|Implemented in this survey?|
The Israeli health care system invests substantial efforts in preparing for major public health emergencies. These preparations were put to a major test during the 2006 Hezbollah missile attacks that affected one-third of Israel's population. That test validated many of Israel's health emergency preparedness principles and activities, while also highlighting numerous areas in need of improvement. Innovative responses to new challenges were developed both during and after the war.
This report focuses on how the Israeli health system responded to new public health challenges posed by the Second Lebanon War (2006). During that month-long war, Hezbollah fired approximately 4,000 missiles on the northern part of Israel, creating a major health threat to over two million civilians and drastically limiting their ability to travel safely to health care facilities. This report identifies various elements of pre-existing emergency preparedness policies that were validated during the war, as well as areas in which new policies had to be developed. It considers both those new policies that were implemented in real-time during the war and those which have been adopted after the war as a result of post-emergency reviews.
The objectives of these new policies were:
Characteristics of this policy:
Incentives for ongoing and post hoc improvement efforts include:
Responding to major public health emergencies in an effective and coordinated fashion; developing innovative responses to new challenges both during and after the emergency.
Humanitarian concerns: All health system actors have an intrinsic motivation to improve health and this may also be enhanced with regard to persons injured in hostile attacks.
Patriotic concerns: A resilient home front was recognized as critical to the State of Israel's ability to improve the security situation along its northern border with Lebanon.
Legal requirements: All health system actors must comply with certain stipulations of the Division of Emergency and Disaster Management (DEDM) in the MOH and the Home Front Command.
Prestige: Major medical centers derive prestige from playing an important role in responding to public health emergencies; this can be important for future fund-raising efforts.
1) Hospitals are reticent to reduce routine activity during emergencies due to concerns about lost revenue;
2) The government compensates health providers for certain categories of special expenses incurred in responding to public health emergencies.
Ministry of Heatlh - the command and control methodology adopted during the missile attacks will serve as the basis for operating the health system in future emergencies; it will also operate community-based centers for treating stress victims., Health plans- will expand their capacity to operate unified clinics to supply medical care in bomb-proof facilities., Hospitals - will enhance their structural protection and enhance their preparedness to protect patients and staff throughout their facilities.
|Medienpräsenz||sehr gering||sehr hoch|
Degree of innovation: This was the first time Israel faced a month-long health threat to a large portion of the civilian population. Many of the innovations, such as the extensive use of electronic health records to ensure continuity of care for displaced populations, had no precedent in Israel or elsewhere.
Degree of Controversy: As noted above, there was little or no controversy during the war about the general strategy of ensuring a coordinated response or about the specific responses implemented, including both the established and innovative responses. After the war, several specific areas of disagreement have surfaced, but even they are relatively limited in scope.
Structural or Systemic Impact: The innovations adopted during the war improved an emergency response that affected almost one-third of the Israeli population. The increased involvement of the health plans in the response efforts also constitutes a significant system change.
Public visibility: Due to the large number of people affected, and heightened public awareness during the war, the emergency response had high public visibility.
Transferability: The extent to which a health system can respond to emergencies in a coordinated fashion depends a great deal on the extent of health system coordination that exists in routine times, and on the overall extent of social solidarity.
Israel's Second Lebanon War broke out on July 12, 2006 when an Israel Defense Forces patrol operating along its northern border was attacked by Hezbollah and two of its soldiers were abducted. In response, Israel opened artillery fire on Hezbollah outposts and later began to send infantry and armored units into Lebanon. Hezbollah began a massive and continued rocket attack on the entire northern part of the country (approximately 5,000 square kilometers). Overall, 3,970 rockets landed in Israel and halted the normal course of life for the over two million people living in the impacted areas. Workplaces shifted to more limited emergency operations and the operation of the social service system was greatly impaired. Israel's Home Front Command ordered the residents of the North to remain in or near underground shelters or other specially protected indoor spaces. Approximately 300,000 residents of the North chose to evacuate the area and stayed with family or friends in other parts of the country. This situation lasted until the ceasefire went into affect on August 14, 2006 - a period of 33 days. As a result of the missile attacks, 42 civilians were killed, 1,489 were injured physically and 2,773 were identified as victims of stress.
In the course of the war, the health system had to operate emergency response models to meet the needs of three key groups of patients: soldiers injured in the fighting in Lebanon, civilians injured (physically or emotionally) by the missile attacks, and civilians in need of routine medical services unrelated to the war. Thus, the war placed major demands not only on the hospitals (who take the lead in treating casualties injured in war or terror attacks) but also on the health plans (who play a major role in routine care and in trauma-related mental health care). All this under conditions where it was dangerous for health care professionals and patients to travel to health care facilities, and where the health care facilities themselves were open to attack.
Prior to the Second Lebanon War, the Israeli health system had already acquired substantial experience in addressing the needs of both injured soldiers and civilians injured in terror attacks. One of the unprecedented features of the Second Lebabon War was the need to provide routine care to a large population over an extended period of time under unsafe conditions. To some extent, there were precursors during the 1993 and 1996 missile attacks on Israel's most Northern cities and towns, but these were limited in duration and geographic scope.
|Implemented in this survey?|
Overall, the innovations in emergency response that were implemented during the missile attacks had two key sources: Israel's extensive prior experience in responding to major security-related public health emergencies and the specific new challenges posed by the missile attacks.
All health systems need to prepare themselves for a wide range of public health emergencies. In peacetime, these include natural disasters, large-scale accidents and terrorist attacks; in wartime, there is a need to respond to both conventional and non-conventional attacks. Israel, because of its unique geo-political situation, must invest substantial efforts and resources in preparing its health system for terrorist attacks and wars. These efforts include comprehensive contingency planning, development of national doctrines and protocols, the development of a wide variety of coordination, control and command mechanisms, and extensive training at the individual, organizational, and national levels, construction of vital infrastructure and equipment.
A key feature of Israel's approach to emergency preparedness is national (governmental) control of preparedness for all mass casualty events and national coordination of the real-time response. This is a non-trivial challenge in a health system which, while largely publicly financed, relies primarily on non-governmental hospitals and health plans (HMOs) for the provision of services. Under normal conditions, there is significant competition among health plans and among hospitals in an environment of regulated competition. During public health emergencies, all of the key providers are highly motivated by patriotic and humanitarian reasons to respond to national health emergencies, but are also interested in protecting institutional interests (including considerations of prestige and financing) while doing so. Cooperation is promoted via a mixture of legal stipulations, financial payments and guarantees, and ongoing consultative processes. Thus, in public health emergencies the system is transformed from managed competition to managed cooperation.
The health system's emergency ongoing preparedness efforts and its real-time response to major emergencies are coordinated by the Ministry of Health's Division for Emergency and Disaster Management (DEDM). Policy is set by the Supreme Health Authority, which includes senior representatives of government, hospitals, health plans, MDA and other key players. The driving force behind this setup is to combine government leadership with input from all the care providers to develop effective and coordinated responses.
Since even before its founding in 1948, Israel has had to face a series of wars and waves of terror attacks. This led to substantial investment in preparedness of "the Home Front" in general, and within the health system in particular. Until the first Intifada (1987-1991), the focus was on treating injured soldiers. In contrast, the terrorist attacks associated with the Intifadas, and the missile attacks during the first Gulf War, focused attention on the need to respond to mass civilian casualties. Public health preparedness doctrines, training and exercises have expanded accordingly.
As noted in section "Political and economic background", the Lebanon War brought its own unique challenges, including the need to provide routine care to a large population over an extended period of time under unsafe conditions. The new policies adopted to address these new challenges are discussed in section "Adoption and implementation", which also discusses who generated these ideas and the driving forces behind them.
The approach of the idea is described as:
amended: This is an evolving policy, as was intended by those who first developed Israel's emergency response system.
During the war, particularistic interests were largely (though not completely) put aside. Those differences of opinion that were expressed, were mediated by the Supreme Health Authority. It is
also worth noting that in deliberations of the Supreme Health Authority held in routine times (such as those prior to the war) on preparedness for future emergencies, there are few if any serious
systematic differences in approach and priorities between the hospitals, health plans and the Ministry of Health.
After the war, differences of opinion have been expressed through a mix of complaints about how the emergency response was managed, demands for compensation for special efforts during the war, and demands for changes the regulations and understandings that will guide the response to future public health emergencies. For example:
|Ministry of Health||sehr unterstützend||stark dagegen|
|Hospitals||sehr unterstützend||stark dagegen|
|Health Plans||sehr unterstützend||stark dagegen|
|Israel Defence Force||sehr unterstützend||stark dagegen|
The Supreme Health Authority is one of the authorities operated under the jurisdiction of the National Emergency Council of the Ministry of Defense. The Council operates under a governmental decision from 1986, which authorized the control of the effective functioning of the civilian economy. According to this decision, each governmental ministry is authorized to operate the crucial organizations in order to ensure supply of services during emergencies. In some cases, there is a conflict of interest between the authority of the MOH over the EMS and health plans to the authority of the Home Front Command, which is authorized by law to operate organizations which are declared as Assistance Organizations (such as the EMS and the health plans), in all areas of Civil Defense.
No new laws related to emergency preparedness or response were put into place during the war.
|Ministry of Health||sehr groß||kein|
|Health Plans||sehr groß||kein|
|Israel Defence Force||sehr groß||kein|
An important feature of public health emergency preparedness is the need to respond flexibly and creatively when emergencies arise. This is because major public health emergencies are often qualitatively different from those that had occurred in the past, and sometimes the unique challenges posed by the latest emergency were unforeseen. Systems for responding to emergencies must build in the capacity to respond in unforeseen ways, and still preserve coordination among a range of actors within, and outside, the health system. In Israel, this is achieved through simulation exercises involving scenarios not previously encountered and ongoing consultations during real public health emergencies.
The health system's emergency response effort was coordinated by the Supreme Health Authority. One of its main coordination mechanisms was telephone conference calls involving over 20 participants, which were held several times each day during the war. One of its great achievements was virtually complete adoption of its decisions and guidance by all the governmental and non-governmental actors involved, despite the fact that in many cases they were not legally binding. Thus, with the onset of the war, the health system shifted from managed competition to managed cooperation. This was made possible largely by the investment in the development of coordination mechanisms prior to the onset of the emergency.
Other pre-existing policies validated during the war included:
During the war, the system also introduced numerous unplanned responses and policies that involved innovations or significant expansions of pre-existing plans. Key examples include the following:
This list is consistent with Israel's self-perception as a society which is adept at improvising effectively in the face of new challenges. All of the items listed above were implemented successfully.
Some of these innovations were led by hospitals, others by health plans, and still others by government. All were done in coordination with the other parties involved via the Supreme Health Authority, under the leadership provided by the Ministry of Health. It was the existence of this coordinating mechanism that made it possible for the health system to quickly develop and implement many of these innovations.
As discussed in section "Main objectives and incentives" above, a number of motivating factors were at work, with the predominant ones apparently being humanistic/medical concerns and patriotic concerns. Legal requirements, economic considerations and considerations of prestige also played a role.
It is also important to note that almost all the physicians, nurses and other health care professionals, who usually work in hospitals and clinics in the North, remained in the impacted area and continued to work there despite the serious risks posed by the missile attacks. This is in contrast to the large portion of professionals and managers among the population of the North as a whole who fled to other parts of the country. And this, despite the fact that most employers had not made use of the Requirement to Work orders authorized by the government. This reflects the high degree of commitment of Israeli health care professionals, particularly in times of national emergency.
Emergency preparedness systems need a capacity to learn from past successes and failures, and it is best if that learning occurs quickly, as similar emergencies can recur.
In the wake of the war, an intensive and multi-pronged effort has been launched to review the health system's response and to learn the appropriate lessons for the future. Some of these review efforts are taking place within the health system, with each hospital and health plan launching its own internal review effort and the Ministry of Health reviewing the system response. In addition, as part of broader reviews of the operation of the Home Front during the war, the health system's response is being reviewed by the parliament's foreign and defense affairs committee, the Comptroller-General, and a governmental commission of inquiry. Aside from these official review efforts, voluntary organizations (such as the Israel Medical Association), the press, and various academics have also put critiques forward.
Some of these suggestions are being given serious consideration, others less so. Some key actors have argued that independent physicians should not receive special compensation from government as the government did not issue them orders to desist from providing services.
The widespread involvement of actors outside the health system in the review process contrasts with the review of responses to smaller scale emergencies (such as the response to localized terror attacks), which tend to be handled by the health system alone.
Another important mechanism for improving emergency preparedness is learning from other countries. Because of the needs imposed by its geo-political situation, Israel has become a world leader in emergency preparedness and receives many delegations from other countries seeking to learn from its experience and strategies. At the same time, Israel is also constantly learning about, and from, parallel developments in other countries and from comments and questions by experts in other countries on how Israel has dealt with emergencies. To facilitate such input, a number of scientific publications about the health system response to the Lebanon War are in process and opportunities for bi-national and international symposia on this topic are being explored.
Abschlussevaluation (intern), Abschlussevaluation (extern)
Struktur, Prozess, Ergebnis
Not all of these bodies mentioned above have published their conclusions to date. At this stage, the general consensus seems to be that, overall, the health system performed reasonably well (some would say "quite well") during the war, particularly in comparison with other systems of municipal and social services. The successes were in part due to pre-planning for various exigencies that were foreseen, flexible response to others that were not foreseen, frameworks for cooperation and communication that had been developed over the years, and the motivation and commitment of the professionals and organizations involved.
At the same time, there is agreement that there were various problems and mistakes and that there are many areas for improvement. These include:
A fuller list of both achievements and problems can be found in Ecker et al (forthcoming).
The DEDM has a well-developed process for reviewing health system performance in recent emergencies and for adapting its policies in accordance with the findings of those reviews. Immediately after the war it created 17 working groups to examine various aspects of system performance. Their reports have been reviewed by the DEDM and the Supreme Health Authority, and this has led to a set of new policies including:
This list of new policies reflects those elements of the most recent public health emergency (the missile attacks) which were relatively new: its extended duration, its major impact on community-based services, and its pervasive impact on population mental health.
Prior to the missile attacks, it was expected that, overall, the health care system would be able to provide an adequate response to attacks of this nature, but that the response would not be perfect, in part because there are always unforeseen and unforeseeable elements in major public health emergencies.
As a result of the lessons learned during after the missile attacks, the Israeli health system should be in a better position to respond to any future missile attacks or other health threats to large population groups (due to the security situation, natural disasters, or large-scale accidents), including those lasting weeks or months. At the same time, it is recognized that responses to future emergencies will also be imperfect, as each emergency involves new elements and unforeseen challenges.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
The health system's response to the missile attacks validated many of Israel's emergency preparedness principles and activities, while also highlighting numerous areas in need of improvement.
Investment in preparedness for major public health emergencies and real time coordination during emergencies can save many lives. It can be particularly important for a country's most vulnerable populations and, if done well, can also contribute greatly to efficient resource use.
Rosen, Bruce, Bruria Adini, Boaz Lev, Noa Ecker and Daniel Laor
Bruce Rosen , Director, Smokler Center for Health Policy Research, Myers-JDC-Brookdale
Bruria Adini , Senior Consultant, Division of Emergency and Disaster Management, Ministry of Health
Boaz Lev , Associate Director-General, Ministry of Health
Noa Ecker, Research Assistant, Smokler Center for Health Policy Research, Myers-JDC-Brookdale
Daniel Laor, Director, Division of Emergency and Disaster Management, Ministry of Health