Everyone in the world needs - and deserves - decent healthcare, but the way it is distributed depends not only on the wealth of each country but also on its culture and government. Although a skeptical bunch, Israelis have for the past 15 years entrusted their government with collecting health taxes and distributing them to the four public health funds; but to the majority of Americans, this is an anathema. For them, medical services must be in private hands, even though the US system is on the edge of collapse. Europeans, with their strong feelings of social solidarity, generally regard subsidized healthcare as a basic right, while in the US it is for those who "earn" or "deserve" it. In Germany, the obese are almost forced to get in shape or quit smoking, while in other countries there are weaker incentives and in still others, there are none. THESE WERE some of the issues discussed at the recent three-day Fourth International Jerusalem Conference of the Israel National Institute on Health Policy Research. Titled "Improving Health and Healthcare: Who is Responsible? Who is Accountable?" it brought 100 foreign experts and hundreds of Israelis to Jerusalem's International Convention Center. The conference was co-chaired by former Health Ministry director-general Prof. Avi Yisraeli and Prof. Stephen Shortell of the University of California at Berkeley. The organizers even took some responsibility for the participants' health, offering cut vegetables and sushi for snacks rather than burekas. The current head of the 14-year-old institute, Prof. Shlomo Mor-Yosef, noted that while Israel has a serious shortage of hospital beds, needs reform of the mental health system, lacks adequate equity in the supply of health services and suffers from a lack of doctors and nurses, it gets a lot more out of the 7.7 percent of the Gross Domestic Product that it spends on health than the US, which devotes 17% of its GDP to it. The institute, which invests state funds on health policy research, gives grants to about a quarter of the applicants, he said. YISRAELI, AN expert in internal medicine, public health and healthcare management, said that in the "old days," physicians were paternalistic and essentially decided for their patients what treatment they would get. Today, the pendulum has swung to the other extreme, with patients given full autonomy and receiving explanations though usually not capable of making vital decisions by themselves. He urged less stress on extreme autonomy, arguing that it is unfair for patients to have to take decisions mostly by themselves. Accountability - for which there is still no official Hebrew translation - and monitoring are supreme, he said. He urged that the value of social solidarity be revived and that a new model - combining the best of both extremes - be adopted. Shortell, who teaches health policy and management and is dean of Berkeley's School of Public Health, added that another major shift in healthcare was from treating people with acute infections to those with multiple chronic conditions, which today account for 80% of medical costs. Sixty percent of all deaths worldwide are from chronic diseases, he said. In China, the negative impact is $558 billion, the UK $33 billion and India $237 billion a year. Shortell recommended integrated and seamless patient care, using coordinated teams and facilities tailored to patients' needs as well as patient educators, physician feedback on quality, nurse care managers and patient reminders for managing chronic conditions. The California expert cited Maccabi Health Services, Israel's second-largest health fund, for largely following this successful model. EUROPEAN COUNTRIES and Israel share the social model of healthcare, said Prof. Martin McKee, an expert in public health at the London School of Hygiene and Tropical Medicine who was raised in Belfast, Northern Ireland. This involves a system of transfers from rich to poor, young to old, employed to unemployed and healthy to ill. While European systems are not monolithic, 40% of those living on the continent believe the poor themselves can escape from poverty (meaning you don't really have to help them) compared to 71% of Americans. "There is less social solidarity in the US," explained McKee, who is research director of the European Observatory on Health Systems and Policies, "because it is a big country, and the rich can live far from the poor. There are only two political parties, so other ideologies - especially socialism - have little place. The US is much more racially heterogeneous than Europe, and thus Americans are less generous in spending money on the poor." Americans, he concluded, also feel less intergenerational solidarity, so the elderly may be less looked after. Migrants are vulnerable, with poor access to healthcare, possible harassment and some working in the sex industry, he said. THE UNITED KINGDOM, with its National Health Service, provides universal health care that is much better than the US system, contended Prof. Margaret Whitehead of the World Health Organization's Collaborating Center for Policy Research on the Social Determinants of Health at the University of Liverpool. On her first visit to Israel, she quoted a Financial Times journalist who said any fool can design a health service with private medical insurance for the affluent. "The challenge is to design a health system that also covers the poor and inarticulate." A system with a cross-subsidy from the better-off to more disadvantaged people and the equitable delivery of services based on clinical need is preferable than one based on social influence or income, said Whitehead. She expressed disgust at placards she had seen waved at US demonstrations against health reform that portrayed President Barack Obama as a Nazi. The US is "infamous for its lack of social solidarity," said Prof. Lawrence Brown, a political scientist who teaches public health and management at Columbia University's School of Public Health in New York. More than 47 million residents lack health insurance, and the figure grows by one million a year. Still, he said, the situation is not dire, because the public sector "has a huge influence in healthcare, and if private insurance doesn't meet the needs, government can come in to fill gaps. There is a safety net of voluntary organizations and public hospitals. Still, many Americans can't get specialists, medications or hospital care as needed." He explained that much of the opposition to universal health insurance is that "people are afraid they will pay into healthcare for all and then won't get any when they retire because no money will be left. The reality is a lot less alarming than portrayed. I'm surprised solidarity has weathered the situation as well as it has." PROF. REGINA HERZLINGER, the first woman to receive tenure and be a department chairman at the Harvard Business School, revealed that she was born in Israel and taken by her family to New York at the age of seven. Thus, the leading economist has followed Israel's health system and is "very excited about the great success of this country. It has a much higher life expectancy" than the US and other developed countries, and admirable healthcare. However, she worries about the rise in copayments, the decline in government funding and the growing shortage of medical manpower. Saving money for the health system by controlling benefits or supply can be harmful and even produce results opposite to what one expects. North Carolina's Duke University Medical Center, for example, managed proactively to cut hospitalization expenses of treating congestive heart failure by 40 percent. But "they lost every penny they saved, as they are paid by health insurance companies using diagnosis-related groups. If healthier, patients go to the hospital less frequently - and if admitted, they stay for shorter periods." She noted that state-provided Medicaid is available for the poor, but half of all US physicians, who have private practices, refuse to see Medicaid patients. A new facet of US medicine are the chains of "retail medical clinics" opened in supermarkets and other commercial spaces; most, she said, offer better care than hospital emergency departments. It is mostly poorer people who go there. FORMER HEALTH Ministry director-general and now director of Tel Aviv Sourasky Medical Center, Prof. Gabi Barbash, urged governments to create trust, hold open public dialogue, adopt transparency and take decisions based on scientific evidence. "There is a growing lack of faith in governments. Politicians - and doctors - have never been very good at cost containment. Many government decisions conflict with popular opinion," he said. "A weak government cannot easily make major decisions, and carrying out reforms is difficult if legislators don't last long. One has to build coalitions, but this is very difficult to accomplish. We need to promote a genuine and trustworthy process and confront politicians with data. We must translate technical terminology into political language." Israel Prize laureate Prof. Mordechai Shani - who helped establish and directed Sheba Medical Center, was twice Health Ministry director-general, helped create the Patients' Bill of Rights and heads the Tel Aviv University School for Health Policy - addressed the issue of encouraging patients to follow healthful lifestyles. "Some say one should reward patients who follow healthful lifestyles, while others want to punish those who don't. But 50% of patients don't follow their doctors' recommendations about exercise, diet and smoking. The UK considered withdrawing benefits from alcoholics and drug addicts unless they are willing to participate" in programs to kick their habits, said Shani. "Some in-vitro fertilization patients are required to stop drinking, while others get bonuses such as a free IVF cycle if they lose weight." About half of US residents think it's fair to charge people who have unhealthy lifestyles for their healthcare. They also don't want to cover people hurt in the perpetration of a crime, he said. "Irresponsible health behavior can be considered antisocial. But this involves philosophical and ethical problems, and raises issues of fairness. It puts responsibility on patients who might unable to control themselves or less educated. We must be sure we know what actions lead to certain conditions, as many illnesses are multifactorial involving social, environmental or genetic factors." Yet, as healthcare costs rise and many conditions are shown to be preventible, Shani predicted that holding patients personally responsible for their health will become more common. HEALTHCARE SUPPLIERS can use "appeals, carrots or sticks" in dealing with customers, said Harald Schmidt, a research associate at the London School of Economics and a fellow in healthcare policy at the Harvard School of Public Health, said the Germany health system strongly encourages residents to improve their health by following a beneficial lifestyle. If patients go to the dentist for regular checkups, their copayment is lower. There are even "no-claims bonuses" for insurance premiums - as with vehicles - if you don't use services such as hospitalization. Germans who pass physical tests get reductions on insurance costs. On the other hand, said Schmidt, if you get sick from having cosmetic surgery, tattoos or piercing, you have to pay for treatment. "Some people become fatalistic and say they can't influence how they act," concluded Schmidt. "Some have genetic factors that prevent them from reaching health goals. Those who argue for personal responsibility and those who advocate social responsibility must move beyond the blame game. I propose adopting co-responsibility for health. It's time to move on, as the two sides are complementary, not competitive. We should encourage people to be healthy, but not make it too burdensome."