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Preparedness for the N1H1 epidemic

Country: 
Israel
Partner Institute: 
The Myers-JDC-Brookdale Institute, Jerusalem
Survey no: 
(14) 2009
Author(s): 
Dr. Dror Guberman, Dr. Michael Dor, Prof. Revital Gross
Health Policy Issues: 
Public Health, Prevention
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Abstract

The purpose of the policy is to reduce morbidity and mortality related to the N1H1 flu epidemic and to preserve a normal functioning of the Israeli society. It includes multi-system cooperation between primary emergency and tertiary care, centrally coordinated by the ministry of health. The main principles are full transparency and uniform messages to the public to promote compliance with behavioral recommendations.

Purpose of health policy or idea

To reduce morbidity and mortality related to the N1H1 flu and to preserve normal functioning of the Israeli society.  

The Israeli policy to address the epidemic is based on multi-system cooperation which includes primary care, emergency care and tertiary care. Policy is defined centrally by the ministry of health (MOH) through directives issued periodically. They contain policy directives on such issues as performing blood tests to identify the virus, prescribing anti-viral medication, and vaccination policy. The main principles of the N1H1 policy are:

  1. Transparency of policy to the media - the directives are available to the media and general public on the MOH website; the media are updated about new directives.
  2. The messages to the media and public are provided centrally by the MOH and coordinated with the sick funds and hospitals in order to prevent public confusion and thus facilitate compliance.
  3. The public are periodically updated regarding the incidence of N1H1 and the recommended treatment for it. There is ongoing reports on deaths due to N1H1 (to prevent rumors which may increase  panic). Rather than trying to  assuage,  the policy is to provide reliable reporting. 
  4. The MOH and sick funds issue instructions to the public on how to prevent contagion and what to do if you suspect the virus. 
  5. The MOH also issues guidelines to large companies, government agencies etc. on how to deal with an epidemic in the office. 
  6. Diagnostic tests for N1H1 are performed only on hospitalized patients and patients presenting at emergency rooms. All data are concentrated at the ICDC 
  7. 26 primary care clinics regularly monitor N1H1 presenting cases as an indicator for trends in prevalence in the community. They report directly to the Ministry of Health. 
  8. If N1H1 will develop to a pandemic the plan is to postpone elective procedures and discharge as many patients as possible.

The current rules of conduct are based on the WHO recommendations and include:

  • Prevention - frequent washing of hands with soap and water especially after coughing or sneezing; covering nose and mouth with tissue when coughing or sneezing.
  • If ill, self-imposed isolation when symptoms are suspected and for 24 hours after the fever has subsided.
  • Provision of medical treatment to populations at risk and to others who have severe symptoms. Treatment includes administration of the Tamiflu and Relenza medication (free of charge) and hospitalization if needed.
  • Vaccination policy will be implemented after vaccinations arrive (due in October). Vaccinations for all the Israeli population have been ordered but will arrive gradually (due to the limited  production pace). The first groups to receive vaccinations will be medical teams and risk groups - pregnant women, chronic patients, obese. Vaccinations will be provided to all free of charge.  Vaccinations will be encouraged but not enforced.

Incentives - The main incentive to the public to follow the MOH directives regarding prevention is the fear of contracting the disease, the information on the possible severity of outcomes and the clear instructions, which are expected to facilitate compliance. The incentive to receive medical treatment when needed is providing medications free of charge (with no co-payments). Providing vaccinations free of charge is expected to facilitate compliance.

Main points

Main objectives

To reduce morbidity and mortality related to the N1H1 flu and to preserve normal functioning of the Israeli society.

Type of incentives

Clear and coordinated information to the public to increase compliance with instructions; treatment and vaccinations free of charge to increase compliance

Groups affected

1. Public ? their behavior is the key to containing the pandemic and preventing complications, 2. Medical facilities ? need to follow new directives, 3. MOH - responsible for coordinating policy between all medical organizations.

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Characteristics of this policy

Degree of Innovation traditional neutral innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent system-dependent system-neutral

The policy follows the WHO directive and therefore is not innovative. However the implementation strategy in Israel is unique. 

The policy is consensual as it was formulated in cooperation with the main actors who consequently support it.  

The policy is based on the existing structure of the health system, with the main change being tight coordination between the different organizations and actors to implement the policy. 

Public visibility is very high - the directives are publicized in the media as part of the policy to gain public cooperation. 

The policy is rather system dependent as it is based on structural features of the Israeli system e.g. central control by the MOH and tight coordination between actors. 

Political and economic background

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Origins of health policy idea

The policy for N1H1 is based on the WHO directives for  coping  with an influenza pandemicThe basic regulations were formulated in 2003 (CEO DIRECTIVE ) and further developed in a 2005 directive.

Initiators of idea/main actors

  • Government
  • Providers
  • Payers

Stakeholder positions

All the main actors responsible for providing preventive and curative services for N1H1 support the ministry of health policy. This is related to the fact that the MOH safeguarded special funds for hospitals in case of a pandemic. The MOH will provide sick funds with the necessary vaccinations and medications free of charge. As the policy is equipped with a budget and formulated in cooperation with the main actors, all involved support it.

Actors and positions

Description of actors and their positions
Government
Ministry of Healthvery supportivevery supportive strongly opposed
Providers
Hospitalsvery supportivevery supportive strongly opposed
Payers
Sick fundsvery supportivevery supportive strongly opposed

Actors and influence

Description of actors and their influence

Government
Ministry of Healthvery strongvery strong none
Providers
Hospitalsvery strongvery strong none
Payers
Sick fundsvery strongvery strong none
Ministry of Health, Hospitals, Sick funds

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The main features contributing to successful implementation of the policy were:

  1. The MOH issued clear directives regarding response at all levels of the health system.
  2. Working groups were formulated for preparing the regulations. Regulations were widely disseminated to all parts of the system via conferences, directives, media and other channels of publication.
  3. The MOH checked that the regulations were understood and implemented by hospitals and sick funds.
  4. Ongoing personal contact with individuals responsible for implementing regulations to hear about their problems and to advise on overcoming them. 
  5. Regulations were updated regularly based on feedback from the field, changes in mortality trends in Israel and changes in WHO policy on this epidemic. For example, only after several weeks did it become apparent that the risk groups were different than those for influenza - pregnant women rather than the elderly.
  6. Another feature of the implementation process was the organization within the MOH as well as the tight cooperation with other actors in the health system and an ongoing dialogue between all involved. The strategy is based on cooperation, with all actors participating in policy formulation, and on immediate responses to their concerns and implementation problems. The Division of Community Medicine in the MOH is responsible for policymaking and implementation. Three task forces have been established. 1) the Division for Emergency Situations is responsible for coordination with the different agencies in the health system (municipalities, army etc). 2) The Division of Public Health is responsible for day to day management (e.g. vaccinations, medications, formulating regulations,  monitoring of morbidity). 3) The Division of Community Medicine is responsible for all contacts with the sick funds. 

The main factor affecting success in reducing morbidity and mortality related to the N1H1 flu and preserving normal functioning of the Israeli society, is the behavior of the public and their compliance with the recommended conduct. It is yet to be seen if the public campaign is successful and if the public will indeed comply with the vaccination policy.

Another problem which may be encountered is the capacity of the hospitals and community facilities to cope with a pandemic situation (e.g. staff, beds etc.). The MOH has prepared some contingency plans but it is yet to be seen if they will indeed be effective.

Another possible problem may be the resistance of healthcare professionals to vaccinations as there is yet scarce evidence regarding their safety and efficacy. They may thus refrain from receiving vaccinations or recommending them to patients. This concern is addressed by dissemination of information through professional channels.  

Monitoring and evaluation

There is no formal evaluation of the policy. There is regular monitoring of morbidity and ongoing collection of data on parameters such as number of vaccinations and medications provided for N1H1 cases. 

Expected outcome

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low high very high

It is early to be definitive at this stage regarding the impact of the policy. If the pandemic breaks and the policy effectively leads to minimizing mortality the impact on quality of care is expected to be high as well as the impact on cost-efficiency. The impact on equity is also expected to be high as the care provided under this policy is free of charge and provided equally to all population groups. 

References

Sources of Information

 

  • Ministry of Health, Director General Directive 34/09 August 17, 2009
  • WHO strategic action plan for pandemic influenza, 2007
  • WHO / CDS / EPR / GIP / 2006.2a

Author/s and/or contributors to this survey

Dr. Dror Guberman, Dr. Michael Dor, Prof. Revital Gross

Dr. Guberman is the head of the Department for Community Medicine, Ministry of Health.  

Dr. Dor is the head of the Division of General Medicine, Ministry of Health  

Prof. Gross is a senior researcher at the Myers-JDC-Brookdale Institute and Bar Ilan University  

Suggested citation for this online article

Guberman, Dror, Dor, Michael, and Revital Gross. "Preparedness for the N1H1 epidemic". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/is/a14/3