In recent decades, Western countries have been forced to deal with increasing demand for healthcare services due to far-reaching demographic, social and economic trends, including the rise in life expectancy and population aging, the changes in patterns of morbidity, the accelerated rate of technological and scientific development, the upsurge in health awareness and the rise in the standard of living. Most countries have difficulty keeping up with this demand increase for several reasons, including the inadequate rate of physician training, reduction of work hours in this field, particularly among young physicians (due to an increase in women working in this profession, among other reasons), as well as an increase in retirement rates.1
To the backdrop of these trends, the ideal percentage of physicians within the Israel population has been debated in the past decade. In addition to the systematic factors delineated above, there are local circumstances heightening the strain on the Israel healthcare system as well. The rise in number of retiring physicians, the sharp decline in the number of doctors immigrating to Israel, and the failure to expand the scope of physician training frameworks in medical schools – have all given rise to very real concern regarding an anticipated physician shortage in Israel, and generated a reexamining of the scope of medical manpower required by the healthcare system.
This state of affairs led to the establishment of various committees that recommended the expansion of physician training institutions. These include the Committee to Examine the Future Need for Physicians (the Pazi Committee) established by the Higher Education Authority, which submitted its recommendations in October 2002; the Committee to Examine the Need for Establishing an Additional Medical School in Israel (the Halevy Committee) that submitted its recommendations to the Planning and Budgeting Committee of the Higher Education Authority in 2007; and the Committee to Examine Estimates of Future Labor Force Needs in the Health System: Doctors and Nurses, (hereinafter: the Bennun Committee) that submitted its preliminary report in June 2007. The adoption of these committees’ recommendations led to the gradual expansion of the centers for physician training so that in the 2010 school year there were 525 students in their first year of medical school. Upon establishment of the medical school in Safed, this number will rise to 600 students per year (compared to approximately 300 in the year preceding the expansion).2 Although this expansion of the training facilities is in itself an important step, on its own it is a far cry from solving the manpower crisis in the medical system, and it is doubtful whether it will change the downward trend in the percentage of physicians in Israel in coming years, as reflected in the following diagram.
Trends in the percentages of physicians in Israel3
Evidently, the past forty years have seen varying trends in the percentages of physicians in Israel. The 70’s of the previous century saw a continuous increase in the number of physicians per 1,000 persons, and in the 80’s, the number of physicians remained static due to the decline in immigration to Israel during these years. In the early 90’s there was an accelerated increase in the percentage of physicians as a result of surges of immigration, but the late 90’s saw the beginning of a downward trend in the percentage of physicians, again due to decreased immigration.4 In 2008, the percentage of physicians (medical license holders under 65) was 3.46 physicians per 1,000 persons, with a total of 25,542 physicians.5 In 2009, the percentage declined further to 3.43 per 1,000 persons (a total of 25,850 physicians) 6.
But how can we tell if this is the ideal percentage? Is there a shortage or excess of physicians in Israel, and what is the criterion for determining this?
Comparing the percentage of physicians in Israel to the percentage in Western countries
One of the most widely accepted tools employed by decision-makers for determining the ideal percentage of physicians (as well as Israel’s data in other fields), is the use of data of financially and technologically developed countries boasting advanced healthcare systems, as a criterion for measuring Israel’s position and examining the disparity between the ideal and reality. This data is published each year by international bodies such as the OECD and the WHO, providing research bodies and policymakers with databases for comparisons of this sort. Thus, the average percentage of physicians in the OECD countries generally serves as a point of reference for the percentage of physicians in Israel as far as Israel’s specialists and decision makers are concerned.
The problem is that the various healthcare systems worldwide differ in the way they develop and operate, and are contingent on various and diverse factors such as the availability of financial resources, demographic conditions, the governmental environment, and the accepted culture and practice in the fields of medicine and healthcare. It is therefore practically impossible to use a common starting point, which is reliable and acceptable, with regard to the ideal or “natural” percentage of physicians for all the different countries. The ideal percentage of human resources is derived largely from normative assumptions, which may vary from one country to another.7
Nonetheless, as a result of recurring comparisons between Israel and other Western countries, over the years it has become the widely accepted claim among economists and health specialists that the percentage of physicians in Israel is relatively high. This claim is reflected in various documents dealing with the issue, and is prevalent within the healthcare system and beyond. The June 2010 Report of the Committee for Planning Medical and Nursing Human Resources in Israel, for instance, determined that the percentage of physicians in Israel is relatively high compared to the Western world8. The Ministry of Health backs this assertion, 9 as did the group of specialists dealing with human resources in the healthcare professions, at the Ninth Dead Sea Conference. 10 In an economic survey made by the Bank of Israel Research Division in June 2009, this claim was once again raised.11
The percentage of physicians per 1,000 persons in select countries including Israel, 2007.12
This diagram, excerpted from the report of the Committee for Medical and Nursing Human Resources in Israel, shows that in 2007 there were 3.49 doctors per 1,000 persons, a rate approximately 13% higher than the average in OECD countries, placed at 3.10 physicians per 1,000 persons.
Trends in the percentage of physicians per 1,000 persons in Israel and in the OECD.13
The diagram illustrates that while in recent years there has been a moderate downward trend in the percentages of physicians in Israel, there is an upward trend in the percentages of physicians in the OECD countries. Despite these opposite trends apparent in the past decade, the percentage of physicians in Israel is still higher than that in most of the OECD countries according to this comparison.14
Against the data presented above, important questions arise regarding the manner of the comparison and the nature of the data on which it is based. These questions relate to the methodology used in the international comparison presented in the aforementioned documents, as well as in others. Although some of these methods call to mind the pitfalls and limitations earlier referred to, for lack of an alternative method of comparison to the professionals’ satisfaction, these problems are pushed into the corner and not accorded the attention they deserve. Ultimately, the claim that the percentage of physicians in Israel is high relative to the Western countries is ingrained, and serves as the premise for the professional and public discussion regarding this important issue.
We would therefore like to indicate two primary pitfalls in the comparison in question, which cause the false portrayal of the percentage of physicians in Israel as high relative to the Western countries:
- Erroneous selection of the comparison countries
- Imparity between the OECD definitions and Israel’s official data.
Israel’s position in a variety of international comparisons is primarily a result of the comparison group and the comparison methods selected. The decision to use the average percentage of the OECD countries as a basis for the comparison of economical and social indicators, including the percentage of physicians, was of course not coincidental. OECD constitutes a multinational forum for debates, coordination, and economic cooperation, and it boasts approximately 30 democratic, free market countries as its members. Furthermore, the OECD collects and coordinates the statistical data of its members, publishes long-term research studies, and maintains databases on a wide range of topics, including healthcare. Dozens of indicators in the fields of healthcare economics, healthcare infrastructures, quality indexes relating to medicine, percentages of morbidity and mortality, etc. make up an inexhaustible and convenient database for international comparisons. In 2010 Israel joined its ranks, and the international comparisons between Israel and the OECD countries were thus reinforced. Above all, the OECD is viewed as an exclusive membership club, entry to which is reserved for the world’s most developed countries, while the very membership in the OECD serves as a business card for economic success.
This perception stems from the historical roots of the OECD. The OECD was founded in 1961 as a continuation of the OEEC, established to uphold the Marshall Plan for the recovery of Europe in the aftermath of World War II. Initially, the OECD included only the countries of Western Europe and North America, but additional countries from Eastern Europe and other areas worldwide, gradually joined the ranks.15
Most of these countries are significantly lagging economically compared to the founder countries, and even compared to Israel, yet it seems that their joining the OECD in no way derogated from the organization’s exclusivity and its persona as a representative of the worldwide economic elite, at least among the population and policymakers in Israel. This is in spite of the fact that these less economically developed countries’ data is included in the OECD average in various international comparisons. In many indicators, including the percentage of physicians, they lower the average of the OECD data.
The identities of the countries play a decisive role in any international comparison, and directly influence its results. 16 We must therefore scrupulously examine the observation group on which the comparison is based, and not just accept it naturally. For instance, we should question whether Israel should be compared to the average of countries that include Turkey, Mexico, Poland and Hungary (most of which joined the OECD during the 90’s), whose national product per capita was approximately $12,300 in 2008, while Israel’s parallel datum is $28,300.17 Likewise, it seems inappropriate to compare Israel to the US, which so differs from it structurally and normatively, especially upon examining the two countries’ social legislation systems. This distinction sharpens upon examining the two countries’ health systems: a private health system still maintained in the US, vs. universal health insurance in Israel, anchored in the National Health Insurance Law. So, too, the question arises whether it is appropriate to compare Israel to the East Asian countries (Japan, South Korea) in view of their considerable cultural differences. All this creates a very problematic picture with regard to the selection of the comparison group. We will later see that comparing Israel to the EU countries radically shifts the country’s international rating.
The problematic nature of the international comparison is also reflected in the disparity between the definition of the physician population measured in Israel and that measured in the OECD. In accordance with the requirements of the OECD that aims to achieve a definition as homogenous as possible for all its members, the OECD countries’ data relates to the number of practicing physicians, i.e. physicians actually engaged to provide clinical treatment. Below are several examples excerpted from the technical definitions of the OECD database, Health Data 2010:
- Austria: "includes physicians in activity who are members of the Austrian Medical Chamber… excludes physicians without medical practice (in industry, administration, research...)".
- Germany: "Data contain the number of physicians that are actively practising medicine in public and private institutions and provide services directly to patients (head-count data)".
- Sweden: "Head count data. Excludes non-practising physicians, retired professionals and professionals working abroad. Includes professionals who are foreigners".
In contrast, Israel’s data relates to the number of medical license holders under 65 according to the database of the Ministry of Health. 18 Since not all medical license holders in Israel actually practice medicine, this datum published by the Ministry of Health does not show the number of physicians actively practicing medicine, but rather the number of persons licensed to practice medicine in a given year. As we shall later see, the number of practicing physicians is smaller than the number of license holders under 65, thus, the percentage of physicians in Israel is in fact lower than that portrayed in international comparisons.
The number of practicing physicians in Israel can be currently gleaned from two sources: the annual manpower surveys conducted by the Central Bureau of Statistics (CBS), and the report entitled Practicing Physicians – Administrative Data published by the Health Ministry in 2010. The CBS bases its figures on a sample of 44,000 households, and these provide an estimate of those employed in all branches of the economy, including medicine.19 The survey’s advantage is that it illustrates the employment trends in a continuum of time. For years, this survey constituted the sole source for the estimating the number of professionals employed in healthcare professions. The survey’s drawback is obvious: it is based on a sample. Consequently, there are considerable imparities throughout the years in the workers’ data. Furthermore, the lower the frequency of those employed in the sample, the greater the inaccuracy of the survey’s results. For instance, according to a survey of human resources the number of physicians has, in recent years, ranged from 21 to 25 thousand a year. These changes are a result of sampling errors, and this data should therefore be viewed with great caution. 20 Finally, the decision to categorize the interviewee as a practicing physician is based on his description of his primary occupation. For example, an interviewee in this survey who defines his occupation as Chinese medicine, and states that he has a private clinic for the provision of Chinese medicine, will be categorized in the survey as a practicing physician. The survey’s data may also include interns (students in their seventh year of medical studies) and foreign physicians training in Israel.21 Due to the drawbacks of the CBS survey, the number of medical licensees (under 65) is the datum generally used in international comparisons.
However, in view of the survey’s advantage, the Pazi Committee chose to base its estimate of the number of physicians in Israel on the average number of practicing physicians (based on the CBS survey) combined with the number of license holders under 65.22 A comparison between the CBS survey and the Health Ministry’s data shows that the percentage of license holders under 65 that serve as practicing physicians, has averaged 91% in the last decade. 23 Therefore, not only does the erroneous selection of countries lower the international average, but the percentage of physicians published by the State of Israel is inflated – thus is formed a wide and unrealistic disparity between the international average and Israel’s data.24
To bypass this bias, we suggest the use of a report published by the Ministry of Health in 2010, called Practicing Physicians – Administrative Information, which includes a head count of physicians employed in the primary health organizations – the four health funds (kupot cholim), the Civil Service Commission, the IDF, and 94 hospitals, including Israel’s largest. 25 The file refers to a total of 21,214 physicians, i.e. 2.8 practicing physicians per 1,000 persons, that constitute 82% of the licensees under 65 as of the 2009 yearend (25,850 physicians) – a percentage lower than that calculated on the basis of the CBS surveys.
This report has several disadvantages: the information does not include all of Israel’s practicing physicians, it lacks information regarding hospitals in East Jerusalem, psychiatric hospitals, many of the institutes for chronic illness, as well as physicians employed in private institutes and clinics, who do not work with the health funds (kupot cholim). 26 Despite its shortcomings, the Health Ministry’s report is the lesser of two evils compared to the CBS averages, which are characterized by inconsistent changes and great fluctuation in the number of physicians from one year to the next. The disadvantage in using the CBS surveys is also apparent in the document published by the Knesset Research and Information Center in its reference to the planning of medical human resources in Israel. The document states that “these examples illustrate the problematic nature of the datum relating to the number of practicing physicians according to the CBC human resources survey, as well as the pitfall in using this datum in planning the medical manpower in Israel”27 (not bolded in source).
Thus, for the first time, we have solid, reliable and current information regarding the number of practicing physicians in Israel, not based on a statistical sample. As stated, this report includes Israel’s main healthcare organizations, and since the percentage of physicians in private clinics is apparently extremely low28, it appears that the Health Ministry’s Report delineates the approximate number of practicing physicians in Israel. It should therefore be favored over the number of license holders with regard to anything pertaining to international comparisons that measure the percentage of practicing physicians in each country.
Based on this datum, we will present an international comparison between Israel and a select group of countries. In our opinion, this group reflects a point of reference more appropriate to the State of Israel’s needs, economic situation, and values with regard to its obligations vis a vis its citizens, as opposed to the comparison to all OECD countries.
EU15 refers to the senior countries of the EU, which were members prior to its expansion in 2004. The 15 countries are: Austria, Italy, Ireland, Belgium, Brittan, Germany, Denmark, Holland, Greece, Luxemburg, Spain, Portugal, Finland, France and Sweden.
In contrast to the majority of the countries that joined the EU in the 2000’s, and as opposed to many OECD members, these countries enjoy a high economic standard based on free market principles, alongside developed welfare and healthcare systems. Israel resembles, or at least aims to resemble, these countries financially and ideologically. Therefore, their economic and social achievements, including in the field of healthcare, may serve as a more appropriate point of reference than the OECD average. It should also be noted that EU15 was determined by a team of professionals as a comparison group on which is based the National Health Index developed by the Israeli Medical Association.29
We will now make the comparison based on the presumptions presented above.
The Percentage of Practicing Physicians – Israel vs. the EU15 Countries
The diagram shows that the change in the comparison group raised the group’s average as a point of reference from 3.1 to 3.59 physicians per 1,000 persons. Israel, on the other hand, slid to the bottom of the scale on account of the more accurate redefining of the physician population (practicing physicians as opposed to license holders under 65), preceding only Finland and Britain. The percentage of practicing physicians in Israel is significantly lower than the EU15 average, at approximately 22%.
Although they did not explicitly say so, the Pazi Committee and the Halevy Committee both assumed that the ideal percentage of physicians ranged from 2.8 and 3.0 physicians per 1,000 persons, in accordance with the OECD country average in the years during which these committees operated (The Pazi Committee submitted its conclusions in 2002, and the Halevy Committee in 2007.)30 Pursuant to the conclusions of these committees, the Committee to Examine Medical and Nursing Human Resources in Israel determined in June 2010 that “after having examined the rate of manpower training in Israel and abroad, as well as data regarding the percentage of physicians in various countries, the current committee has also decided to adopt a percentage of 2.9 physicians per 1,000 persons, as a point of reference that should not be lowered. This is not a very ambitious goal in view of the OECD average currently at 3.1 and the average of the 15 original EU countries currently at 3.5.” 31
Thus, the percentage of practicing physicians is at the lower end of the ideal range set forth by the Pazi and Halevy Committees several years ago. This datum contradicts the false impression created by the commonly accepted, misleading comparison of the medical license holders in Israel and the average percentage of practicing physicians in the OECD, according to which, Israel apparently has an excess of physicians compared to the West.
1 The Ministry of Health, Report of the Committee for Planning Medical and Nursing Human Resources in Israel, June 2010, page 9.
2 The Knesset Research and Information Center, The Absence of Tools for Planning the Medical Human Resources in Israel, by Sheli Levy, July 2010, page 2.
There are three primary tracks of physician training: training in Israeli medical schools, the training of Israelis who studied abroad, and the training of those who studied abroad and immigrated to Israel as physicians. The scope of training in Israeli medical schools has been largely consistent throughout the years, but the other two tracks fluctuate. This makes long-term planning difficult, and may create excessive dependence on external bodies. Furthermore, the number of training facilities for physicians in Israel is limited, resulting in a decelerated rate of new physicians entering the system, yet the medical schools in Israel train 120 foreign medical students, who, for the most part, return to their place of origin upon completion of their studies.
3 Ibid, page 20
5 Ibid, page 19.
6 The Ministry of Health, Human Resources in the Healthcare Professions 2009: Physicians, page 28.
7 For instance: the percentage of nurses in Holland is 8 per 1,000 persons, and the parallel figure in Ireland is nearly double. Conversely, the percentage of physicians in Holland is among the world’s highest, at 4 per 1,000 persons, compared to only 3 per 1,000 persons in Ireland.
8 Ibid, page 19.
9 The Ministry of Health, Press Release on the Occasion of Israel’s Joining the OECD, May 10, 2010.
10 The Israel National Institute for Health Policy Research, The Ninth Dead Sea Conference: Human Resources in the Healthcare Professions, June 2008, page 19.
11 The Bank of Israel, Economic Developments in Recent Months, June 2009, page 26.
12 The Ministry of Health, The Report of the Committee for Planning Medical and Nursing Human Resources in Israel, page 21. As was stated in the committee report: the data pertaining to the OECD countries relates to the percentage of practicing physicians, while Israel’s data relates to the number of medical license holders under 65.
15 The Ministry of Foreign Affairs, A Spokesman’s message: An important political and economic achievement: Israel is on its way to the OECD. May 16, 2007. http://www.mfa.gov.il/MFAHeb/Spokesman/2007/Israel+to+join+OECD+160507.htm [Entry date: November 4, 2010].
16 An example of this can be found in the annual reports published by the State Revenue Division of the Ministry of Finance, which state: “Israel’s rating in international comparisons on taxation, results, among other things, from the comparison group to which Israel is compared and from the method of comparison. Those who maintain that Israel resembles the countries of Western Europe, will choose to compare Israel to the EU countries, and they may conclude that the taxation in Israel is approximately three percent of GDB lower than average in those countries. Conversely, those who prefer to use the OECD countries as a comparison group will conclude that Israel’s taxation rate is approximately 4 percent of GDB higher compared to the OECD average…Moreover, we must also take into account institutional and economic imparities between the countries, which influence the taxation rates.” The Ministry of Finance, The State Revenue Division – Annual Report 2007, page 46. http://www.finance.gov.il/hachnasot/ [entry date: March 9, 2011].
17 Based on Purchasing Power Parity (PPP). UN National Accounts Main Aggregates Database http://unstats.un.org/unsd/snaama/dnllist.asp [Accessed on November 4 2010], data processing.
18 It should be noted that in 2010, the OECD added a new index “Professionally active physicians” that relates to the general population of doctors that are “professionally active,” i.e., not only those with clinical occupations, but also those who engage in healthcare administration, medical research etc.
19 The Research and Information Center, ibid, page 17. According to the CBS, “practicing” workers are defined as those who worked at least one hour during the determining week (the week ended on the Saturday prior to the conducting of the survey), in any field, in return for a salary, profit, or other consideration.
20 The Ministry of Health, ibid, page 15.
21 The Research and Information Center, page ibid.
22 The Ministry of Health, ibid, page 13.
23 Ibid, page 6. Data processing.
24 If this does not suffice, a deviation related to the OECD data artificially increases the percentage of physicians in Israel in the following manner: the OECD calculates the percentage of physicians based on a number of persons smaller than that actually existing in Israel, as the OECD does not include in the Israel population those living beyond the green line. Based on these calculations, the OECD publishes that the percentage of physicians in Israel is higher than 3.6 physicians per 1,000 persons, thereby further raising Israel’s datum. OECD Health Data 2010.
25 Ministry of Health, Human Resources in the Healthcare Professions 2009: Practicing Physicians – Administrative Data, 2010, page 193.
27 Research and Information Center, page 6-7.
28 According to a 2003 survey made by Dr. Naomi Bitterman of the Technion’s Neeman Institute, the percentage of Israel’s medical school graduates primarily employed as physicians in private clinics, is no more than 2.6%. S. Bigelman “Hanging the Robe,” Medical Time (16) 2, February – March 2005, page 40.
29 The Israeli Medical Association, The National Health Index, September 2009.
30 The Ministry of Health, The Report of the Committee for Planning Medical and Nursing Human Resources in Israel, page 2.
31 The 15 original EU countries’ average, which, contrary to the OECD average, is slightly higher than the percentage of physicians in Israel, is casually mentioned once in the Committee’s report and not referred to again.