., Social Functions of Medical Practice. Jossey-Bass, San Francisco, 1970. 51 Shuval, J.T.. Javetz, R. and Shye, D., Self-Care in Health - Physicians’ Views. Brookdale Institute of Gerontology and Adult Human Development, 1988 (Hebrew). 52 Sicron, M., Aliyah to Israel: 1948-1953. Falk Institute for Economic Research in Israel and the Central Bureau of Statistics, Jerusalem, 1957 (Hebrew).

I1391

214

53 State Controller’s Office. Annual Report 37, Jerusalem, 1986 (Hebrew). 54 Tulchinsky. T.H., Lunenfeld, B., Haber, S. and Handelsman. M., Israel Health Review, Israel Journal of Medical Sciences 18 (1982) 345-355. 55 Wolfe, S., Worker conflicts in the health field: an Overview. International Journal of Health Services 5 (1975) 5-8. 56 World Health Organization. World Health Statistics Annual 1988 Geneva. 57 Yishai, Y., Interest groups in Israel. The Jerusalem Quarterly 11 (1979) 128-144. 58 Yishai, Y.. Politics and medicine: the case of the Israeli national health insurance. Social Science and Medicine 16 (1982) 285-291.