(photo credit: Judy Siegel)
Public health and the public good, critics say, are no longer the main considerations when health policy is set - as Finance Ministry budget officials in their 20s and mid-30s dictate terms to experienced medical professionals in the Health Ministry, which is becoming increasingly impotent.
Private interests and narrow economic considerations, the critics further assert, are fuelling incoherent and anti-social government policies that affect every Israeli.
Octogenarian Health Minister Ya'acov Ben-Yizri, it is said, has been taking advice from personal advisers and from vested interest groups outside the ministry, and ignoring the counsel of ministry professionals. He is said to have backtracked on agreements over the health budget after coming under the influence of Treasury bureaucrats, without even informing his experienced director-general, Prof. Avi Yisraeli, a former director-general of the Hadassah Medical Organization.
One zigzag: first allowing two health funds - Clalit Health Services and Maccabi Health Services - to offer, in their supplementary health insurance policies, a list of lifesaving drugs not subsidized by the Treasury; then forbidding the practice.
Ben-Yizri has been on vacation abroad for most of the past month and could not be reached for comment on these assertions. But the minister, with help from his personal spokesman Tal Harel, has presented the deferential agreements with the Treasury on health budget cuts and policy changes as "great achievements."
What has not been highlighted, say the critics, is that his giving in to the Finance Ministry on significant issues will result in the weaker and poorer elements in society having less coverage and being forced to pay for more health services out of their own pockets.
(Harel did not return several requests Thursday to defend the minister's position. The Finance Ministry spokesman, Eli Yosef, refused to let The Jerusalem Post interview a relevant official to discuss the issues, and was only prepared to allow written questions to be sent to the spokesman's office).
While the government has adopted a policy of privatizing a large number of state services, in the health sector it appears to be aiming at near-nationalization of the four public health funds and initiating the establishment of a poorly-conceived fifth health fund to be operated by hospitals in the center of the country that are likely to ignore the poor and periphery populations.
The Arrangements Bill, which began as an Ottoman law meant to function only as an emergency measure, was latched on to by Treasury officials several years ago as a way to make major changes in government policies without their having to pass the moderating influence of the Knesset's legislative process. This year, the Treasury has prepared an Arrangements Bill that accompanies the Budget Law of 2008 as a motley collection of more than 300 policy changes that fill 120 printed pages. The bill, along with agreements reached between Ben-Yizri and Finance Minister Ronnie Bar-On without the involvement - or, sometimes, the knowledge - of senior ministry officials, includes several major proposals that affect the health system.
Among them is the decision to add some NIS 275 million to the basket of health services each year through 2010, but at the same time cut allocations to the four public health funds by hundreds of millions of shekels.
In addition, the Finance and Health Ministries want the power to appoint 75 percent of the members of the health funds' boards of directors (numerous political appointees will undoubtedly be added to the boards), with only 25% elected by the membership. Each of the health funds will have to pay the new board members a total of several million shekels as salaries, even though the directors now are not paid a salary.
The Treasury also wants to clamp salary restrictions on all senior health fund staffers in a way that - according to the insurers - will prevent advancement and discourage the most qualified and highly trained experts from working there.
Prof. Dov Chernichovsky, a senior expert in health system policy and economics at Ben-Gurion University of the Negev in Beersheba and senior researcher at Jerusalem's Taub Center for Social Policy Research in Israel, commented: "We have a very real problem in policymaking on health matters, and the situation is deteriorating. There is not enough turnover of top policymakers in the Health Ministry, and it has never been a fair player in the system because it owns and operates government hospitals. It can't be an objective policymaker and regulator. Treasury officials take advantage of this weakness."
He added that "most of those who have become health minister [over the years] got the job even though it was not their first choice," and charged that "the ministry is still identified with the medical and hospital establishment, so it is liable to take non-objective decisions."
Chernichovsky further charged that Treasury budget people "micromanage and are over-involved in changing the structure of the health system, when this is not their business."
The BGU expert noted that "in principle, a fifth health fund would be a blessing, because competition is needed. But if we do it the way the Treasury has supported, under pressure from some state hospitals, we may as well abolish the whole system of public health funds and replace it with a British-style National Health Service in which a state authority contracts services directly from suppliers. Real competition, with twice as many health funds that compete for members among the whole population and is equitable, is preferable."
He said the Treasury's proposal of a fifth health fund, with services provided by hospitals, "runs counter to the necessary separation of the health funds from the hospitals that would improve service and increase competition. It also flies in the face of the correct trend to move medical care into the community."
Chernichovsky advocated allowing some choice of medical services for a fee to operate in the public hospitals, similar to the successful system in Jerusalem's voluntary hospitals, so doctors would be able to earn more and not be tempted to abandon their workplaces at 2 p.m. for private clinics and hospitals in the afternoon and evening. Doctors should be able to work full-time for their public employers for a fair wage, he said.
He also recommended a complete reorganization of the system that decides which medications will be subsidized by the Treasury and included in the basket of services provided by the health funds. "I am against our current medication policy. The state must take control of it and decide, on the basis of clear medical evidence of efficacy, which drugs should go in the basket," he said. "Some people buy medications for their illnesses instead of [spending what little money they have on] food, even though [some of] these drugs have not been proven effective."