|Implemented in this survey?|
Until recently co-payments were collected for well-baby care provided during the first eighteen months of life. In January 2010 this co-payment was eliminated with the objective of removing a financial barrier to access which was problematic mainly for low-income families and those with many children. The change was highly consensual as all stakeholders recognized that co-payments for preventive services do not reduce overutilization of care but rather lead to underutilization of care.
The main objective of the policy was to eliminate a financial barrier to access to well-baby care. The elimination of the co-payment is probably particularly important for low-income families and families with many children. In addition, making the service free to all, communicates to families at all income levels that the government believes this is an essential service and as a result it encourages them to seek care promptly.
The main objective of the policy was to eliminate a financial barrier to access to well-baby care.
Families with young children, Professionals in well-baby clinics
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The policy was rated neutral in terms of innovation because - on the one hand - this was one of the first times that a co-payment had been completely eliminated, while on the other hand, discussions of just such a change had been taking place for many years.
The policy was rated rather consensual because none of the major actors objected to the cancellation on professional or principled considerations, however, some of the professionals within the Ministry of Health had advocated giving higher priority to reducing co-payments for other services.
Structural/systemic impact was rated neutral because the policy made a profound change in the well-baby care system, but this constitutes only a small part of the overall health care system. At the same time, this policy is serving as a precedent in discussions about eliminating or at least reducing co-payments for other types of preventive services.
Public visibility was rated high because the policy received headline attention in both the print and electronic media, albeit for a limited amount of time.
Transferability was rated high as many health systems have co-payments, and in some cases these include co-payments for preventive services. There, too, the arguments for co-payments essentially do not apply to preventive services.
Every year, the Ministries of Health and Finance negotiate an agreement regarding issues of mutual concern, with special attention to budgetary issues. In the agreement for 2009 (signed in 2008), the parties agreed that 35 million shekels of new monies would be set aside in the Minister of Health's (MoH) budget for reducing co-payments on pharmaceuticals for the elderly. The Minister at the time was a MK from the Pensioners' Party so it was natural for him to focus on services for the elderly. Because of the change of cabinet in early 2009, this budget was not implemented.
In early 2009 there were new elections and a new cabinet was established. In the new cabinet, the Prime Minister officially serves as the Minister of Health, while the Deputy Minister of Health is in practice the political figure at the helm of the MoH. The new Deputy Minister of Health is from an ultra-orthodox religious party, which has a special sensitivity to the needs of low-income families and those with small children. He also came into office with a history of a strong working relationships with the Ministry of Finance, as he had previously chaired the Knesset Finance Committee.
Upon assuming office, the Ministry of Finance notified Deuty MoH that he could determine how to allocate the budget. It was left to the MoH to decide which services would benefit from a co-payment reduction. There were a variety of proposals within the MOH, including pharmaceuticals, specialist visits for children, and well-baby visits. In the end the Deputy Minister decided that the monies would be used for well-baby visits -- both because of the inherent importance of the issue and because the MOF supported this direction and even added a further NIS 5 million for this purpose (for a total of NIS 40 million on a yearly basis).
The change in leadership at the Ministry of Health resulted in a higher priority for well-baby services in the decisions about how to use the funds for reducing co-payments.
|Implemented in this survey?|
The mother and child healthcare system (MCHS) was begun in the 1920s in Jerusalem by Henrietta Szold and the Hadassah Women's Organization; over time it grew to be a nation-wide, internationally respected system of preventive care (Freed et al., 2000). The main populations served by the MCHS are pregnant women, infants, and young children to age 6. With regard to each of these groups, the MCHS provided a wide range of health promotion and disease prevention services at the individual level, along with activities that focus on the group level - both within the MCHS facility and at other sites in the community. In the case of infants (the focus of this paper), the services provided at the individual level include immunizations, screening and developmental tests, referrals and follow-up, home visits, health education, counseling, and supportive listening (Palti et al., 2004; Palti, 2006).
In 2006, approximately 145,000 infants received care at over 1,200 clinics belonging to the MOH, the health plans and two local governments. The MOH operated 44 percent of the clinics and cared for approximately two-thirds of the infants. The health plans operated 50 percent of the clinics, including many relatively small clinics in rural areas, and cared for 20 percent of the infants (Rosen, 2006). The other major service providers were the municipalities of Tel Aviv-Jaffa and Jerusalem. All of the service providers operate under the supervision of the MOH and are expected to conform to service guidelines promulgated by the Ministry.
Prior to the policy change, families had to pay NIS 550 for the well-baby care provided to each child during their first year-and-a-half of life. In practice, many of the well-baby clinics (particularly those run by the MOH) did not condition receipt of services on payment of these fees in the case of low-income families. However, they are still believed to have served as a barrier to care, as not all families were aware of this lenient implementation of the co-payments, and others were uncomfortable asking for special treatment. Moreover, when the well-baby clinics would forego the fees, they ended up being under-budgeted and this adversely affected their ability to give comprehensive, high-quality services. A 2007 Myers-JDC-Brookdale survey found that 20 percent of new parents did not pay the officially-required well-baby co-payment (Rosen et al., 2007).
For more than a decade, leading Israeli public health experts and health economics experts have argued that co-payments for preventive services are counter-productive. They note that the primary objective of co-payments for curative services is to reduce incentives for over-utilization. However, no such risk of over-use exists in the case of preventive servics. Moreover, the State has both a welfare and an economic interest in promoting the use of preventive services, particularly with regard to well-baby care (Ofer, 2003; Rosen, 2006).
Moreover, in recent years, various experts in government and academia have highlighted and lamented the growing share of health care financing (overall) being borne by households (Gross et al, 2007; Bin Nun, 2009). They are concerned about equity and access issues. They have noted that the private share in financing national health expenditures has increased from 31 percent in 1996 to 42 percent in 2008. This has generated a climate of public and professional support for reductions in co-payment levels for a wide range of services.
The approach of the idea is described as:
renewed: In 2002 the MOH leadership brought about a reduction of the co-payments for well-baby clinics.
The Ministry of Finance deferred to the MoH on the decision about how best to use the funds available for reducing co-payments. At the same time, they recognized that well-baby care would be a very good use of the monies.
There were various proposals within the Ministry of Health about how best to use the funds available for reducing co-payments, where other alternatives considered included medications and visits by children to specialists. The Deputy Minister of Health who came into office in early 2009 is especially committed to improving access to care for low-income children, and he decided that the funds would be used to reduce co-payments for well-baby care.
The Knesset was not directly involved in this issue. In general, in recent years, there had been various bills proposed for eliminating co-payments for a range of preventive services, but these had not been adopted into law.
The academic community was strongly supportive of the move, recognizing the importance of prevention and the absence of a risk of overuse. Their influence was not as part of the immediate policy process, but through a longer-term effect on attitudes.
The health plans were moderately supportive of the idea. Their emphasis was on making sure that the subsidy received from the government would be at a level that would fully compensate them for the loss of co-payment revenue.
Thus, no major groups opposed the policy in principle. There were some professionals within the MOH who would have preferred to apply the co-payment reduction monies to other services, but these were not strongly held positions. Others were concerned that the monies available would not suffice to cover the costs of eliminating co-payments for well-baby care. The Deputy Minister and members of his top management team provided the leadership for the reduction of the co-payments for well-baby care.
|Ministry of Health||very supportive||strongly opposed|
|Ministry of Finance||very supportive||strongly opposed|
|Deputy Minister of Health||very supportive||strongly opposed|
|Labor, Social Affairs and Health Committee||very supportive||strongly opposed|
|Health plans||very supportive||strongly opposed|
|Israel Medical Association||very supportive||strongly opposed|
|Public health experts||very supportive||strongly opposed|
|Health policy / economics experts||very supportive||strongly opposed|
|Ministry of Health||very strong||none|
|Ministry of Finance||very strong||none|
|Deputy Minister of Health||very strong||none|
|Labor, Social Affairs and Health Committee||very strong||none|
|Health plans||very strong||none|
|Israel Medical Association||very strong||none|
|Public health experts||very strong||none|
|Health policy / economics experts||very strong||none|
The Ministry of Finance allocates the funds to the MOH as part of the standard budget implementation process.The MOH then transfers the monies to the various providers of MCH services - its own Public Health Service, the health plans and the municipalities of Jerusalem and Tel Aviv.
The MOH also used the mass media to communicate to the public that they would no longer be asked to make co-payments for these services.
There are no concrete plans at present to conduct a formal evaluation.
Improved access to care, particularly for families with low-incomes and/or many children. This should result in more and earlier visits to well-baby clinics, and ultimately to improved infant/child health status.
Also reduced financial burden of out-of-pocket payments for these families.
Reduced administrative burden for clinic staff.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The policy is expective to increase system equity because the co-payment had served as a barrier to care primarily for low-income families. It is also expected to improve cost-efficiency as improved access will result in better health outcomes. The policy is not expected to have a major effect on the quality with which the well baby services themselves are provided.
Rosen, B.; Elroy, I.; Nirel, N. Key Findings from a National Survey of Mothers Regarding Preventive Health Services for Children in the Tipat Halav Framework. Jerusalem: Myers-JDC-Brookdale Institute, 2007.(Hebrew).
Ofer, G. 2003. Disparities and inequality in the health care system: economic perspectives.Tel Hashomer: Israel National Institute for Health Policy.(Hebrew).
Palti, H. Preventive Services for Pregnant Women and Children at a Crossroads. Jerusalem: Taub Center, 2006.
Rosen, B. Report of the Tipat Halav Strategic Planning Committee. Jerusalem: Ashalim and the Ministry of Health, 2006.(Hebrew).
Palti, H.; Gofin, P.H.; and Adler, B. "Evaluation of Utilization of Preventive Services for Infants in Israel: Personal and Organizational Determinants". Harefuah 143(3):184-188, 2004. (Hebrew).
Freed, G.L.; DeFriese, G.H.; Williams, D.; and Behar, L. 2000. "Preventative Service Delivery for Children in a Managed Care Environment: Contrasts and Lessons from Israel. Health Policy 55:209-225.
Bin Nun, G. 2009. "From National Health Insurance to the Age of Gold and Platinum" in The Health System: Where is it Heading? (H. Doron, ed.). Ben Gurion University.
Gross, R.; Brammli-Greenberg, S.; and Rosen, B. 2007. "Co-payments: The Implications for Access to Services and Equity". Law and Business 6:197-224 (Hebrew).
Brammli-Greenberg S, Rosen B, and Gross Revital (2005). Co-payments for physician visits: how large is the burden and who bears the brunt? Research report Myers-JDC-Brookdale Institute, Jerusalem. (Hebrew).
Rosen B. Brammli-Greenberg S. Gross R. Feldman R. Forthcoming. When Co-Payments for Physician Visits Can Affect Supply as Well as Demand: Findings from a Natural Experiment in Israel's National Health Insurance System International Journal of Health Planning and Management.
Nir Kaidar and Bruce Rosen
Nir Kaidar is the coordinator of health economics at the Israel Ministry of Health.
Bru ce Rosen is the director of the Myers-JDC-Brookdale Instittute's Smokler Center for Health Policy Research