School health services are a long-standing and central component of the public health service in Israel, although over the past thirty years it has withstood many upheavals. Today, after years of endless changes with service in some locations nationalized (that is, in some districts the service is operated directly by the government), and in other locations, privatized, the service is unstable and its future is as unclear as ever.
The current lack of clarity calls for professional and public discussion regarding the optimal framework for operating the school health service. This study and the paper that ensued examine how the relevant stake holders in the field view the current status of school health services from the perspective of manpower, the role of the school nurse, as well as measurement methods of effectiveness, and to clarify which models of service they see as optimal going forward.
The analysis of the situation in the field and the alternate policies presented at the end of the research are based on written sources and a series of in-depth, partially structured interviews conducted with 13 decision makers and service providers in the field. Among them were central decision makers from relevant government ministries and professionals from a variety of fields: nurses, past and present inspectors, and doctors. The interviews focused, among other things, on the following questions: What is the opinion of the interviewee regarding the privatization of the school health services and what should be the future of the service? Should the school health services be nationalized and operated directly by the Ministry of Health or privatized and operated by a contractor? Is the decentralized model a good one, as in the current situation in which some of the districts are nationalized and others privatized?
Three factors stand out as central for the discussion of school health services in general and for the role of the school nurse in particular: manpower challenges in school health services, the integration of the school health service within the overall public health service, and the methods for measuring the effectiveness of the service. The findings are worrisome regarding the current situation of the school health service in Israel as well as for its future and it is portrayed as characterized by a chronic shortage of manpower, difficulties in filling positions in the school service, and neglect of the “soft” aspects of the service which are not easily quantified and measured, like health education. All of these are tightly connected to the severing of professional ties between school nurses and the Tipat Halav public health service in the majority of health districts and the loss of status and attractiveness that the profession of school nurse has experienced. These factors produce a vicious cycle: the lack of professional attractiveness is a central reason for difficulties in filling positions as well as a result of the severing of professional ties and loss of status of the role. All of these are connected to basic underlying problems in the national health system, which throws a dark shadow over the school health service as well – the chronic and severe shortage of nurses. The number of nurses in Israel relative to the size of the population is among the lowest in the developed countries. According to OECD data, in 2020, Israel had 45,400 active nurses, that is, about 5 nurses for every 1,000 population, versus an OECD average of 9.5 (OECD, 2021).
According to those interviewed, five possible models are presented for operating the service: a model that rests on outsourcing the entire service; a decentralized model (outsourcing or government operation); Schools Promoting Health; a nationalized and uniform national service; school health services run by the local authority. Each model has its own service provision method and definition of the role of the school nurse as well as integration within the Tipat Halav service. There is no reason not to discuss interim possibilities as well that might combine components from several models.
The multiplicity of opinions regarding the most desirable model for school health services is one of the most outstanding findings of this research. The lack of agreement mainly reflects how each stake holder sees the desirable framework for service operation – beginning with outsourcing, through a decentralized service and the handing over of responsibilities to the local authorities, or the complete nationalization of the service and its operation by the government. Discussion of the school health services gained particular importance during the Covid-19 epidemic as the importance of the integration of public health services into the education system became clear in dealing with the epidemic beginning with vaccinations through to promoting health. Nonetheless, the basic problems of the school health services in Israel are tied to a great extent to structural issues in the public health service, including the serious shortage of nurses. Improving school health services, whether privatized or nationalized, is largely dependent on finding solutions to these problems.
Finally, the school health service can serve as a test case of the larger question – the future of the welfare state and the rise of the market ideology. Against the ideology that promotes market values stands the concept of the continuing operation by the government of long-standing social services like school health services and public health services as an expression of the social nature of state. As in other policy areas, it seems that the struggle taking place in Israel between these two world views is far from over.