Is There a Doctor (or Nurse) in the House?

Some actions have been taken in recent years to reverse these trends and it remains to be seen if these will be sufficient. Even the great advancements in technology have not changed one fundamental fact about healthcare – providing medical services requires significant manpower.  The field is composed of a broad workforce spanning nurses, specialists, medical technicians, pharmacists, and much more. The effectiveness of a healthcare system depends greatly on having a sufficient and available workforce to meet demand where and when it occurs.  Shortages can cause significant pain for patients and inefficiency in operations.  However, upgrading the supply of healthcare professionals, particularly physicians, requires years of foresight and planning due to long length of training.

Prof. Dov Chernichovsky, Chair of the Taub Center’s Health Policy Program and an economist at Ben-Gurion University, and Taub Center researcher Eitan Regev published a new paper in the Center’s State of the Nation Report 2013 discussing trends with regards to the supply of physicians and nurses in Israel as well as the investment being made today to educate professionals who will work in these fields in the future.

Over the last couple of decades, Israel has benefitted from a high physician-to-population ratio in comparison to other developed countries, namely due to the great immigration wave of doctors from the former Soviet Union.  Starting in the late 1990s, the share of physicians relative to the population began dropping in Israel, while the share in the OECD has been rising.  Despite the decline, Israel still remains slightly ahead of the OECD with 3.0 physicians per 1,000 standardized persons (i.e., after adjusting for the size of different population age groups) compared to 2.8 in the OECD.

These figures, however, do not provide insight into the distribution of physicians among specialties or across the public and private healthcare systems.  As discussed in the Taub Center’s recent policy brief “Hot Issues in Israel’s Healthcare System,” by Liora Bowers, the Israeli Medical Association has identified anesthesiology and geriatrics as having current shortages, and has warned of potential future shortages in general surgery, internal medicine and pediatrics, among others.  Similarly, the State Comptroller’s 2009 report indicated that Israel had 30 percent fewer anesthesiologists than the recommended standard, which it cited as partly responsible for long waiting times on elective surgeries.  Furthermore, there is concern that physician specialists are increasingly drawn towards work in the private, rather than public, healthcare system.

Chernichovsky and Regev examined the causes for the declining share of physicians in Israel.  As shown in the first figure, Israel is educating far fewer physicians than other developed countries.  OECD countries produced 11 medical school graduates per 100,000 people in 2010, compared to only 4 in Israel.

While these figures may be worrisome, there are some other relevant factors to consider.  First, Israel currently has significantly more students starting medical school today than it has had in previous years.  Part of this increase comes from the opening of Israel’s fifth medical school in 2011, which welcomed 125 students (students holding bachelor’s degrees or those who completed three years of study at European medical schools) via two shortened tracks of study.  There are also other initiatives underway to increase the number of students and streamline the medical education process.  These include the initiation in recent years of several four-year medical school programs targeted at students already holding an undergraduate degree and relevant biology coursework, as well as a reduction by six months in the length of medical school education.

Because entry to medical school in Israel is extremely competitive and capacity is limited, hundreds of Israelis graduate from medical schools abroad, in places such as Hungary, Romania and Italy, many of whom return to Israel after completing their studies.  Israelis studying abroad are subject to a different licensing exam to practice medicine in Israel than their counterparts who studied locally.  Graduates of medical schools in the U.S., Canada and the U.K. are exempt from this exam, and there has been some discussion on broadening the list of countries whose graduates are exempt.  In early 2013, the Knesset voted to exempt Israeli graduates of foreign medical schools from the Israeli licensing exam, if they have passed the equivalent United States licensing exams.  The various initiatives described above are expected to have a noticeably positive impact on physician supply in the coming 6-8 years.

Chernichovsky and Regev highlight that Israel’s healthcare workforce challenges are even greater in nursing than they are for physicians.  As indicated in the second figure, while the U.S. and other developed countries have seen an increase in their nurse-to-population ratio over the last decade, Israel’s numbers have slightly declined over this period.  At 4.9 nurses per 1,000 people, Israel had less than half of the supply of nurses than the OECD in 2011, which stood at 10.3.

The third figure shows that the low supply is exacerbated by an extremely low – and declining – number of nursing graduates in the country.  Israel produced only 11.2 nursing graduates per 100,000 people in 2011, compared with 42.8 in the OECD. Over the past decade, Israel has seen a 43 percent reduction in the rate of nursing graduates.  As a result, the average age of the nursing workforce has risen, with half of Israeli nurses now over the age of 45.  The two primary factors underlying the declining rates of new graduates are relatively low wages that do not provide sufficient incentive for entering the field, and a heavy workload due to the nursing shortages.  The issues of high work load and low number of graduates are mutually reinforcing and have led to a deteriorating situation in recent years.  A nurses strike in 2012 led to a new agreement resulting in significant wage increases.  The coming years will reveal if the compensation increase was sufficient to spur a renewed interest and higher enrollment in nursing studies.

Overall, the findings presented in the Taub Center study paint a mixed picture of the situation of the healthcare workforce in Israel.  On the one hand, Israel has experienced a declining supply of physicians and nurses in recent years, while other developed countries have seen a growth in supply.  Furthermore, the number of medical school and nursing graduates in Israel is one-half and one-quarter that of other OECD countries, respectively.  The fact that Israel’s population is relatively young, and therefore requires fewer health services, mitigates some of the impact of the low supply of healthcare professionals.  In addition, there have been concrete steps taken to alleviate the physician shortages, ranging from increased medical school capacity to the relaxation of licensing regulations for medical students learning abroad.  The situation in nursing is worse and it remains to be seen whether the new wage agreement signed in 2012 will incentivize entry into the field and help reverse the particularly concerning decline in nursing graduates.  Continuing to address these workforce challenges is crucial to ensuring that the Israeli healthcare system can provide high quality, effective and accessible care to its citizens.