Treasury edict to outsource health services in elementary schools has many parents and experts concerned.
By JUDY SIEGEL-ITZKOVICHhealth care kids 88(photo credit: )
During the early years of the then-impoverished State of Israel, there was a public health nurse in nearly every school, and immunizations, medical checkups and health education were regarded as vital. Today, when Israel is a hi-tech wonder with impressive economic growth, the state "can't afford" to supply all available vaccines to elementary school children; educate them about the risks of smoking, drinking, drugs, junk food, eating disorders and physical inactivity; and regularly examine their hearing, sight, weight and posture.
Why? Because Finance Ministry budget division officials (no matter who is minister) are keen to slash costs; health promotion and disease prevention have low priority, and despite the protests of its public health experts, an impotent Health Ministry caves in.
"The Health Ministry is like a dish rag versus the Treasury's directives," says Dr. Yitzhak Kadman, founder and head of the independent National Council for the Child (NCC), whose watchdog organization depends on private donations so as not to be dependent on the government it prods and criticizes.
"In recent years, the Finance Ministry has been interested in privatizing as many state services as it can. Its modus operandi is to dry up funds for a service, causing the level of performance to drop. Then, when everyone agrees that the government service is functioning poorly, it hands over responsibility to a non-governmental organization or company," says Kadman, a social worker by training.
Although Prime Minister Ehud Olmert has committed himself (so far) to preventing the privatization of tipat halav(well-baby) services, he did not intervene to prevent the privatization of school health services 10 months ago. Instead of Health Ministry-employed public health nurses going to schools to vaccinate, educate and conduct checkups on all children, between 300 and 400 were transferred to the Aguda Lekidum Briut Hatzibur (Association for the Advancement of Public Health or AAPH). Its director Yehuda Cohen says the association is a non-profit voluntary organization. The Treasury did not agree to run a pilot project to see if privatization was a successful model. Instead, it chose the AAPH to provide school health services for three years to first-to eighth-grade pupils around the country without issuing a public tender.
"Since 2002, there has been a serious decline in public health and disease prevention services. The manpower slots in real terms have dropped by 40 percent due to Treasury decisions. And now there are 140,000 babies born a year, with less money being spent to vaccinate," says Kadman who produces numerous letters from parents who complain that their children are overdue for shots.
"I don't have a fight with Cohen and his association," he insists in his small office in Jerusalem's Talpiot industrial quarter. "My problem with it is that services are not provided by the state; the association works only as a contractor with a limited budget set by the Treasury. There were vaccine shortages and a major lag in vaccination of some 160,000 children. The association nurses have caught up somewhat, but there are tens of thousands of children who have not been vaccinated on schedule, and health education and medical checkups on schoolkids is almost nonexistent," he charged.
The ideal, adds Kadman, is to have a nurse who is an employee at every school. She is there when children are sick or have other problems. That is besides her role as a health educator who also does medical checks. If a 14-year-old girl refuses to be weighed, maybe she has anorexia, or maybe she is pregnant. Pupils who cause trouble in class may have problems seeing what's on the blackboard, but vision is rarely tested. One nurse per 750 pupils is very good; in the US, it is one per 300. In Israel, it is one per 3,000 on average, and in some towns it is close to one per 5,000. Few schools even have a nurse's room any more."
Before the Treasury started to "dry up" funds, the school health service budget reached almost NIS 80 million a year, states Kadman. It was then cut to NIS 70.4 million in 2003, then to NIS 54 million, and was raised back up to only NIS 64 million when the AAPH took over, even though it was responsible for more children than before. Kadman adds that "if you believe in privatization, you at least need red lines beyond which you don't go. If you hand over school health services to a contractor who can't have a deficit, why not privatize the Israel Defense Forces or... the Treasury budget division? I believe the government will in the end recognize its mistake in the schools, have no choice and restore health promotion and disease prevention as a state service. It is a matter of principle and government vision - and beyond other considerations such as who does it most cheaply."
ALTHOUGH The Post asked the Finance Ministry spokesman's office (the spokesman's job has been vacant for several months) to interview relevant officials or at least comment on criticism nearly a week before deadline, no reaction was issued or permission granted.
The Knesset Education Committee and the Knesset Committee on the Rights of the Child held sessions last October after many complaints were filed by parents, nurses and others. Treasury official Reuven Kogan told MKs that privatization would save NIS 7 million a year. When Tel Aviv parents filed a suit in the High Court of Justice against the Health Ministry and their municipality, which refused their request to pay privately for school nurses to provide first aid, the court ruled in their favor. The Education Ministry then contracted Magen David Adom for NIS 20 million a year to send medics to schools "within 15 minutes." Kadman charges that the service is little used, as most teachers and parents don't know about it.
"Kogan's claim of NIS 7 million from privatization did not include the NIS 20 million cost of MDA," Kadman says. "With NIS 20 million, a state service could improve what is being offered in the schools, and decent services could, in the long term, save much more public money on hospitalization and other needs when the children grow up."
BEN-GURION University president Prof. Rivka Carmi - a pediatrician, geneticist and former dean of BGU's Health Sciences Faculty - called on the government last week to expand the basket of vaccinations for babies and schoolchildren, improve the quality of coverage and ensure that highly trained nurses supply all needed services.
Speaking at the Beersheba Conference for the Child (organized by the NCC, BGU and the Beersheba Municipality), Carmi said lifesaving vaccines not paid for by the Health Ministry include vaccines against rotavirus, chicken pox, papilloma virus (which causes cervical cancer), whooping cough and pneumococcal pneumonia. She also expressed concern about reports that AAPH is not functioning properly, including the recent mistaken vaccination of 100 first graders in Givatayim against measles, mumps and German measles. Cohen said staff had injected harmless sterilized water rather than the active vaccine, which always arrives in powdered form with an empty syringe and a container of sterile water. A batch meant for Spain had come with the water already in the syringe, leading nurses to inject the water only. A Health Ministry panel is investigation the incident, which some suggest may have been part of the AAPH nurses union's struggle to be recognized as state rather than AAPH employees.
Moriah Ashkenazi, head of the Public Health Nurses' Union, denied that there was any connection between their struggle and the Givatayim incident. "We don't want to work for a contractor. There is a precedent for these demands," she said. "Court stenographers worked for the state and were privatized, but a labor court recognized their continuing status as state workers."
Cohen, who has a bachelor's degree in economics and went directly to work in the Health Ministry when Victor Shemtov was minister, spent 25 years there as an economist. The AAPH, he says in its headquarters in a very cluttered, three-storey villa in Jerusalem's Arnona quarter, is not a new non-profit entity. It was established in 1972 by the ministry to operate projects and develop services. With its status as a recognized voluntary, non-profit, tax-exempt organization, it could solicit donations and hire staff who were not state workers, which pleased the Treasury. "As it is not a state agency, it is more flexible, works faster and needs less infrastructure," says Cohen, who was the unpaid AAPH treasurer who initiated rehabilitation projects for the mentally disabled and helped develop community services and implementation of the Geriatric Nursing Law.
TODAY, WITH responsibility for school health services, the association has no stockholders and is not allowed to run on a deficit. "We were exempt from competing with other non-profit organizations for this because we have a lot of experience. Now we has a total of 350 full-time slots for public health nurses, and a total of 550 actually working for us, some part time."
Asked whether at the end of his three-year contract, the Treasury could replace him and the AAPH with an organization or company that offers services even more cheaply, Cohen - whose salary is equivalent to "a government hospital department head" - says that theoretically this could be done. "We live in a dynamic world, and of course I am concerned. But we were brought in to make the school health service more efficient. Efficiency is doing the best possible work with the least amount of money. We are experts in quality, prevention and equity," says Cohen in his headquarters, where files and papers are everywhere, even in stairwells, because of lack of space.
Asked about criticism of the AAPH's functioning since April, Cohen said: "You can judge our functioning by how many children we have vaccinated, which is 300,000 since last April; 170,000 should get shots each year, but there was a backlog. We came in an emergency to save the situation. If the government wants a nurse in every school and to provide a larger basket of services, it will have to change the law and allocate more funds. Some of the complaints have been part of a nurses' campaign against us."
Cohen firmly believes in the notion that the Health Ministry should supervise health services and not to have a conflict of interest from also supervising them. "It is much better for non-profit organizations to supply more and more services." As for medical checkups and health education, the law requires that it be given to first and seventh graders. We give one hour, on average, of this, but we locate children at risk and work on them. Health education doesn't have to be frontal in classes."
Cohen said he was not aware of how the MDA first-aid to schools service is doing, because "the Education Ministry is in charge." But MDA spokesman Yerucham Mandola denies Kadman's claims that it is little used. "It operates separately and does not come at the expense of our ambulance service, with a different phone line, Mandola says. "Since it began, we have received 10,000 calls from schools; we then decide from the description whether the child needs a medic. We have treated bleeding, fractures, cuts, falls from heights and diseases."
To become better known, the MDA first-aid service has issued stickers, signs and leaflets to schools, and a survey among school principals, he adds, shows that they are satisfied.
Although his predecessor Dr. Alex Leventhal strongly opposed privatization of the school health services, newly appointed Health Ministry chief of public health services Dr. Itamar Grotto says he favors ministry supervision of such outsourced services provided by non-profit organizations.
"I was not in the job when the decision was made [he taught public health at BGU and previously was in public health in the IDF]. But the services must be budgeted properly on a per-pupil basis. It is unfortunate, however, that the AAPH was brought in from April and did not start at the beginning of the school year." As for vaccinations, he said reports showed that 90% of first graders have received the necessary shots, but only 75% of second- and eighth-grade pupils can say the same. As for health education and medical checks, "the association does some, but it is still very little. They are improving, but have to do more. In general, I am satisfied that the trend is improvement."
Whatever happens to the school health services, it is just one battle in the 21st century war between those who demand state responsibility for vital functions and those who prefer outsourcing.
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