Health in Israel: patterns of equality and inequality.

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. There is formal equality in access, distribution, and quality of the health services; nevertheless, there are pockets of deprivation that affect certain segments of the population. The paper focuses on three topics: (a) structure of the health care delivery system in terms of coverage, geographical and social distribution, and the public/private balance of the services; (b) processes of health care delivery in terms of utilization and quality; (c) health outcomes in terms of mortality, morbidity, health behavior, and disease vulnerability. Inequality in Israel appears to be structured in terms of six dimensions: coverage of health insurance, distribution of health services, the balance of public and private sectors of health services, utilization of existing services, quality of health services, and health outcomes as expressed by mortality, morbidity, health behavior and risk factors. Only two types of health care are not covered by the general health insurance: (a) dental care, and (b) long-term nursing care. Given the small area of Israel there are striking differences in the geographic distribution of health personnel of various types. There is evidence for gaps between needs and institutional services for many elderly who are on waiting lists for institutionalization. The ratio of primary care physicians to population is 1:2326 in development towns and 1:1852 in the older more established veteran communities. Kibbutzim, which are also located in large part in geographically remote areas, enjoy high quality health services and are not characterized by low ratios of health care personnel. In 1968-69, 6% of those insured by the sick funds purchased services at least once from a private physician, while in 1975-76 this figure rose to 32%. As in other countries, utilization of preventive services is generally correlated with socio-economic status and with education. While the network of primary care facilities in Israel is widespread and generally accessible, it is poorly integrated with the hospital system. Longevity has increased over the past years and is relatively high; 76.6 for women and 73.1 for men in 1984. Nevertheless, differences between Jews and non-Jews may still be seen among both men and women. The same may be said concerning mortality and especially with regard to infant mortality. Differences with regard to certain risk factors among Jewish infants and adults are correlated with socio-economic class and country of origin.