What does it mean to actually have good health? A recent study by Prof. Dov Chernichovsky, Taub Center Health Policy Program Chair, and myself released in the annual Taub Center “State of the Nation Report, 2014” brings a new perspective to the discussion of health and healthcare in Israel.
A common measure of a population’s health is its life expectancy, and at 82 years, Israel is among the top performers in the OECD in this regard.
However, “good health” is a much more holistic concept than the simple notion of life or death. A father may contemplate whether his knees can support a game of basketball with his daughter. An elderly person may worry about her ability to bathe herself or remember to turn off the stove. A mother may be concerned about the constant look of sadness in her teenage son’s eyes, or her painful headaches. While musculoskeletal pain, mild dementia, depression or migraines may not directly cause death, such conditions have a significant impact on the health and well-being of individuals.
For much of the history of healthcare policymaking and modern medicine, however, the emphasis has been on addressing causes of death. Beginning in the 1990s, however, significant efforts have been devoted to re-conceptualizing health – measuring not just the number of years lived, but the years lived in good health, broadly defined. Such a perspective gives value to everyday functioning and well-being, and expands the scope of the healthcare system to address disease burden more holistically. An accepted metric for capturing the concept of disease burden is the Disability-Adjusted Life Years (DALYs) measure, which accounts for both death and disability/poor health.
The Taub Center study is the first to discuss the DALYs measure of disease burden in Israel (as calculated in a comprehensive global effort by the Institute for Health Metrics and Evaluation at the University of Washington), and put the findings in context of their policy implications. Indeed, the study highlights the important role that conditions that do not cause death nonetheless play in the health of Israelis. While heart disease, stroke and cancers together cause 42% of deaths in the country, these conditions are responsible for only 18% of the disease burden in Israel. In comparison, while orthopedic problems and depression are not responsible for virtually any deaths in Israel, they together account for a whopping 19% of the poor health in the country.
The hypothesis prior to undertaking our research was that Israel’s healthcare system would prioritize treating conditions that may lead to death over those that may contribute substantially to DALYs. Nonetheless, the study revealed that Israel’s healthcare system – in terms of funding – is actually more aligned with addressing disease burden in the broad sense (both death and disability/poor health combined) than just death alone. This distinction is quite pronounced among the older age groups, which account for a large share of deaths in the country but a much more nominal share of overall disease burden. For example, 34% of deaths – but only 7% of disease burden – occurred among Israelis over 85 years of age in 2010. In parallel, 5% of healthcare funds were allocated to this age group. In other words, the Israeli healthcare system actually does a relatively good job of allocating funding across age groups in alignment with the burden of disease found among the age groups.
However, examining the allocations of the Health Basket Committee – which distributes about NIS 300 million annually towards new treatments for inclusion in the health basket – reveals different priorities. The Committee allocates over half the funding to new treatments for cancer, heart disease and stroke, which as noted above, are responsible for less than a fifth of the disease burden in Israel. In contrast, the Committee dedicates only 1% of new funding to treatments for orthopedic disorders, which contribute to 14% of overall poor health in Israel. The problem is that the Committee’s mandate is restricted to the funding of new technologies and medicines. The Committee is thus limited in its ability to allocate funding towards existing treatment methods (such as expanding access to physical and psychological therapy or innovative prevention programs) or to expand eligibility to new populations (such as subsidized dental care for those over 11 years old).
Re-conceptualizing health by considering overall disease burden – rather than only mortality – helps shed light on many conditions that hurt the daily well-being of Israelis. Such a perspective also highlights the importance of elements outside of the traditional medical system with regards to physical and mental health; factors such as the surrounding environment, community and social services, and exercise and diet. Israeli healthcare system policymakers and administrators should adopt a disease burden mindset to help truly promote “la’briut” among the population.
Published as an op-ed in the Jerusalem Post here