COVID-19 and beyond: Health minister Horowitz’s top five challenges

Israel’s new health minister is inheriting a sick country that needs a lot of healing, despite the low number of daily COVID-19 cases.

MK Nitzan Horowitz (Meretz) will be sworn in as health minister if the government passes a confidence vote in the Knesset on Sunday. He is not a medical professional, but he has spent the last two decades engaged in social justice efforts, from fighting for foreign workers to serving as a board member of the Association for Civil Rights in Israel.

Horowitz is inheriting a ministry that suffered through a nearly year-and-a-half battle against a global pandemic that was intensely politicized by Prime Minister Benjamin Netanyahu.

He is also taking over against the backdrop of a number of fraud schemes that center around his ministry.

Last week it was reported that two top advisers of former health minister MK Ya’acov Litzman are being probed for conspiring to influence government policy in health sector issues such as food in exchange for bribes. 

Litzman is also under investigation himself for two offenses during his tenure: one that involved his meeting with Jerusalem’s district psychiatrist to pressure him into issuing a false assessment for accused sex offender Malka Leifer and the other for trying to influence inspectors to reopen a restaurant that failed a health inspection.

Horowitz’s job will be to maintain the low number of daily COVID cases while moving beyond the pandemic to other issues plaguing Israel’s healthcare system, and to gain back the trust of the Israeli public in the system.

“The things that he will need to deal with will require out-of-the-box thinking and major reforms,” Prof. Dan Ben-David, president and founder of the Shoresh Institution for Socioeconomic Research, told The Jerusalem Post. “I hope that he has the requisite sense of humility required to know that he should surround himself with some of the top people in the field.”

These should be the next health minister's top five priorities:

Mental illness – mainly but not only depression – is among the fastest growing health challenges for the State of Israel.

A recent survey published by Tel Aviv University researchers found that the level of personal resilience experienced by Israelis hit a two-year low during the recent Gaza escalation.

The researchers measured resilience on a scale of one (lowest) to five (strongest). In 2018, Israelis’ level of resilience was 4.68. At the height of the pandemic in October 2020, it fell to 4.28. In January 2021, during the third wave, it dropped to 3.48. And during the recent Gaza operation it plummeted to 2.47.

The data is “very concerning” and even “dangerous,” the study’s lead researcher Dr. Bruria Adini told the Post.

Israel still lacks services for and understanding of mental health issues, said Prof. Hagai Levine, former chairman of the Association of Public Health Physicians.

“We treated the COVID-19 pandemic well with the vaccines, but now we have some seriously traumatized people,” Levine told the Post.

He said there has been an increase in people coming to their family physicians for other causes that are rooted in stress and depression.

"There is a connection between mental and physical health,” he said. 

Coalition agreements have indicated that the new government plans to add psychological services for the public – an important first step if it is implemented.

At the same time, the government should specifically focus on the mental health needs of healthcare workers after coronavirus, the Meron tragedy and the latest war – all of which struck within less than two years.  

“Healthcare workers need to be mentally well to care for the population,” Levine said.

While Israel was among the first countries to come out of the coronavirus crisis, vaccinating close to 5.5 million Israelis and thereby opening up its economy, health experts understand that the pandemic is not over yet.

With hundreds of thousands of new daily coronavirus cases worldwide, Israel is still vulnerable to vaccine-resistant COVID variants that could enter the country through Ben-Gurion Airport.

In general, the Health Ministry has maintained a tight and effective closure on the border since the third wave. Any unvaccinated Israelis or Israelis returning from countries with high infection must quarantine on arrival for a minimum of 10 days. And all passengers are required to take a PCR-grade coronavirus test before boarding and upon arrival.

Minimal group of vaccinated tourists have been entering Israel since last month. An announcement by the Tourism and Interior ministries last week indicated that individual vaccinated tourists will be able to enter beginning as early as July 1. It will be the new health minister’s job to test and confirm that these travelers are COVID-free during their time in Israel. 

Earlier this month, a group of 16 olim (new immigrants) from India who maintained they tested negative for COVID in their hometown were found to have had the virus on arrival. Surveillance caught the infected immigrants and they were put into state-run COVID hotels until they recovered. Strict screening protocols must be maintained.

At the same time, health officials must keep tabs on what is happening inside the country. Israel must find a way to maintain a minimum number of daily tests to catch outbreaks before they start.

Ben-David suggested that serological testing could be offered to patients undergoing routine bloodwork, for example. Or PCR testing could become part of one’s annual checkup.

The Israeli healthcare system entered the COVID-19 crisis in a starved condition, forcing Israel to enter three lockdowns for fear that the hospitals would collapse under the strain of so many seriously sick individuals.

That is because the country does not have enough doctors, nurses, technicians or even aides.

Israel has one of the worst nurse-to-population ratios, with five nurses per 1,000 people – a figure that is significantly lower than the Organization for Economic Cooperation and Development (OECD) average of 8.8 - and the number of nursing school graduates is also low, meaning there is little expectation for growth.

When it comes to physicians, Israel has only slightly less doctors per capita than the average OECD country. However, that is primarily because of the huge influx of new MDs in the 1990s from the former Soviet Union - and these doctors are aging.

While doctors over the age of 75 make up only 1% of the entire workforce in OECD countries, in Israel they make up more than 10%, Ben-David explained. And, like nursing students, Israel is at the bottom of the OECD in terms of the number of new medical school graduates.

During the coronavirus crisis, Health Minister Yuli Edelstein added around 2,000 new positions, but the financing was done via extra-budgetary payments earmarked for the virus and the positions were meant to expire on June 30.

A decision was made to extend the positions until a new government was formed and the next budget was prepared, making it the responsibility of the new health minister to fight for those roles.

Furthermore, Israel’s hospital residents work untenable 26-hour shifts - a situation that hospital heads say has to change.

The issue of infrastructure is vital, as the number of hospital beds per capita has been plummeting for decades, leaving Israel with the highest hospital congestion rate in the developing world. This leads to a deficient level of care, despite the high professionalism of the staff.  

“We have this dichotomy: Very good physicians and nursing staff that qualitatively speaking are the best in the world, working in a system that in some cases is not part of the developed world,” Ben-David said.

And people being treated in hospital corridors leads to unnecessary infections.

Israel went into this pandemic with the highest number by far of people dying from infectious disease per capita in the developed world – 73% more than No. 2, Greece.

A March 2020 state comptroller report highlighted Israel’s lack of a detailed program to close identified gaps in the healthcare system – including intensive care beds and equipment.

As a new state budget is set to be approved for the first time since March 2018, it is essential that the health minister works closely with the finance minister to obtain the needed money.

At the same time, Horowitz should strive to run his ministry more efficiently by providing hospitals and health funds with a greater sense of control and accountability, implementing new modes of measurement and evaluations for success.  

“The health system often takes a Band-Aid approach or is extinguishing fires all the time,” Levine said. “The system needs more long-term planning and execution.”

While Israel is young compared to OECD countries, its people are rapidly aging - and the Health Ministry has not prepared for this new reality.

The number of elderly in Israel is expected to reach 1.66 million by 2035, according to projections by the Central Bureau of Statistics - an increase of 77% between 2015 and 2035, which is “going to be a huge drain on the health system,” Ben-David said.

Health officials need to shift their focus to finding better solutions for elder care, both in nursing homes and through in-home care. This could include telemedicine and digital monitoring programs that could save money and keep the elderly safe.

“Health is one of the most important aspects that determines quality of life,” Ben-David said. “The COVID-19 pandemic showed the deficiencies of our country’s health system. No one can claim it isn’t broken - it is.”

The question now is whether Horowitz will take the steps needed to fix it.