What motivates physicians to propose private services in a mixed private-public healthcare system? A mixed methods study.

BACKGROUND: Implementation of private elements, including private insurances, in public healthcare system is now common in many countries, and its impacts have been well studied. Little, however, is known about the motives leading physicians, major role players in the system, to promote the usage of private services. The aim of this study was to explore the various motives leading physicians within public systems to propose private services to their patients, while examining the possible associations to their specialty and level of commitment. METHODS: A total of 197 physicians from specialisms loaded more to private/public sectors participated in a cross-sectional telephone survey regarding their attitudes on their practices, private insurances, access to healthcare, and job satisfaction. The association between the likert scale questions to their recommendation to purchase private insurance, and the commitment they felt towards patients were analyzed using Generalized Estimating Equations (GEE) as well as logistic regression models. RESULTS: Our findings suggest physicians engaged in dual practice are less likely to promote private insurances among their patients if they are satisfied with their public job (OR = 0.92, 95%CI 0.89,0.94). Physicians perceived private insurances as beneficial for patients, were found likely to promote them (OR = 1.65, %95CI 1.16, 2.35). The commitment physicians felt toward patients who paid out-of-pocket money was associated to their sense of being trusted and valued (OR = 1.99, 95%CI 1.33, 2.88; OR = 1.5, 95%CI 1.05, 2.13 respectively). CONCLUSION: This study suggests a deeper understanding of physicians' daily experience of the private-public mix and it's consequences, and could provide a platform for future studies. Further studies on physician's role in health privatization processes are needed, and could aid policymakers in their efforts to strengthen healthcare systems around the world.

From bioethics to biopolitics: "Playing the Nazi card" in public health ethics-the case of Israel.

While bioethicist Arthur Caplan claims that "The Nazi analogy is equivalent to dropping a nuclear bomb in ethical battles about science and medicine", we claim that such total exclusion of this analogy is equally problematic. Our analysis builds on Roberto Esposito's conceptualization of immunitas and communitas as key elements of biopolitics. Within public health theories and practices there is an inherent tension between exclusion (immunitas) and inclusion (communitas) forces. Taking the immunitas logic to the extreme, as National Socialist medicine did in the name of securing the German race, is a constant danger that needs to be taken seriously into consideration when discussing public health policies. The tension between the silencing of the Holocaust in bioethical debates on one side, and the persistent use of National Socialist medicine metaphors, on the other hand, is the focus of this paper. By delving into the meanings and the implications of this two-edged discourse, we argue that comparing post-war bioethics with pre-war medical practices from a biopolitical perspective has the potential to depict a more nuanced account of continuities and discontinuities in bioethics.

An alternative way of understanding exit, voice and loyalty: the case of informal payments for health care in Israel.

This study examines Hirschman's model of exit, voice and loyalty with regard to informal payments in the Israeli healthcare system. Based on a national survey, we investigate the extent of "black" payments, its characteristics and its correlated factors. We find that informal payments do exist in Israel-although it seems that there has been a decline in the phenomenon. Contrary to the literature, we find no relationship between the option of voice or dissatisfaction with healthcare services and informal payments. However, we do find a negative correlation between trust and the use of such payments. This finding is consistent with Hirschman's insight that a lack of loyalty may lead people to strategies of exit. We suggest that given the fact that health care in Israel is a public service, the exit option may actually be a quasi-exit behavior. Copyright © 2015 John Wiley & Sons, Ltd.

Is socioeconomic status associated with utilization of health care services in a single-payer universal health care system?

OBJECTIVES: To assess an association of Socio-economic status with utilization of health care services between years 2002 and 2008 in Israel. METHODS: We retrospectively analyzed the utilization of health care services in a cohort of 100,000 members, 21 years and older, of a Clalit Health Services. The research compared utilization according to the neighborhood SES status; and clinic's location as another SES proxy. Data included: Charlson Score morbidity factor, utilization of health care services (visits to primary physicians and specialists, purchase of pharmaceuticals, number of hospitalization days, visits to ED, utilization of laboratory tests and imaging). The analysis was performed using Generalized Linear Model (GLM) technique. RESULTS: People with lower SES visited more the ED and primary physicians and were hospitalized for longer periods. People with higher SES visited more specialists, bought more prescription drugs and used more medical imaging. The associations between SES and most of the services we analyzed did not change between 2002 and 2008. However, the gap between lower and higher SES levels in ED visits and the use of prescription drugs slightly increased over time, while the gap in visits to specialists decreased. CONCLUSIONS: The research shows that even in a universal health care system SES is associated with utilization of health care services. In order to improve equity in utilization of services the Israeli public health should reduce economic barriers and in parallel invest in making information accessible to improve "navigation skills" for all.

Circles of exclusion: obstacles in access to health care services in Israel.

The Israeli National Health Insurance Act establishes a formal framework that guarantees equal access to health care services. The author analyzes the ways in which the neoliberalization of Israeli society, through partial privatization of the public health care system, and its structure of citizenship interact in excluding significant social groups, such as Israeli Arabs and migrant workers, from equal access to health care.

The physician as a neoliberal subject - A qualitative study within a private-public mix setting.

Research on neoliberalism in health care has insufficiently explored the intermediary role of physicians in neoliberal subjectification. This paper studies the construct of the physician as a neoliberal subject in the Israeli health care system, using qualitative data from in-depth interviews with 21 medical specialists. We interviewed physicians from specialties in which private practice is both less common (infectious disease and intensive care) and more common (orthopedics, cardiology, and cardiothoracic surgery). Our analysis focused on two key issues: the physician's role in society and the value placed on health care. We found a spectrum of views. At one end, some perceived themselves as entrepreneurs, managing themselves both as an enterprise and a product, and perceived health care as a commodity. At the opposite end, we found a professional ethos that considered the physician as a public servant, and health care as a human right. Both views were in constant tension with neoliberal subjectivity. Further research should investigate the association between institutional belonging, whether public or private, and the internalization of the main characteristics of the neoliberal worldview.

The role of public-private partnerships in extending public healthcare provision to irregular migrants: stopgap or foot in the door?

In this commentary to the paper "Ensuring HIV care to undocumented migrants in Israel: a public-private partnership case study" by Chemtob et al. we discuss the role of public-private partnerships (PPPs) as a mechanism for integrating previously excluded groups in public healthcare provision. Drawing on PPP case-studies as well as on Israel's pandemic preparedness policies during the Covid-19 outbreak, we examine potential implications for the populations in question and for health systems.In our view, Chemtob et al. describe an exceptional achievement, where a PPP served as a stepping stone for the subsequent integration of irregular migrants' in publicly funded HIV care. However, we argue that in many other cases PPPs are liable to undermine public healthcare and inclusionary claims. This view is informed by the fundamentally different concepts of healthcare that underlie PPPs and public healthcare provision (namely, health care as a commodity vs. access to healthcare as a right) and existing evidence on PPPs' role in facilitating welfare retrenchment. In contexts that are dominated by an exclusionary stance toward irregular migrants, such as contemporary Israel, we believe that PPPs will become stopgaps that undermine health rights, rather than a first foot in the door that leads toward equitable provision of healthcare for all.

From public vs. private to public/private mix in healthcare: lessons from the Israeli and the Spanish cases.

BACKGROUND: Different forms of public/private mix have become a central mode of the privatization of healthcare, in both financing and provision. The present article compares the processes of these public/private amalgams in healthcare in Spain and Israel in order to better understand current developments in the privatization of healthcare. MAIN TEXT: While in both Spain and Israel combinations between the public and the private sectors have become the main forms of privatization, the concrete institutional forms differ. In Spain, these institutional forms maintain relatively clear boundaries between the private and the public sectors. In Israel, the main forms of public/private mix have blurred such boundaries: nonprofit health funds sell private insurance; public nonprofit health funds own private for-profit hospitals; and public hospitals sell private services. CONCLUSIONS: Comparison of the processes of privatization of healthcare in Spain and Israel shows their variegated characters. It reveals the active role played by national and regional state apparatuses as initiators and supporters of healthcare reforms that have adopted different forms of public/private mix. While in Israel, until recently, these processes have been perceived as mainly technical, in Spain they have created deep political rifts within both the medical community and the public. The present article contains lessons each country can learn from the other, to be adapted in each one's local context: The failure of the Alzira model in Spain warns us of the problems of for-profit HMOs and the Israeli private private/public mix shows the risk of eroding trust in the public system, thus reinforcing market failures and inefficient medical systems.

Ensuring migrants' right to health? Case of undocumented children in Israel.

After 18 years of providing government-subsidised medical insurance for children of undocumented migrants, the Israeli Ministry of Health (MOH) decided in 2018 to abruptly reverse its policy. Many children will have access to medical care only in cases of emergency. The policy change is set to potentially impact several thousands of children currently living or born in Israel. The non-profit, humanitarian sector is already seeing the impact on undocumented migrant children, with dozens of families reaching out to Physicians for Human Rights Israel to seek help accessing care for their children. These policy changes seem to be politically motivated, aiming to exclude undocumented communities from the public healthcare system as part of a general strategy of encouraging them to leave Israel. Such actions are antithetical to public health, human rights and medical ethics considerations. The Israeli Medical Association is beginning to challenge the stance of the MOH. To conform to international guidelines-both legal and medical-government ministries and relevant official bodies must follow the advice of the medical community to ensure respect for the right to health.

Rethinking the private-public mix in health care: analysis of health reforms in Israel during the last three decades.

OBJECTIVES: To analyse the process of health care privatization using the case of Israeli health care reforms during the last three decades. METHODS: We used mixed methods including quantitative analysis of trends in health expenditures in Israel and qualitative critical analysis of documents describing the main health reforms. RESULTS: Israel epitomizes how boundaries between the private and public sector become blurred when health care services are subject to privatization, both of finance and supply. Additionally, the continuous growth of public-private relationships in health care results in systems that lack both equity and efficiency. CONCLUSIONS: More than three decades of experience show that such private-public partnerships increase both inequality and inefficiency. While most discussion surrounding the private-public mix in health care focuses on financing infrastructure, in Israel, the public-private mix has become a central way of financing and delivering services, making its damaging influence more pervasive.

A Republican Egalitarian Approach to Bioethics: The Case of the Unrecognized Bedouin Villages in Israel.

This article argues that current, mainstream, liberal approaches to the right to health and to bioethics are not adequately aware of the structural and political character of health and illness. We propose a radical egalitarian definition of the right to health as the basis for the discussion of a republican egalitarian perspective on bioethics that redefines autonomy and stresses the importance of equality, political participation, and the common good. The violations of the right to health in unrecognized Bedouin villages in Israel are analyzed to exemplify the possibilities opened by the republican egalitarian approach.

Blurring the boundaries between public and private health care services as an alternative explanation for the emergence of black medicine: the Israeli case.

Black medicine represents the most problematic configuration of informal payments for health care. According to the accepted economic explanations, we would not expect to find black medicine in a system with a developed private service. Using Israel as a case study, we suggest an alternative yet a complimentary explanation for the emergence of black medicine in public health care systems - even though citizens do have the formal option to use private channels. We claim that when regulation is weak and political culture is based on 'do it yourself' strategies, which meant to solve immediate problems, blurring the boundaries between public and private health care services may only reduce public trust and in turn, contribute to the emergence of black medicine. We used a combined quantitative and qualitative methodology to support our claim. Statistical analysis of the results suggested that the only variable significantly associated with the use of black medicine was trust in the health care system. The higher the respondents' level of trust in the health care system, the lower the rate of the use of black medicine. Qualitatively, interviewee emphasized the relation between the blurred boundaries between public and private health care and the use of black medicine.

The Israeli Medical Association's discourse on health inequity.

The present paper analyses the emergence and characteristics of Israeli Medical Association (IMA) discourse on health inequality in Israel during the years 1977-2010. The IMA addressed the issue of health inequality at a relatively late stage in time (2000), as compared to other OECD countries such as the UK, and did so in a relatively limited way, focusing primarily on professional or economic interests. The dominant discourses on health inequalities within the IMA are biomedical and behavioral, characterized by a focus on medical and/or cultural and behavioral differences, the predominant use of medical terminology, and an individualistic rather than a structural conceptualization of the social characteristics of health differences. Additionally, IMA discourses emphasize certain aspects of health inequality such as the geographical and material inequities, and in doing so overlook the role played by class, nationality and the unequal structure of citizenship. Paradoxically, by disregarding the latter, the IMA's discourse on health inequality has the potential to reinforce the structural causes of these inequities. Our research is based on a textual critical discourse analysis (CDA) of hundreds of documents from the IMA's scientific medical journal, the IMA's members journal and public IMA documents such as press-releases, Knesset protocols, publications, and public surveys. By providing knowledge on the different ways in which the IMA, a key stakeholder in the health field, de-codifies, understands, explains, and attempts to deal with health inequality, the article illuminates possible implications on health policy and seeks to evaluate the direct interventions carried out by the IMA, or by other actors influenced by it, pertaining to health inequality.

The role of civil society in health care reforms: an arena for hegemonic struggles.

The present paper argues that current mainstream understandings of civil society as ontologically different from the state and essentially positive (either normative or functionally) are problematic in order to understand the development of health care reforms. The paper proposes to ground an explanation of the role of civil society in health care reforms in a Gramscian understanding of civil society as analytically different from the state, and as an arena for hegemonic struggles. The study of health care reform in Israel serves as a case study for this claim.

Immigrating to a universal health care system: utilization of hospital services by immigrants in Israel.

BACKGROUND: During the 1990s, Israel absorbed approximately 1 million immigrants. The entitlement to citizenship and social rights in a country with universal health care coverage makes the Israeli case of special interest concerning immigrants' utilization of health care services. OBJECTIVES: 1. To describe utilization patterns of emergency room and in-hospital services among recent immigrants to Israel. 2. To determine if and when there is convergence of health care utilization patterns on the part of recent immigrants with native-born and long-established immigrants to Israel. METHODS: Data was obtained from Clalit Health Services computerized database and included sociodemographics, date of immigration,presence of chronic disease, emergency room visits, and hospitalization days among all covered residents.Descriptive analysis of the group characteristics, multivariate analyses to determine influential factors, and tests for trend were conducted. RESULTS: Rates of emergency room and hospitalization were lower for immigrants, and remained so even after 10 years. CONCLUSIONS: Economic and cultural factors influence health care utilization among immigrants and may lead to inequity in health care delivery and consequent health outcomes. A better understanding is needed for the differences in health care utilization patterns between immigrants and veteran Israelis.

Medical humanitarianism, human rights and political advocacy: the case of the Israeli Open Clinic.

In the context of neo-liberal retrenchments humanitarian NGOs have become alternative healthcare providers that partially fill the vacuum left by the welfare state's withdrawal from the provision of services to migrants and other marginalized populations. In many cases they thus help to build legitimacy for the state's retreat from social responsibilities. Human rights organizations play an important role in advocating for migrants' rights, but in many cases they represent a legalistic and individualized conceptualization of the right to health that limits their claims for social justice. This paper analyzes the interactions and tensions between the discourses of medical humanitarianism, human rights and political advocacy using the example of an "Open Clinic" run by an Israeli human rights organization as a case-study: In 2007 dramatically increasing patient numbers provoked an intense internal debate concerning the proposal to temporarily close the "Open Clinic" in order to press the government to take action. Based on protocols from internal meetings and parliamentary hearings and in-depth interviews, we have analyzed divergent contextualizations of the Clinic's closure. These reflect conflicting notions regarding the Clinic's variegated spectrum of roles--humanitarian, political, legitimizing, symbolic, empowering and organizational--and underlying conceptualizations of migrants' "deservingness". Our case-study thus helps to illuminate NGOs' role in the realm of migrant healthcare and points out options for a possible fruitful relationship between the divergent paradigms of medical humanitarianism, human rights and political advocacy.