Distr.

GENERAL

E/1990/5/Add.39(3)
20 January 1998


Original: ENGLISH
Initial report : Israel. 20/01/98.
E/1990/5/Add.39(3). (State Party Report)


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[go to part II of the document]
PART III

CONTENTS (cont')
Paragraphs
Article 12 - The right to the highest attainable standard of health529 - 598
Article 13 - The right to education599 - 687
Article 15 - The right to take part in cultural life and enjoy scientific progress688 - 791
Article 12 - The right to the highest attainable standard of health

Introductory overview

529. Israel is a member party of the World Health Organization (WHO). Israel's last report to the WHO, "Highlights on Health in Israel", was submitted in 1996 and covers data up to 1993. It is attached in Annex 3 of this report.

530. This introductory overview is a reproduction of the summary of the report, updated to 1996, with the addition of the following table, which presents the main data on the indicators of the physical and mental health of the Israeli population and on the change in these indicators over time:


SELECTED HFA INDICATORS FOR ISRAEL
Indicator title
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1. Demographic and socio-economic
Mid-year population, total
3,879,000
3,949,700
4,026,700
4,037,600
4,159,100
4,232,900
4,298,800
4,368,900
4,441,600
4,518,200
4,660,100
4,946,200
5,123,500
5,261,400
5,399,300
5,539,700
Mid-year population, male
1,938,300
1,973,000
2,010,800
2,011,600
2,075,700
2,112,300
2,144,600
2,179,000
2,215,100
2,253,200
2,321,000
2,458,300
2,543,000
2,609,400
2,675,800
.
Mid-year population, female
1,940,700
1,976,700
2,015,900
2,026,000
2,083,400
2,120,600
2,154,200
2,189,900
2,226,500
2,265,000
2,339,100
2,487,900
2,580,500
2,652,000
2,723,500
.
Live birth, total
93,484
93,308
96,695
98,724
98,478
99,376
99,341
99,022
100,454
100,757
103,349
105,725
110,062
103,330
114,543
117,182
Live birth, male
48,144
47,204
49,566
50,838
50,914
50,911
50,936
50,559
51,603
51,638
53,013
54,141
56,603
57,775
58,855
60,155
Live birth, female
45,340
46,104
47,129
47,886
47,564
48,465
48,405
48,463
48,851
49,119
50,336
51,584
53,459
45,555
55,688
57,027
Total fertility rate
3.14
3.06
3.12
3.14
3.13
3.12
3.09
3.05
3.06
2.90
2.80
2.80
2.70
2.80
2.90
.
% Unemployed persons, total
5
5
5
5
6
7
7
6
6
9
10
11
11
10
8
6
Annual rate of inflation
133
102
132
191
445
185
20
16
16
21
18
18
9
11
15
8
GNP, US$ per capita
5,423
5,746
5,968
6,526
5,977
5,474
6,677
7,881
9,660
9,633
10,958
11,766
12,589
12,346
13,580
15,406
GDP, US$ per capita
5,615
5,887
6,151
6,729
6,240
5,699
6,922
8,140
9,911
9,887
11,223
11,987
12,822
12,522
13,752
15,660
GDP, PPP$ per capita
6,922
7,756
8,269
8,813
9,221
9,807
9,947
10,728
11,339
11,794
12,647
13,288
13,942
14,346
15,205
16,273
2. Health status
Number of deadborn fetuses,
1,000 + grams
422
504
482
506
469
459
423
457
453
418
343
396
409
.
.
Number of deaths, 0 - 6 days,
1,000 + grams		 .
385
328
380
370
321
325
317
326
280
293
258
242
204
208
193
Number of live births, 1,000 + grams .
91,205
94,224
96,765
96,157
97,248
97,637
97,801
99,119
99,406
101,283
104,182
107,132
109,149
111,391
113,993
Number of deaths, 0 - 6 days,
500 + grams		 .
629
550
608
575
551
525
522
469
461
460
414
408
339
365
331
Number of deadborn fetuses,
500 + grams
455
547
529
539
509
524
478
517
515
469
381
448
458
.
.
.
New cases, tuberculosis
249
227
232
222
257
368
239
184
226
160
234
505
345
419
343
392
New cases, hepatitis - total
3,924
4,525
3,146
3,898
4,965
4,558
3,208
2,058
2,813
2,452
2,650
1,751
1,353
3,547
3,891
2.308
New cases, hepatitis - A . . . . . . . . . .
.
.
1,037
3,041
3,483
2,165
New cases, hepatitis - B . . . . . . . . . .
.
.
139
138
132
69
New cases, syphilis . . . .
122
160
54
32
41
45
.
.
156
118
.
New cases, gonococcal infections . . . .
644
674
424
127
135
146
0
0
0
0
0
0
Indicator title
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
New cases, pertussis
19
25
62
78
7
24
47
96
7
260
189
35
99
138
71
59
Number of new cases, measles
215
228
7,864
129
137
3,005
1,951
438
178
29
212
991
66
141
1,565
28
Number of new cases, malaria . . . . . .
36
94
268
251
183
67
213
58
26
45
Number of new cases, diphtheria
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
Number of new cases,
tetanus
2
3
3
2
2
3
1
1
3
1
0
5
0
2
1
1
Number of new cases,
acute poliomyelitis
11
8
5
4
1
2
0
2
16
0
0
0
0
0
0
0
Number of new cases,
congenital rubella		 . . . . . .
0
2
. . .
0
6
2
1
0
Number of new cases,
neonatal
0
1
2
1
0
0
0
1
2
1
0
0
0
0
0
0
Number of new cases,
rubella
881
451
602
2,302
7,189
556
284
4,220
1,718
354
99
437
2,145
104
62
46
Number of new cases,
mumps
3,041
5,956
5,092
3,904
6,584
2,113
1,052
2,579
6,999
891
364
349
676
895
891
117
Estimated cumulative cases,
HIV seropositive		 . . . . . . . . . . . . . .
2,000
2,000
New cases, clinically
diagnosed AIDS		 .
0
2
8
5
10
25
19
24
34
45
37
39
55
32
53
Hospital discharges:
infectious and parasitic diseases		 . . . . . . .
22,798
. . . . . .
30,245
.
Hospital discharges:
all cancers		 . . . . . . .
30,632
. . . . . .
54,374
.
Number of new cases of cancer,
all sites, total
8,866
8,942
8,980
8,663
9,785
9,930
10,106
10,088
10,165
10,987
12,253
13,109
13,354
14,072
.
.
Number of new cases of cancer,
all sites, male
4,400
4,409
4,393
4,273
4,794
4,883
4,961
4,992
4,878
5,283
5,820
6,117
6,389
6,694
.
.
Number of new cases of cancer,
all sites, female
4,466
4,533
4,587
4,390
4,991
5,047
5,145
5,096
5,278
5,704
6,433
6,992
6,965
7,378
.
.
Number of cases,
malignant neoplasms, total		 . . . . . . . . . . . . . . .
.
Indicator title
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
Number of cases,
malignant neoplasms, male		 . . . . . . . . . . . . . . .
.
Number of cases,
malignant neoplasms, female		 . . . . . . . . . . . . . . .
.
Number of new cases of trachea/
bronchus/lung cancer, total
718
715
757
755
858
883
792
870
829
937
946
949
905
987
.
.
Number of new cases of trachea/
bronchus/lung cancer, male
536
532
565
543
637
647
554
654
601
667
692
680
661
700
.
.
Number of new cases of trachea/
bronchus/lung cancer, female
182
183
192
212
221
236
238
216
228
270
254
269
244
287
.
.
New cases, cancer of the
female breast
1,174
1,152
1,243
1,128
1,317
1,289
1,360
1,305
1,409
1,616
1,811
2,005
2,049
2,153
.
.
New cases, cancer of the cervix
64
82
86
85
66
95
79
91
97
124
118
117
148
139
.
.
Number of cases, diabetes mellitus . . . . . . . . . . . . . . .
.
Number, mental health patients
in hospital, 365 + day
6,163
6,106
6,141
6,102
5,977
5,854
5,606
5,285
5,076
5,014
4,951
4,865
4,812
4,824
4,771
4,578
Number of new cases of
mental disorders
4,548
4,486
3,962
3,570
3,812
3,485
3,124
3,115
2,933
3,196
3,293
3,558
3,517
3,699
3,714
4,141
Number of new cases
of alcoholic psychosis
13
5
30
31
39
28
22
26
29
23
27
35
38
35
45
51
Number of cases,
mental disorders
8,678
. .
8,164
8,059
7,780
.
7,167
7,036
.
6,877
.
6,867
6,866
6,949
6,846
Hospital discharges: diseases of
circulatory system		 . . . . . . .
64,876
. . . . . .
102,302
.
Hospital discharges:
ischaemic heart disease		 . . . . . . .
31,127
. . . . . .
47,439
.
Hospital discharges:
cerebrovascular diseases		 . . . . . . .
7,365
. . . . . .
12,425
.
Hospital discharges:
diseases of respiratory system		 . . . . . . .
41,060
. . . . . .
65,368
.
Number of cases, chronic
obstructive pulmonary diseases		 . . . . . . . . . . . . . . .
.
Indicator title
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
Hospital discharges:
diseases of digestive system		 . . . . . . .
42,879
. . . . . .
63,786
.
Hospital discharges: diseases
musculoskeletal & connect.tissue 		. . . . . . .
14,708
. . . . . .
26,280
.
Hospital discharges:
injury and poisoning		 . . . . . . .
37,069
. . . . . .
55,576
.
Absenteeism due to illness,
days per person per year		 . . . . . . . . . . . . . . .
.
Newly granted invalidity
(disability) cases		 . . . . . . . . .
13,445
14,117
11,659
18,176
20,667
20,801
15,516
Number, persons receiving social
benefits due to disablement		 . . . . . . . . .
108,499
111,702
113,931
118,401
125,436
132,618
140,089
% of disabled regular occupation,
15 - 64 years		 . . . . . . .
21
. . . . . . .
.

E/1990/5/Add.39
page 1
E/1990/5/Add.39
page 1
531. The population of Israel is relatively young. This is understandable in light of the fact that the population has increased almost sixfold since the country's independence in 1948, mainly as a result of immigration.

532. Life expectancy at birth in Israel was 76.6 years in 1992, close to the average in the European Union (EU). Male life expectancy was 74.7 years, the third highest among a reference group of 20 European countries*. In marked contrast, female life expectancy was 78.5 years, sixteenth highest and well below the EU average of 80.0 years. Thus, the difference in life expectancy in Israel between men and women is the smallest of the 20 reference countries. The same situation existed in 1994 when life expectancy for men was 75.5 years and for women, 79.5 years. This mortality pattern, where male mortality is among the lowest in the reference countries, while that of women among the highest, also holds for all the main causes of death.

533. Infant mortality declined by 37 per cent between 1982 and 1992, but remained the second highest among the reference countries. By 1995, however, the rate had fallen from 7.5 to 6.8 per 1,000 live births.

534. The Standardized Death Rate (SDR) for cardiovascular diseases in the 0-64 age group was close to the EU average in 1992. The SDRs for ischaemic heart disease were the fifth highest of the reference countries for women but the eighth lowest for men. The SDRs for cerebrovascular diseases in the 0-64 age group were close to the EU average for women and below the average for men. In both these diseases, both male and female SDRs fell sharply from 1982 to 1992.

535. The SDR for cancer in the 0-64 age group was one of the lowest in the European reference countries. The overall cancer rate for men was the lowest of all these countries, while the rate for women was close to the EU average. The SDR for external causes was below the EU average for men and close to the average for women. With respect to suicide, Israeli males show a lower average than general in the EU (its increase of 43 per cent over the last 10 years is, however, one of the highest) but the rate for women is about the average.

536. Nationwide health promotion programmes have gained momentum during the last few years, especially those emphasizing physical activity. The percentage of smokers in the over-20 population declined from 38 per cent in 1973 to 31 per cent in 1992. Among women the drop was even greater. A number of new laws restricting smoking in public areas and workplaces have recently come into force. Alcohol consumption in 1993 was the lowest of all the reference countries.

537. Persons aged 20-74 who were taking medication or following a special diet for hypertension make up 8.5 per cent of the population. The prevalence of high-serum cholesterol (240 mg/dl or more) in the working population




* The 15 member States of the European Union plus Iceland, Israel, Malta, Norway, and Switzerland.aged 20-64 is 18.3 per cent. Some 25 per cent of this population has been estimated to be overweight. Since the 1950s, the intake per head of total calories, fats, animal fats, and protein has increased. The level of leisure-time activity in the general population is low: some 20 per cent of persons aged 14+ participate in such activity at least once a week.

538. Environmental control is the joint responsibility of the Ministry of Health and the Ministry of the Environment. Popular awareness of environmental issues is growing: air and water quality are the key issues.

539. Health expenditure has continued to rise as a percentage of GNP, reaching 8.7 per cent in 1995.

National health policy

540. After years of political and professional debate, the health-care system in Israel is at last in the process of fundamental reform, both of its conceptualization and its services. There are three major elements to the reform:

- a National Health Insurance Law

- the withdrawal of the Government from direct health-care provision

- the internal reorganization of the Ministry of Health.

The National Health Insurance Law

541. The Israeli Government has always assumed its responsibility to ensure universal enjoyment of basic health services. This commitment, which grew in scope over the years, was for the first time legally entrenched, with the enactment of the National Health Insurance Law 1994, which came into effect in January 1995. The following is the main features of this complex piece of legislation. (The full text is attached in Annex 1 to this report.)

542. This new law is based on mandatory insurance. All residents of Israel are insured by one of the four authorized health funds, each of which must provide, at least, the basic package of services and medications, as detailed in the law. Health insurance premiums are centrally collected by the National Insurance Institute, in the same way Social Security Insurance is collected (see under article 9 of the Covenant). These premiums are then distributed to the Health funds according to a capitation formula. It should be stressed that one's right to health services is secured even in case insurance premiums failed to be paid.

543. The basic package of services mandated by the law includes all basic physical and mental primary care, including services and medications. Every insured person has the right to choose his/her health fund and no fund may refuse to enrol an applicant, regardless of age, or physical or mental condition.

544. The State's responsibility under the law is not only to regulate the activities of the Health funds (including recognition, supervision, enforcement, etc.). Actually, regulation powers were always given to, and used by, the Minister of Health in various laws - the People's Health Ordinance 1940, the Physicians Ordinance [New Version] 1976, the Dentists Ordinance [New Version] 1976, the Rights of the Patient Law 1996 (full text of the latter is attached in Annex 2 to this report).

545. The importance of the National Health Insurance Law in the context of the present Covenant, lies in that it imposes on the Ministry of Finance the final responsibility to refund the health funds for any gap between their income from insurance premiums and their factual expenses on all services mandated by the law.

546. The Ministry of Health's goal is to concentrate on policy-making, long-term planning, setting performance standards, quality control and quality insurance, and the evaluation of essential data. Hence, internal reorganization of the Ministry has already resulted in the establishment of new departments, e.g. a department of performance standards.

547. The Ministry owns and operates a portion of Israeli hospitals - 23 per cent of general hospitals, 50 per cent of mental health hospitals, and 4 per cent of geriatric hospitals. The remainder are profit-making or public non-profit facilities. Under the reformed system, government hospitals will become self-financing, non-profit facilities. The Ministry of Health will supervise their operation but not participate directly in their day-to-day operation.

548. The first steps taken by the Government towards transformation of its hospitals into legally autonomous entities have encountered resistance, especially from trade unions. The process is certainly going to be a long one.

549. At community level, primary health care is provided in Israel by the following:

- Health fund clinics

- Hospital outpatient clinics and emergency rooms

- Private clinics

- Family health centres (also provide preventive care).

550. Most primary care is supplied by the four health funds, either by direct provision through its own clinics and medical staff or by purchase. Member premiums cover the cost of most of these services, both outpatient and in-patient, as well as medications. Each insured person is free to choose any of the general practitioners or specialist physicians from the list employed by his/her health fund. Most affiliated physicians are not paid fee-per-visit but by salary or reimbursement.

551. A national survey of health services utilization, conducted in the first quarter of 1993, showed that 83 per cent of the most recent visits to a general practitioner/family doctor were made to health fund clinics, 12 per cent to private clinics, and 3 per cent to hospital outpatient clinics or emergency rooms. With respect to visits to specialists, 61 per cent took place at health fund clinics, 21 per cent at hospital outpatient clinics or emergency rooms, and 16 per cent at private clinics.

552. Family health centres span the whole country, operated by central government, local government authorities or the health funds, according to an agreed geographical distribution. Some 1,000 cover the urban areas while public health nurses visit small and peripheral localities at least once every two weeks. The services provided comprise physicians' examinations, developmental examinations, monitoring of breastfeeding, vaccination, and guidance and advice to mothers.

Long-term policy

553. In 1989 the Ministry of Health issued its Guidelines for Long-term National Health Policy in Israel, in which it formulated recommendations incorporating and promoting equity in health, health promotion and disease prevention, community involvement, intersectoral cooperation, primary medical care and international cooperation as the six principles underlying health objectives and priorities for Israel.

554. The strategy that follows aims at translating a number of policy goals into specific activities based on solid epidemiological data. The strategy is based on the following principles:

(a) Equity in health: While absolute equity in health is out of reach for biological/genetic reasons, the National Health Insurance Act that came into force on 1 January 1995 at least ensures equity of access to health-care services for the whole population. In addition, emphasis will be placed on reducing the gaps in health status between different population groups, such as new immigrants from specific countries, certain ethnic minorities, and people living in underprivileged areas.

(b) Primary health care: The main means for ensuring equity will be primary health care, as defined by the World Health Organization under its policy of Health for All by the Year 2000. Primary care will include health promotion, health protection, disease prevention, medical care, and rehabilitation and will be delivered by multidisciplinary teams of staffers from medicine, nursing, social work, and other health professions.

(c) Government responsibility: The Government will assume responsibility for the health of the people to the same degree as its responsibility for its welfare in other domains, such as security and education. It will be accountable to the people for the health service it guarantees.

(d) The rights of individuals and the general public: Individuals and the public at large will have the right to participate actively in shaping public health services and in supervising them. The Government will encourage such participation, which will include public debate, including in the mass media.

(e) Appropriate health technology: The Government will take measures to ensure the use of the appropriate technology, from the scientific, technical, social and economic points of view, in all areas of health care. It will encourage all concerned to take similar measures.

(f) Intersectoral and interdisciplinary action: To ensure an appropriate level of health, the Government will foster coordinated action by all sectors and disciplines concerned.

(g) Relationship between divisions of the health-care system: The Government will ensure appropriate mutual relationship between the primary, secondary and tertiary sections of the health system. This will entail removing unnecessary duplication, strengthening primary care, and providing incentives to hospitals to support other divisions of the system.

(h) Command and coordination: The Ministry of Health will provide command and coordination across all components of the strategy. In view of the intersectoral nature of the strategy, it will be approved by the Government as a whole.

555. The strateg