Israelis over the age of 30 will probably remember a school nurse who sat in a special room with first aid equipment to treat minor injuries and headaches, was always ready to listen to their problems, performed health tests and taught them about healthy behavior. The nurses were state employees and integral members of the school staff.
Thanks to Finance Ministry budget cutting and the reluctant acquiescence of an enfeebled Health Ministry, the institution of school nurse is gone and unlikely ever to return.
Instead, private contractors hire nurses told to work as vaccination machines to give shots to children they don’t even know. Even if the government reversed its decision and reinstated the position, it is unlikely they will find qualified women willing to carry out the relatively lowpaid job.
A three-hour roundtable on the privatization of the School Health Service over a decade and plans by the Treasury to adopt the same failed formula for well-baby (Tipat Halav) clinics was held earlier this month at the Van Leer Jerusalem Institute.
Although Health Minister Ya’acov Litzman was due to speak according to the printed invitation, he did not show up because he attended a Knesset committee meeting instead.
Nobody from the Treasury appeared, either.
The story that unfolded from the discussion was like a Greek tragedy.
Treasury bureaucrats have long had a mandate from the highest echelons of government to avoid building new state institutions, opening new state services or hiring state employees with pensions and other benefits; instead, they hire contractors to do the work for a fee in the hope that they will do it more cheaply without constituting a long-term state commitment.
If there is a government service they want to privatize, officials first cut the budget to make it decline and, declaring it a failing proposition, announce its privatization. So it was in 2007 with the State Health Service, in which some 300 state nurses were each employed to work in a number of schools rather than only one.
The Health Ministry then selected – without a public tender – a contractor company with the ironic name of “Public Health Association” and headed by a former ministry employee to provide vaccinations and other services in the schools.
Later, when this provider failed to meet its commitments, it was replaced by Natali, a company better known for its monitoring of and ambulance service for private heart patients. The “Association” was severely criticized by the State Comptroller for the inadequate level of its services. Other contractor companies were added, but the criticism continued.
In one locality, a private nurse mistakenly injected schoolchildren with only water rather than reconstituted vaccine, so they had to roll up their sleeves again. In many places, the contracting companies failed to meet their vaccination quotas, forcing the shots to be administered months late. Without refrigerators in nurses’ rooms, vaccinations were stored in the home refrigerators of some private nurses and had to be lugged with their computers to distant schools, especially in the South.
THE INTERESTING (and depressing) roundtable was organized by the Van Leer Jerusalem Institute’s Center for Social Justice and Democracy in memory of Yaacov Chazan, which it founded in 2000 with the Kibbutz Movement’s Yaacov Chazan Memorial Fund. The center, which memorializes the late Mapam Party MK, social activist and Israel Prize winner, aims to connect theoretical discussion and academic activity with social action and lobbying of decision makers.
Since 2007, the Center for Social Justice has been engaged in a far-ranging research project, examining areas that are the state’s responsibility and the shifting boundaries between the public and the private spheres. The study aims to discover which of the government’s roles can be privatized and which cannot, and on the basis of its findings to produce a policy paper that will be presented to the public and government officials.
“The privatization of the School Health Service was unprofessional and capricious. The ministry’s public health chief [Prof. Alex Leventhal] even resigned in protest, and in 2012, his successor Prof. Itamar Grotto conceded that ‘mistaken decisions were made,’” recalled Rami Adut, head of the policy change sector of the Chazan Center.
“It was agreed that by the end of 2016, the service would revert back to the state.”
But in fact, this commitment will not be carried out by the end of December, and in protest, the Israel Nurses Association in the Histadrut announced that when the new school year begins in September, it will be without any nurses. Asked to comment, the Health Ministry said that it is “committed to give the best public health services to children. In recent years, the School Health Service [provided by private contractors] has brought the ministry satisfaction in all districts” with high vaccination rates and screening, unlike in the years before as criticized by the State Comptroller.”
As a result, said the ministry, it will continue privatization in the center of the country, but de-privatize it in the northern district (not including Haifa), in addition to the southern district, which has already been deprivatized because no contractors wanted to bid on it because of lack of profitability from the widely dispersed Negev schools.
Adut said at the roundtable that in all cases of privatization by the state, “there must be public discussion every few years to assess if it was successful or not. With the School Health Service privatization, the government didn’t learn any lessons from its mistakes. We worry that it will make the same mistake with Tipat Halav.”
Prof. Yitzhak Galnoor, academic director of the State Responsibility and the Limits of Privatization project at the Chazan Center and an emeritus professor of political science at the Hebrew University, told the audience of 60 professionals that the 300 public nurses should have been retained and their number expanded due to population growth.
“Instead of this, the service was privatized, and this sad tale demonstrates the failure to think in advance.
What cost the state NIS 70 million a year, the Treasury changed to save money, but now it costs NIS 130 million annually. This was confirmed by the State Comptroller. For the sum that officials thought they would save [but didn’t], it wasn’t worth destroying a public institution. Now they want to do this to Tipat Halav.
The state has an interest to be concerned with its babies and children.
They have to have a strong safety net,” Galnoor said.
MK ORLY Levy-Abecassis, former head of the Knesset Children’s Rights Committee who has four children in the school system, said that the Treasury’s “drying up of the School Health Service started in 2003. Then they said it’s no good – let’s privatize! It was ridiculous. The Education Ministry wasn’t even asked. Treasury officials didn’t do their homework.”
As there were no nurses to treat pupils’ minor injuries, the Education Ministry thought of teaching first aid to teachers and school janitors, but it didn’t get off the ground.
Then, the Health Ministry made a deal with Magen David Adom to send ambulance medics to schools for NIS 10 million a year to deal with emergencies.
“This alone was more than the Treasury initially said privatization would save,” said the MK. “The ministry set a standard of one nurse per 1,600 children, but this wasn’t observed. Now the figure is one nurse per 10,000 children. There was no follow-up of children from year to year. If a pupil loses a lot of weight from the previous year because she suffers from eating disorders, the private nurse will not know. Some kids are traumatized by shots, so the vaccinating nurse and a teacher hold them down. If a child doesn’t feel well, the teacher isn’t allowed even to give an aspirin. The parents have to leave work and take the child home.”
The MK added that when the Health Ministry saw privatization of services in the South was a failure because of dispersed Beduin communities and long distances between schools, it hired public nurses to do the job. “It was fortunate that this happened just before polio virus was found in the area. They were ready to vaccinate all the children efficiently.”
Israel Medical Association chairman Dr. Leonid Eidelman said, “Things are easily destroyed, but it’s hard to build. It isn’t that Treasury bureaucrats didn’t think. They planned privatization because that is their mandate. That is their interest.
They tried to show they would save money, but it was only in the short term. In the long term, it lost a lot of money. Opponents of their policies have to unify to prevent the same being adopted in Tipat Halav.”
Eidelman noted that good health will come with good nutrition, good habits and education on disease prevention.
These have to be taught at a young age. Afterwards, it’s hard to change behavior. The US annually invests $8,000 per citizen on public health, while we invest only $2,500.”
Nurses Association head Ilana Cohen, a former MK, called for a national commission to investigate the School Health Service privatization.
“If we don’t raise a fight, Tipat Halav services owned by the Health Ministry, municipalities and health funds will be privatized. Parents are opposed, but they don’t know how to fight it. If there are no financial incentives, nurses will not go back to the service. Conditions, especially in the South, are poor. Public nurses have to take their vaccines and computers with them when they visit schools. There must be special rooms with refrigerators in the schools so they can work properly.”
Dr. Milka Donchin of the Hebrew University-Hadassah’s Braun School of Public Health and Community Medicine and chairman of the Healthy Cities project, said that at an important meeting in the Knesset on the School Health Service, Litzman – then Chairman of the Knesset Finance Committee – “didn’t let anybody speak. He said: ‘We will privatize the School Health Service. That’s government policy.’ Since then, he has denied it, claiming that it was the Treasury who pushed it, and that he opposed it, but I was there.”
All public health experts and MKs, said Donchin, “agree that the public health nurses have to return to the schools and be an educational figure.
There must be regular budgeting for a broad public health services.
I am frustrated, and I worry about Tipat Halav. Promoting the health of babies and toddlers interests many people. This is our chance to show that the best platform for this age group are public well-baby clinics, of which there are 950 for 160,000 babies born each year.”
Mira Hazanovich, a nurse by profession and national supervisor of public health in the Health Ministry, appeared at the roundtable, but she also expressed criticism of the privatization.
“Contractors did not do well in the South. The Health Ministry has roles in prevention and setting policy, what is done in Tipat Halav and in the schools and setting standards for all service providers. The professionalism of public nurses and doctors is high. We do community work and education, unlike the contractors.”
When the ministry provides services, it “also has weaknesses. Unfortunately, there is no flexibility in management and operations. It wants to computerize more services, but it can’t shift manpower from one place to another to meet needs or to raise salaries for incentives. Private companies can do this. We are not able even to ensure that schools have rooms for nurses. The ministry hasn’t opened a new Tipat Halav clinic in Harish, which is due to become a city of 100,000 people, or in cities with a lot of growth. It can’t afford it. We need to improve the salaries of public health nurses, which are considerably lower than in the hospitals and health funds. We need a short- and long-term work plan for manpower and infrastructure, and perhaps offer a higher differential salary to public nurses. We need to keep them in the system and give them improved training,” said Hazanovich.
“The average age of the handful of public health physicians who work with us in the South is 62,” said Dr. Manuel Katz, the ministry’s pediatrician responsible for mother and child health and deputy district health officer in the southern region.
“In four years, they will retire and be gone. We were all for deprivatizing the School Health Service in the South. The vaccination rate in some areas was between zero and 10%. I was chairman of a committee for deprivatizing all over the country, but it was decided to do so only from Ashkelon and southwards. Damage was done to the children. There was a flow of public nurses to the private sector and other professions. When the new Assuta Hospital in Ashdod opens next year, more public health professionals will go to work there.”
Finally, Irit Livneh, the Education Ministry’s health supervisor, completed the depressing picture.
“The school principals are fed up.
There were school nurse rooms, but nobody used them for vaccinations, as they are owned by the local authorities center and are full of cartons.
Each school was allocated only one hour per school year on teaching health. We send out directives, but in the field, they are almost never implemented. We can’t blame the principals, because there is a lack of faith in the system. Parents’ associations have to be included in the process and be our partners, and teachers’ associations should take responsibility as well.”