The School Health Services: Between Privatization and Nationalization

The student health service is an organization with a  long history and undeniable importance. Great significance is ascribed to these services among professionals, academics, and the authorities, who recognize that preventive medicine and health promotion among young people produce . The Covid-19 crisis offers an opportunity to shine the spotlight on this important public service, to assess its status in Israel, and to emphasize the necessity of investing and promoting the service.

The school health service is a central and well-established component of Israel’s public health services. The service is provided to all Israeli students from Grades 1 to 9, under the responsibility and financing of the Ministry of Health. The school health service rests on two main supporting pillars: preventive medicine (vaccinations, developmental examinations, and screening tests), and health promotion (counseling and guidance for students, parents, and educational staff; identification of risk behaviors; and participation in school programs to promote health and a healthy lifestyle). Today, however, after years of constant change, the status of the school health service is weakening, and its future is less clear than ever. A new study published by the Taub Center, “The School Health Service in Israel: Between Privatization and Nationalization,” by Baruch Levi, Rami Adut, and Nadav Davidovitch, looks at the current structure of the service and how it has changed over the past three decades. In so doing, the study sheds light on current challenges the service is facing.

The study findings indicate that although the school health service is recognized as an important public service, uncertainty has surrounded it for many years, both in terms of its operating structure and in terms of the degree to which available resources accommodate population growth and the development of the services provided. The school health service is operated under a nationalized model in the Southern District, in the Ashkelon District, and in the Northern District, while in Israel’s other districts and in the large cities (Jerusalem, Tel Aviv, and Haifa) the service is still privatized, despite the agreement signed in 2015 between the Ministry of Finance and the Histadrut (General Federation of Labor) regarding direct employment in the government sector. However, it is not only the lack of a uniform operating structure that is eroding the status of the school health service (both in the districts where it is privatized, and in those where it has been returned to the state), but also a personnel shortage arising both from an insufficient number of positions and from difficulties in filling existing positions.

The school nurse shortage reflects the lamentable state of nursing staff in Israel: the number of nurses relative to the population is among the lowest of all developed nations. OECD data indicate that, in 2020, Israel had 45,400 employed nurses, i.e., just 5 employed nurses per 1,000 people, versus an average of 9.5 employed nurses per 1,000 people in the OECD countries.

The chronic general shortage of nurses is reflected in the number of nurses per student in the school health service, which since 2010 has amounted to one nurse per 5,000 students, compared with one nurse per 1,600 students between 1997 and 2003. It should be noted that the nurse to student ratio started dropping even before privatization of the service was underway, reflecting a major process of decline in Israel’s medical personnel supply. Alongside the drop in the number of employed nurses, the number of students in grades 1 to 9 grew by 400,000 over the past two decades, which, of course, has contributed to the current ratio.

This problem is naturally also related to the shortage of job positions and to the difficulty of filling the existing positions, especially in those districts where the service has been nationalized. In the Southern District, for instance, the number of employed nurses per thousand people is 3.8 – the lowest ratio in Israel. The sparse supply of nurses, and the field’s decline in popularity as a career track in recent years, have together created a vicious cycle of cause and effect: the profession’s unattractiveness is a major factor behind the difficulty in filling positions, while at the same time it is an outcome of the field’s diminished status.

This situation, along with a change of approach on the part of the Ministry of Health as reflected in an emphasis on quantifiable measurements of performance, have marginalized health promotion. Health promotion is regarded as a “softer” component of the service, one focused on counseling, guidance, and prevention. For example, the basket of school health services includes one lesson on health education per year per class, and even with this low level of activity there are gaps between the districts. In the Ashkelon District, the service provides 33.6% of the health education classes that it is supposed to provide, and in the Southern District it provides only 11.4%, compared to a national average of 75.5%. In the Southern District, where figures are especially low, health education coverage appears to be virtually nonexistent in Grades 5 and 6, and the Northern District also shows relatively low levels of activity.

One major finding of the Levi, Adut, and Davidovitch study is that there are multiple views regarding the desired operating model for Israel’s school health service, with proposed models including outsourcing, decentralized service under the responsibility of the local authorities, and nationalized service operated by the state. But the question of which operating structure is the best may remain moot so long as the fundamental problem of insufficient positions and manpower goes unsolved.

The Covid-19 pandemic has placed the necessity of incorporating public health activity into the education system on the public agenda, in terms of vaccinations and health promotion in times of epidemic. The crisis has also highlighted the crucial importance of the school health service. Improving the service, whether under a privatized or a nationalized model, and solving the national structural problem of a severe shortage of nurses, will benefit the entire healthcare system, and Israeli society as a whole.