Recollections of the last official doctors’ strike that hit the public health
system – 127 days of it, until the middle of July, 2000 – seem all too familiar
to those following the present anguish in the hospitals, health fund clinics and
families with members needing care.
Even many of the names of the
protagonists and antagonists are familiar.
Country gets break from doctors’ strike until after Pessah
Ehud Barak, now defense
minister, was then Labor Party prime minister; Binyamin Netanyahu, now prime
minister and health minister, was head of the Likud opposition. The chairman of
the Israel Medical Association, now Dr. Leonid Eidelman, was then
Dr. Yoram Blachar, who aroused the fury of the man in charge of the
Today, Netanyahu doesn’t intervene; Agudat Yisrael MK
Ya’acov Litzman runs the ministry as a deputy minister. During Litzman’s first
year in the hot seat and Blachar’s last, the two battled over health matters on
a regular basis. In 2000, the active health minister was Shlomo Benizri of Shas,
now serving a four-year sentence after being convicted for accepting
While there’s a vivid feeling of déja vu, much has changed in the
past 11 years. There is a severe shortage of physicians, with Israel shifting
from the prestige of having the highest number of doctors per 10,000 citizens to
the shame of having one of the lowest. Many Russian immigrant doctors who
arrived en masse in about 1990 and blessed the health system are becoming
The Finance Ministry’s budget and wage chiefs have become
hugely powerful, replacing Health Ministry officials in making decisions about
doctors and nurses, public-health spending, pricing and hospital
Nearly all agree that the eclipsed ministry has no say and
has become impotent and irrelevant on these issues.
Thanks to the
Treasury’s first Arrangements Bill in the late 1990s, the state share of health
spending has been reduced to little more than half, and individuals needing
services have to dig deeper into their own pockets.
WITH THE European
Union uniting the continent, Israeli medical students abroad who earn a European
license can practice anywhere they like. More and more senior physicians and
researchers are lured to “greener pastures” in the US and elsewhere by high
salaries at a time of worldwide physician shortages; Israeli medical
professionals are regarded as among the best minds and best trained, and are
eagerly sought abroad. Take a law degree and sue doctors for alleged malpractice
instead of being accused of it yourself, or get hired by a pharmaceutical or
information technology company.
Respect for medicine seems to have
eroded, as half of medical students and residents are women, and it appears to
be more a low-paid “woman’s profession” like social work, school teaching,
nursing, physiotherapy and cleaning.
Private medical centers such as Tel
Aviv’s Assuta Medical Centers or the Herzliya Medical Center thrive and expand
to 500 beds in the center of the country, as the gap between medical care there
and in the periphery expands. As public hospital doctors’ salaries dwindle, an
increasing number of senior physicians work either partially (during and after
their publicsector jobs) or wholly in these luxury facilities to provide private
care. Women, not always willing to devote all their time to medicine and
research while raising a family, constitute at least half of all medical
students and residents, while shortages grow.
It’s a different world for
medicine, and the need for systemic reform becomes much more vivid and urgent
than it was during the 1999-2000 strike; all sides, including the Treasury,
agree that hiking doctors’ wages is just a partial step to a solution, because
the system has become so “deformed” and imbalanced.
tightlipped Treasury has done little more with its public relations staffthan
issue bulletins on “how much the average Israeli physician earns (NIS 26,000 a
month),” there is no “average” doctor.
There are interns and residents
who spend half the month on duty in teeming emergency rooms, internal medicine
departments and other wards doing dayand- night shifts that last 24 hours
because few senior specialists are still willing to do it.
well-known department heads whose Jerusalem medical centers allow consultations
and the performance of operations in the afternoons and evenings through Sharap
(private medical services); fees are shared by the institution with the
There are health fund physicians who work 9 to 5 in the
community, earn middling amounts per patient seen and treated, and veteran
doctors who never advanced due to lack of opportunity or desire and are stuck at
the same pay scales they earned when young.
As many of the additional
financial benefits of hospital physicians are included in take-home salaries
only for exhausting, family-disrupting overtime work, those who don’t do it get
low returns. And even specialists who retire after decades find that their
pensions go no farther than that of the average gross national
Prof. Yoel Donchin, for example, a senior intensive care
specialist, anesthesiologist and surgical safety and first-aid expert who just
retired from Hadassah University Medical Center after 35 years, receives NIS
8,000 a month. People don’t pay anesthesiologists or intensive care specialists
Sharap, he notes, just as they do not pay privately for neonatologists,
pathologists, radiologists and those in other altruistic specialties like
internal medicine. As a result, hospital residents are reluctant to study for
years to become certified in these fields.
“Conditions in the hospitals
are very bad,” he says in an interview. “Doctors work like those who built the
pyramids in Egypt – without being provided the straw.” Although his views are
“socialist,” meaning he feels that every patient deserves the best possible
medicine without paying extra for it, and he has always strongly opposed
doctors’ strikes, Donchin has reluctantly concluded that they must act now to
shake up the government, especially the Treasury.
Doctors don’t strike
like Bezeq or Electric Company workers; they do not walk away from their posts
and refuse to make repairs. They take care of patients who would be endangered,
said Donchin. Each hospital has an “exception committee” that allows doctors to
take care of such cases.
“The Treasury boys [the all-powerful young
decisionmakers in the Finance Ministry’s budgets and wage divisions] have never
needed to go on strike. They work on personal contracts, get money for every
second they work, and when they leave the Treasury, they go to work for banks
and other companies for elite salaries and benefits. Doctors don’t, so don’t let
these functionaries tell us what to do. If physicians were compensated for what
they really do, the Treasury would collapse.”
DONCHIN ADDED that in
intensive care units (he continues to be responsible for accident prevention at
Hadassah), “the most difficult decisions we have to make are not what drug to
give or procedure to use to save lives, but who attached to a respirator gets a
bed in advanced intensive care and who has to try to survive in an internal
medicine ward. A doctors’ strike at this time is like performing an amputation
to save the patient.”
The retired anesthesiologist calls on the IMA to
require Health Ministry doctors who are administrators and don’t treat patients
to apply sanctions and strike with their colleagues if push goes to
The solution to the healthcare crisis is for the government to
finally decide to spend money on it, rather than to constantly reduce public
funding, Donchin concludes. “We have strategic problems; the government must
change its priorities. If it spends millions on the Iron Dome missile to save a
single person in the south, it can decide to spend money to save the lives of
The IMA’s Eidelman is upset by the fact that
some of the media, especially pro-privatization Ha’aretz, have depicted the
crisis as revolving mostly around the possibility of allowing Sharap in public
hospitals beyond Jerusalem.
“We never made it an issue. Litzman has said
it is a solution – keeping doctors in hospitals day and night, instead of them
going to earn more privately. I don’t understand why people refuse to go into
depth on the issues. We said private medical services in public hospitals might
help in peripheral hospitals, but only if residents were allowed to pay for them
with their supplementary health insurance (Shaban) policies and not out of their
own pockets. In fact, Tel Aviv Sourasky Medical Center and Sheba Medical Center
were permitted to offer Sharap for six years, even though they are public
institutions, but it was stricken down by the courts.”
should be encouraged financially to work shifts, said Eidelman, and residents
should get 150 percent compensation beyond the seventh shift duty in a month.
While younger doctors should get differential payments, retirees whose pensions
are unfairly low should be paid more, he added. “Every problem needs a different
Ben-Gurion University health economist Prof. Dov
Chernichovsky, who also proposes health reforms as a consultant for the World
Bank to developing countries like Colombia and Mexico, advocates the use here of
Shaban to choose one’s physician. About a fifth of the public can’t afford to
pay their health fund the extra fees; the government should pay for them, while
Shaban must become a mandatory payment for the rest of us, he insists.
“Governments don’t like to raise taxes, so they wouldn’t call this an additional
tax, but it could be required as car owners pay car insurance. Shaban payments
now averaging NIS 120 per person per month would rise to about NIS
With universal Shaban, he continued, doctors would opt for working
long hours in their public hospitals rather than outside. Those who continue to
do private medicine would not be allowed to work also in public hospitals, he
said. Senior doctors would also reduce the shift burdens of residents.
increase public funding of public hospital services, says Chernichovsky, “the
Treasury must swallow the pill and agree that in seven years, the amount of
public funding must increase to the OECD level of 70% instead of today’s 53%.
This would restore the situation we had before the first Arrangements Law was in
place and things started to fall apart.”
But his BGU health economist
colleague, Prof. Gabi Bin-Nun – who worked in that field at the Health Ministry
for over 25 years – is a fierce opponent of Sharap and the option of Shaban
covering the patient’s choice of doctors. “Voluntary insurance can’t become
mandatory. It should be put into the basket of health services for which people
pay health taxes. Shaban premiums under the Shaban proposal would push premiums
way up, and the elderly won’t be able to pay.
The public healthcare
system would be damaged. And Sharap will only damage the public system, not
strengthen it, by creating two levels of medicine, one for the poor and one for
the rich,” declares Bin-Nun.
There is only one way out, he continues.
“The Treasury must strengthen the public system with public money. There must be
more fully manned hospital beds. It can’t argue that the doctors got a wage
increase only recently as a result of the 2000 agreement; that has not been
updated from a decade ago. There is no free lunch.”
director-general Prof. Gabi Barbash, who in the late 1990s was a Health Ministry
director-general but returned to his prestigious state-municipal medical center,
is very concerned about the decline in the health system. “There aren’t enough
doctors, nurses and beds.”
He advocates the Shaban system, investing
supplemental insurance in the public hospitals to improve wage and medical
facility conditions there. “It is so hard to recruit the best doctors. I wrote a
letter to the State Comptroller last week stating that at Sourasky, we spend NIS
20 million annually in extra payments for doctors and nurses so we can keep
He believes Treasury officials don’t understand the real problems.
“I invited their health liaisons to visit my hospital to see the problems, but
after two times, they begged off and said they understood everything.
they didn’t understand.”
It’s nearly impossible to get any of the sides
to agree; consider the past eight months of start-and-stop negotiations between
the Finance Ministry and the IMA.
Treasury officials say all that is
needed is some differential pay changes as incentives to young doctors in the
periphery and getting hospital doctors to punch time clocks (which they have
never done) to make sure they are on the job rather than “moonlighting” during
the work day.
Some observers even insist, when all is put into
perspective, the situation in our health system is “not so bad after all.” Dr.
Bruce Rosen and colleagues of the Smokler Center for Health Policy Research at
Jerusalem’s Myers-JDC-Brookdale Institute has just published an article in
Health Affairs on “What the US Could Learn from Israel About Improving the
Quality of Health Care.” Our National Quality Measurement Program, in which all
four health funds voluntarily participate, is among the best of the world, he
stated optimistically. This system monitors what medical services the weaker
socioeconomic sectors get, and this level is constantly improving, wrote Rosen.
The US, where tens of millions have no health insurance at all, pales by
Raise a toast to the optimists and say a prayer for the