In July, Commonwealth Fund staff got some distance from American health care by visiting Israel and the occupied West Bank of Palestine for cross-national health care discussions. The trip involved meetings in Haifa and visits to health care facilities serving Israelis and Palestinians in Haifa, Jerusalem, and the West Bank. Civil strife at the Al-Aqsa Mosque in Jerusalem and elsewhere in the West Bank provided sobering background to our journey — and we got a chance to see firsthand the medical consequences of ethnic and political conflict when we spent a morning at the hospital that treats Palestinians injured in conflicts with Israelis.
The trip was truly a tale of two health care systems that live side by side and interdigitate only at the margins. Israel has one of the world’s highest-performing health systems as judged by national health statistics and health spending levels. It invests modestly in health care, spending about 7.3 percent of GDP in 2016 (compared to an Organization for Economic Cooperation and Development (OECD) median of 9 percent). But it has population health statistics that are as good or better than OECD norms: a 2015 infant mortality rate of 3.1 deaths per 1,000 births, and life expectancy at birth of 80.1 years for men and 84.1 years for women in 2015.
The country’s excellent health results owe a great deal to a system that provides universal health care coverage and prioritizes primary care. Israelis admitted that they consider their hospital care only average in quality by international standards. All Israelis must enroll in one of four HMO-like health plans that pay for all services and directly provide most through a network of clinics and hospitals. We visited one primary care facility in Haifa — owned by Clalit, the largest health plan which enrolls about half the Israeli population. The clinic resembled the community health centers or equivalents that many of us have visited — and worked in — throughout the U.S. and elsewhere in the developed world.
We had conversations with staff from Clalit and other health plans about their use of case managers, social workers, and other health care personnel for managing high-need, high-cost members. Consistent with their universal use of electronic health records and other digital tools, the Israelis described their mostly successful efforts at health information exchange, and their work to develop predictive algorithms to help prevent and manage complex health problems. We came away feeling that we had a lot to learn from the Israelis — and they from us — about optimal approaches to organizing complex care and, especially, the use of digital tools to enhance care generally. Israel is a young, highly entrepreneurial, flexible, and pragmatic country. Its health care system runs lean, and this creates an appetite and aptitude for innovation.
We spent the last day and a half of the trip in and around Jerusalem, where we got an introduction to the Palestinian health care system. To say the least, this system does not have the resources or results of its Israeli counterpart. Spending was USD 294 per Palestinian in 2012 (compared to USD 2,046 per Israeli in 2011). Life expectancy at birth in 2015 was 70.7 years for men and 74.7 years for women, and infant mortality in 2014 was 12.6 deaths per 1,000 live births. The system is hampered by shortages of funding, personnel, and medications and by the pervasive poverty in occupied territories. Restrictions on movement in the occupied territories are also a huge problem for patients and providers.
We visited the principal Palestinian referral center and teaching hospital, Al-Makassed, which is located on the Mount of Olives with a majestic view of Jerusalem. Created in 1968, the facility claims to offer a full range of specialty services, but the plant was modest, and as described to us, funding is unpredictable. It depends on support from the Palestinian Authority — which is perennially in financial crisis — and aid from a variety of nongovernmental sources. Travel restrictions in the West Bank negatively affect health care access by the hospital’s patients, who must get permits from Israeli authorities before they can travel to East Jerusalem. Since Al-Makassed is also the primary source of specialty care for Gaza, access can be a huge challenge for residents of that isolated enclave. We were told that medical staff also frequently face long commutes through many checkpoints to reach the facility — and some have been banned entirely from entering East Jerusalem because of Israeli security concerns.
While we were visiting, the hospital was caring for injured Palestinians who had just clashed with Israeli riot-control forces. One of those patients died the next day.
We also spent a morning with the Israeli branch of Physicians for Human Rights, which organizes trips by volunteer Israeli health professionals to the West Bank and Gaza to provide health services. The visits take place once a week on Saturday mornings, so the group can minister to only 50 villages annually. Physicians for Human Rights has a waiting list of dozens of sites.
My colleague, Eric Schneider, and I had a chance as physicians to sit in on several health care encounters alongside one of the Israeli physician volunteers. We saw one family in which a young son had a previously corrected congenital heart defect (the surgery was in Israel) — but had had no follow-up in years — and the father carried a diagnosis of a rare autoimmune condition known as giant cell arteritis that was being treated with several very toxic medications, again with little continuity of care. The big challenge at this point — so familiar to anyone who has practiced in the United States — was paying for the additional care they needed, since they lacked health care coverage. And this family had the further challenge of getting permits to be seen either in East Jerusalem or, if necessary, in Israel.
There was no avoiding the conclusion that Palestinian health care is vastly inferior to the Israelis’, or that politics is a pervasive influence in the Israeli and Palestinian health care systems. Of course, the last six months have shown that politics is a huge influence on the U.S. health care system as well. The ethnic and income divides that animate U.S. health care politics are better concealed than the Israeli and Palestinian versions, but they are just as important. Our visit was instructive on many levels.
