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Home , Arabs, Jerusalem, Jerusalem District

INEQUITIES IM HEALTH

Inequality in medical care in and in the district of the General Sick Fund

AMIR SHMUELI •

Background: Differences in health and health services use among different ethnic groups within populations have been always a major concern in democratic societies. Past research has documented the gaps both In health and in Downloaded from https://academic.oup.com/eurpub/article/10/1/18/490752 by guest on 27 September 2021 services utilization between the Israeli Arab and Jewish populations. Methods: This studies the 1993 utilization of health services by a sample of 70,000 Arabs and Jews insured by the General Sick Fund (Clalit), the biggest sick fund in Israel, in the . The Arab population consists of Palestinian residents of greater and Israeli Arabs, offering a unique opportunity to study the use of the three population groups. Results: The results show that, while the mean annual cost of care per user is the same for Jews and Arabs, Arabs Insurees are dramatically less likely to use medical services, controlling for age, gender, income, chronic conditions and settlement size. This was found true for both ambulatory and in-patient care and, in particular, for elderly persons. The Israeli Arabs are the most intensive users of care compared to the Jews and the . Conclusion: The gaps in utilization can be attributed to differences in accessibility, traditionalism and sodal and cultural assets. Early findings following the implementation of the National Health Insurance Law in 1995 indicate that some differences in accessibility to and use of medical services between Arabs and Jews have been reduced. The founding of the Palestinian Authority Council will hopefully further enhance the use of medical care and the health state of the Palestinian population.

Keywords: ethnicity, inequality, medical care

Differences in health and health services use among Israeli Arabs WGL (18% of the Israeli population in different ethnic groups within populations have been 1993) has increased steadily, the Palestinian population always a major concern in democratic societies. While OGL has experienced conditions similar to those found both the Israeli Jewish and Arab populations have been in developing countries. experiencing major development and modernization pro- Several recent studies have documented health and cesses over the last 50 years, on the whole the Arab health services use among the Arabs in Israel.3"9 All of population is characterized by lower levels of education them refer to the WGL Israeli Arab population. The and urbanization and by a higher level of traditionalism conclusions are quite uniform in stating that the Arab in both family and community structures than the Jewish population is underprivileged compared to the Jewish population. Arab communities are typically less de- one, judging from both outcome indicators as as the veloped in the infrastructure of their economic and social availability and use of services. resources, such as employment opportunities, education The purpose of this study is to gain some insight into the and health.1'2 inequality in health services utilization between Arabs The Six Day War of 1967 brought about a dramatic and Jews in the Jerusalem district of the Clalit sick fund change in the region. Israel occupied the and in the year 1993. It relies on appoximately 70,000 indi- Gaza and the Palestinian population in these territories vidual medical records, including those of Jews, WGL became part of the social and economic life of Israel. Arabs and OGL Arabs. Thereafter, two groups of Arabs may be distinguished: the Israeli Arabs, who have lived within die THE JERUSALEM DISTRICT (WGL), namely, within the borders of prel967 Israel and General the Palestinians living in the West Bank, outside the Jerusalem district had a population of 630,400 by end of Green Line (OGL). While the standard of living of the 1993, 74% of which was Jewish. The of Jerusalem serves as the centre of the district, both for the Jewish •A-Shmueli' population, which resides mostly in the western part of 1 The Hebrew University and the Gertner Institute for Hearth Policy the city, as well as for the Arab population, which resides Research in Israel, Israel mainly in the eastern part. The population is primarily Correspondence: Amir Shmueli, PhD, The Hebrew University School of Public Health, P.O. Box 12272, Jerusalem 91120, Israel, concentrated in urban areas. However, the district is also tel. +972 2 6758514, fax +972 2 6435083, e-mail: ashniueli9md2.huji.atil comprised of more than 50 relatively small villages (some Inequality m medical care in Israel

of them are new settlements), partially rural and mainly allergy treatments, rehabilitation and occupational Jewish. Over 10% of the population reside in locations health services. with less than 10,000 people. Nonetheless, the geo- Most of the district's primary care is provided through 132 graphical dispersion is small, the travel time by car from clinics, 125 of which are located in Jewish neighbour- anywhere in the district to the city of Jerusalem is no hoods and settlements and seven in Arab neighborhoods longer than 30 min. and villages. Roughly speaking, there were approximately 2,100 insurees per primary clinic serving the Jewish popu- The study population lation but approximately 6,600 insurees per primary clinic The study population consisted of 310,000 individuals located in the Arab parts of the district. This gap is insured by the Clalit sick fund. Approximately 50,000 somewhat narrowed if the population per primary physi- (16%) are OGL Arabs; approximately 4,000 (13%) are cian is considered: 1,500 Jewish insurees versus 3,000 WGL Arabs and the rest are Jews. The OGL Arabs reside Arab insurees per physician (District Headquarters, per- mainly in greater East Jerusalem. The WGL Arabs reside sonal communication). in a few villages in the western part of the district. On the whole, it seems that availability of in-patient and Downloaded from https://academic.oup.com/eurpub/article/10/1/18/490752 by guest on 27 September 2021 The population studied is not representative of the Israeli specialist services is fairly homogenous. In actual fact, population or the district population. Membership of the however, these services may be less accessible to the Arab Clalit is selective (there are three additional national sick population, who are on average poorer (see below) and funds operating in Israel). It is known that, among the make greater use of public transport. In addition, there is Jewish population, the Clalit's population is older, poorer some gap in the primary care services available to the and less educated. Among the Israeli Arab population in populations. 1993, 12% did not have health insurance (most of them aged 18—24 years), compared to 3.5% among Jews. How- METHODS ever, of the insured Arab population, the large majority The survey (94% of those aged 20 years and over) was insured by the A stratified sample of 69,120 insurees was obtained from Clalit. Health insurance ownership patterns among the the list of insurees as of December 1993. The stratifying OGL Arabs are not known. variables were family size, chronic condition, settlement Due to the of the data collection, the use of private size and age. The data, which included both personal medical care is not taken into account in the analysis. characteristics and detailed utilization information for However, the 1992-1993 National Household Consump- 1993, were collected from the personal medical records of tion Survey showed that non-reimbursed expenditures the insurees, matched with utilization data of hospitals for medical care (other than dental care) are negligible and professional clinics.11 among Israeli Jewish and Arabs individuals insured by the The resulting sample consists of 83% Jews and 17% Arabs, Clalit sick fund. Among the Clalit's OGL Arab popula- 15% in OGL settlements and 2% in WGL settlements. tion, private in-patient care is rare (see below), but no information is available as to its use of private primary and The variables secondary care. It should be noted, however, that the • Utilization data package of benefits offered by the Clalit is comprehensive, Utilization of medical services was measured as the '' with practically no limits on care and with only small cost of care evaluated by the Ministry of Health's price list for sharing in prescribed . 1 January 1994- Monetary figures are in New Israeli (NIS). To derive the approximate US$ Availability of and accessibility to services equivalent, divide the figures by 3. Although this measure The most significant advantage of drawing a large sample does not generally reflect the cost of care for the sick fund, from a single sick fund's district population is that supply it provides a uniform price list both for services purchased is held approximately constant. The entire district popu- as well as for services internally provided by the sick fund lation is served by four general hospitals located in various itself and we will refer to that measure as the 'cost of care'. parts of Jerusalem. Hadassah Medical The advantage of using cost rather than physical units Center, which is geographically close to the OGL Arab (in-patient days, physicians visits, etc.) lies in that it population centres (north-east of Jerusalem), serves most provides a single overall and comprehensive measure. of the Arab population. The Clalit sick fund does not The cost of ambulatory care includes payments for out- contract with OGL Arab hospitals serving the Arab popu- patient care, day hospitalizations and care provided by lation only. It is estimated that the private use of these specialists in professional clinics. Data on visits to primary hospitals by the Clalit's Arab insurees is negligible (- physicians, laboratory tests and consumption trict Headquarters, personal communication). were not available so these types of care are not included. Specialists provide most of their care in clinics. In 1993, It has been estimated that the data covers approximately there were two main specialist clinics: one serving the 60% of total ambulatory care costs (District Headquarters, Arab population and the other, located in the Jewish part personal communication). of Jerusalem, serving the entire population. In addition, The cost of in-patient care includes payments for hos- there were four smaller clinics located in various Jewish pitalizations in acute care departments. It excludes sections of Jerusalem, providing occupational therapy, payments for maternity hospitalization, road or work EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 10 2000 NO. 1 accident hospitalizations, psychiatric care, rehabilitative tions of cost data have shown that the mean and standard care and complex geriatric care. While rehabilitative care deviation are approximately proportional over groups as and complex geriatric care are included in the geriatric defined in several alternative ways (by age, age-sex, age- care defined separately (see below), die other types of chronic conditions, etc.). The coefficients in the - geriatric care are excluded (diey are not included in die normal model reflect die marginal effects of the variables package of benefits defined by die National Healdi (differences, in case of dummy variables), exactly as in Insurance Law). Ordinary Least Squares regression. The cost of geriatric care includes home hospitalization, hospitaliiation in non-acute geriatric wards of general RESULTS hospitals and hospitalization in nursing homes. Because Inequality m ambulatory care of die small number of users, geriatric care cost is not The mean observed (unadjusted) cost of ambulatory care analysed separately. per insuree is higher among Jews than among Arabs for The total cost of care includes the cost of ambulatory, all age groups. For the entire population, die figures are in-patient and geriatric care mentioned above. NIS 241 forJewsandN!S95 for Arabs (table I). However, Downloaded from https://academic.oup.com/eurpub/article/10/1/18/490752 by guest on 27 September 2021 • Personal characteristics the main source of that gap lies in die difference in die The personal characteristics used are those available from propensity to use the service. Table 2 indicates diat, the medical records and include (=1 for controlling for age, gender, chronic conditions, income Jews), age (in years), gender (=1 for men), registered and settlement size, Jews are 2.4 times more likely (die chronic conditions (=1 for yes) and settlement size (=1 odds ratio) to use ambulatory care than Arabs. Among for settlements with up to 10,000 inhabitants). The die users from both populations, controlling again for die variable 'registered chronic condition' refers to the in- above characteristics, the mean cost of care is not signi- dication in the record that the insuree is receiving ficantly different. medication for a chronic condition on a regular basis. The For brevity, the effects of the odier covariates presented variables age, gender, health state and settlement size in table 2 (and tables 3—5) are not discussed. serve as covariates in order to identify the ethnic group effect without bias. Inequality m in-patient care Table 1 presents a description of the population studied. The mean in-patient cost per Arab insuree is NIS 223 The Arab population is younger than the Jewish one. The while among Jews, that cost amounts to NIS 387 (table 1). mean personal annual income among the Arabs is half Table 3 reports the two-part multivariate results. On that among Jews. The proportion of persons with regis- average and controlling for other relevant characteristics, tered chronic conditions is 7% among the Arabs and Table 1 Means of the main variables by ethnic group (weighted) 11% among Jews. However, Jews Arabs Total being diagnosed as having a Age (years) 32 26 31 'registered chronic condi- Men (%) 48 48 48 tion' depends a great deal on Insurees with a chronic condition (%) 11 7 10 having some contact with a Annual income (1993 NIS) 43,726 19,488 39,705 primary physician. As will be In small settlements (%) 13 9 12 discussed later on, part of the In-patient cost (1994 NIS) 387 223 359 gap can be attributed to the Ambulatory cost (1994 NIS) 241 95 217 minimal use of ambulatory Geriatric cost (1994 NIS) 26 5 24 services by Arab elderly. Total cost (1994 NIS) 654 323 600 n 57.093 12,027 69,120 The statistical strategy We employed a two-part model for the multivariate analysis.12 First, a logit Table 2 A two part model of ambulatory care cost (t-values in parentheses) model was used to estimate PT [cost >0] E [cost I cost >0] the difference between die (logit regression) (log-normal regression) two ethnic groups' rates of Constant -2.292 (81.5) 330.4 (21.4) utilization (the probability of Age (divided by 10) 0.230 (54.4) 73J (33.2) a greater-than-zero cost). Men -0.001 (0.3) -31.1 (3.5) Second, a Log-normal re- Chronic conditions 0.245 (9.2) 186.9 (11.4) gression was used to identify Income (divided by 100,000) 0.074 (4.4) 3.6 (0.4) the ethnic difference in the Small town 0.108 (4.1) 8.5 (0.7) level of cost of care among Jews 0.886 (32.9) -2.4 (0.2) die users. The Log-normal n 69, 120 23,556 specification1-5 was adopted because earlier investiga- Pr (]: probability; E [ ]: mathematical expectation Inequality m medical care m Israel

Jews are 1.3 times more likely than Arabs to be hos- medical care utilization. However, diey also provide pitalized. However, there is no significant difference in further insight into the issue. First of all, die results show die adjusted in-patient costs per user. diat die Arab population of die Jerusalem district of Clalit is heterogeneous and diat die East Jerusalem Arab popu- Inequality m total medical care lation — and die elderly in particular - uses markedly less Total medical care includes ambulatory, in-patient and services. On die odier hand, the WGL Arabs tend to use geriatric care (as defined above). For die entire popula- services more dian Jews. Secondly, die main gap between tion, die mean total cost of care among Arabs is N IS 323 Jews and Arabs lies in utilization rates radier than in die while die mean cost per Jewish insuree is NIS 654 (table annual intensity of care provided to users. Once in a I). The estimates presented in table 4 indicate diat Jews medical care facility (in a clinic or in die hospital), an are 2.3 times more likely dian Arabs to have a positive Arab patient is likely, on average, to die same amount total cost of care, but among die users of die services, Jews of care received by a Jewish patient widi similar charac- have 238 NIS lower cost on

average than do Arabs. The Table 3 A two-part model of in-patient care cost (t-values in parentheses) Downloaded from https://academic.oup.com/eurpub/article/10/1/18/490752 by guest on 27 September 2021 is that die propensity Pr [cost >0] E [cost 1 cost >0] to use ambulatory - and (logit regression) (log-normal regression) cheaper - services is much Constant -3.679 (70.9) 3069.8 (15.5) higher among die Jews. Age (divided by 10) 0.192 (24.2) 55.3 (14.6) Men -0.001 (0.1) 457.6 (2.8) Some further results: within Chronic conditions 0.545 (13.0) 1717.0 (6.3) Arabs variation Income (divided by 100,000) -0.199 (5.6) -550.4 (3.5) The heterogeneity of die dis- Small town 0.154 (3.1) -81.7 (0.4) trict's Arab population Jews 0.265 (5.5) -109.2 (0.5) makes for an interesting ana- n 69,120 4,575 lysis of die variation within the Arab population. Table 5 presents die estim- ated differences among Jews, Table 4 A two-part model of total cost of care (t-values in parentheses) WGL Arabs and OGL Arabs Pr [cost >0] E [cost I cost >0] in die likelihood of using (logit regression) (log-normal regression) care and in die mean cost of Constant -2.161 (79.4) 994.4 (21.1) care among die users (die Age (divided by 10) 0.227 (54.2) 15.8 (26.0) effects of die odier covariates Men -0.001 (03) -73.5 (3.0) are essentially die same as in Chronic conditions 0.284 (10.6) 983.5 (17.8) die previous analysis and are Income (divided by 100,000) 0.055 (33) -97.6 (4.6) dierefore not reported). Small town 0.115 (4.5) 8.7 (0.3) WGL Arabs are die most in- Jews 0.832 (31.9) -237.5 (5.4) tensive users of ambulatory 69,120 24,580 and in-patient care. They tend to use ambulatory care and total care 3.5 times more dian die OGL Arabs and 1.3 Table 5 A two-part model of medical care cost within Arabs variation" times more than Jews in die Pr [cost >0] E[cost 1 cost>0] district. In addition, WGL (logit regression) (log-normal regression) Arabs are 1.7 more likely Coefficient (t-value) OR Coefficient (t-value) dian die OGL Arabs and j ust Ambulatory care as likely as Jews to use in- Jews-OGL Arabs 1.018 (35.2) 2.8 -13.5 (0.8) patient care. However, diere WGL Arabs-OGL Arabs 1.239 (15.5) 3.5 -64.8 (1.8) are no significant differences Jews-WGL Arabs -0.222 (3.0) 0.8 51.3 (16) in the mean costs of ambu- In-patient care latory and in-patient care for Jews-OGL Arabs 0.316 (6.2) 1.4 101.5 (0.4) users from diese diree WGL Arabs-OGL Arabs 0.505 (3.5) 1.7 493.2 (0.8) groups. Jews-WGL Arabs -0.189 (1-4) 0.8 -384.1 (0.6) Total care DISCUSSION Jews-OGL Arabs 0.958 (343) 2.6 -374.9 (3.3) The results reported above WGL Arabs-OGL Arabs 1.206 (153) 33 -401.6 (1.4) are consistent widi earlier Jews-WGL Arabs -0.245 0.8 26.7 (0.1) evidence regarding die Is- raeli Arab-Jewish gap in a: Covariata ln all equations: age, gender, chronic conditions, income and town see EUROPEAN JOURNAL OF PUBLIC HEALTH VOL 10 2000 NO. 1

teristics. However, among Jews and Arabs who have had care, housing and services and may induce psy- any contact widi the medical system (usually through chological distress diat can adversely affect a broad range ambulatory services), the total cost of care is lower (by of healdi outcomes. This might be particularly true in die more than 200 NIS per year) among the Jews, since they Arab-Jewish conflict-conscious Israeli society. However, use more ambulatory (cheaper) services. Recall that all of the relatively high use of services by the WGL Arabs the above differences are estimated holding age, gender, indicates diat some acculturation is possible and has been chronic conditions and location size constant. taking place. The for these gaps relate to a combination of In January 1995, a National Health Insurance Law was structural, cultural and political factors. By and large, implemented in Israel. It consists of the centralized most of the facilities are operated by Jewish staff and some collection of an income-related healdi tax together widi are located in Jewish areas. The Arabs' lower accessibility die decentralized delivery of medical care by competing to care does not originate only from physical factors, but sick funds. The law was expected to raise die equity of the is also due to social barriers such as and cultural system, as well as to narrow Arab-Jewish differences in

alienation. This is particularly true for the OGL Arab healdi and healdi care use. It is too early to assess die Downloaded from https://academic.oup.com/eurpub/article/10/1/18/490752 by guest on 27 September 2021 population, whose relations with the Jewish population effects of die implementation of die law on die equity of are inevitably influenced by the long-standing political die Israeli system. However, a recent survey of die general conflict in the region that breeds constant tension, fear population provides several indications.15 Approximately and hostility. These have been augmented by occasional one-diird of die Arabs interviewed (versus 16% of the curfews and check-points, which may have prevented free Jews) reported a sense of improvement in die services access to the care facilities in Jerusalem. following die introduction of die law. Arabs were also Another major factor is the cultural traditionalism of die much more likely to believe diat die law had made or Arab society. Lower levels of education and modern- would make healdi care more equitable. The survey found ization make the population less aware of the importance diat 42% of Jews and 30% of Arabs had visited a specialist of preventive and ambulatory medicine when in good during die previous 3 mondis. The 1993 figures found in health and more likely to rely on extended familial the present study show diat 38 and 17% of Jews and Arabs support when sick. respectively have used ambulatory care. Aldiough die As was noted by Shuval, the problems of health care in figures are not readily comparable, diey might be an the Arab population impinge more stringently on die indication of a narrowing in die gap between die two elderly. In ambulatory care, Arabs aged 65—74 years are edinic groups. No significant difference was found less likely to use services dian dieir Jewish counterparts, between Arabs and Jews widi respect to access to primary though the mean cost among users is similar. In in-patient care. Differences were found, however, in die use of care for the same age group, die utilization rates are closer preventive, emergency and mental healdi services. The and the mean cost among Arab users is 17% higher than audiors conclude diat, while diere has been a relative that among Jews. This is probably due to die fact that life improvement in the Arab sector due to increased expectancy among OGL Arabs is found in this age group competition among die sick funds and greater coverage while tliat of Jews is above 75 years, so that much of die since 1995, the equity goals of die Law have not yet been in-patient costs for die Arab population might be a 'last fully met. year of life' care. A distinctive group is die Arab elderly Anodier major recent development is die peace talks aged 75 years and over. They constitute 2.6% of die Arab between Israel and die Palestinians and die constitution population (versus 5.6% of the Jewish population). They of a Palestinian Audiority Council. The council tend to be very low users of ambulatory, in-patient and nominated a Ministry of Healdi, which has formulated a geriatric care and die mean cost of care among die users National Healdi Plan and developed, widi assistance is approximately half that of Jewish users in die same age from international agencies, health services diroughout group in ambulatory care, 75% in inpatient care and about the authority. A Palestinian Health Insurance system has 70% in total care. Apart from a possible 'survival effect', been enacted with free care for children under 3 years and by which Arab elderly who do survive to the age of 75 pregnant women. In parallel, there has been a rapid years and over are relatively healdiy, die principal reasons development in the pnvate sector. for diat gap relate to die factors mentioned above. Both of diese recent developments are expected to im- Inadequate use of medical care by edinic minority popu- prove die healdi state of the populations in the region lations, particularly preventive care, is generally viewed and to reduce die inequalities between them. as an important determinant of poor healdi. It is related to later diagnosis, poor management of chronic diseases and to delays in treatment. A recent review" provides broad evidence from die US on die racial/edinic gaps in grateful to Nira Shamai, Miri , Yoram Levi, Raya healdi and healdi care and dieir implications. The review Brishev and Rina Etkin for their contribution and assistance. The paper was completed while I was visiting the Department of underlines die importance of 'edinicism' as a central Economics and the Institution for Social and Policy Studies at Yale determinant of healdi, transcending differences in socio- University. I thank both for their hospitality and seminar parti- economic status and geographic location. Ethnicism may cipants for their helpful comments. Three reviewers of the journal restrict access to social services such as education, healdi provided invaluable comments. Inequality in medical care m Israel

9 Central Bureau of Statistics. Use of hearth services survey. Jerusalem: State of Israel, 1995. 1 Horowitz D, Lissak M. Trouble in Utopia. : 10 Central Bureau of Statistics. The 1992/3 Household Am-Oved, 1990 On Hebrew). Consumption Survey, parts 1 and 2, 1994. Jerusalem: Central 2 Central Bureau of Statistics. Localities in Israel. Jerusalem: Bureau of Statistics. State of Israel, 1992. 11 Shmueli A, Shamai N, Abraham M, Levi Y. Toward a 3 Reiss N. The hearth care of Arabs in Israel. Boulder, CO: national capitation formula. Tel Hashomen The Israeli National Westview Press, 1991. Institute for Hearth Policy Research, 1995 0" Hebrew). 4 Ministry of Hearth. Interim report of the government 12 Manning WN, Duan N, Rogers W. Monte Carlo evidence committee for the advancement of hearth services in the Arab on the choice between sample selection and two-part models. population of Israel. Jerusalem: Government Printing Office, J Econ 1987;35:59-72. 1993 On Hebrew). 13 Green WH. Econometric Analysis, 2nd edn. : 5 Shuval JT. Hearth in Israel: patterns of equality and Macmillan, 1993. inequality. Soc Sci Med 1990:31:291-303. 14 Williams DR, Collins C. US sodoeconomic and racial 6 Shuval JT. Social dimensions of hearth: the Israeli differences In hearth: patterns and explanations. Annu Rev Sociol experience. Westport, CT: Praeger Publishers, 1992. 1995;21:349-86. 7 Zidani S. Survey of the hearth services in the Arab sector 15 Farfel M, Rosen B, Berg A, Gross R. Arabs' and Jews' perceptions and use of the hearth system following the in Israel. Shefaram: The Society for Hearth Services Downloaded from https://academic.oup.com/eurpub/article/10/1/18/490752 by guest on 27 September 2021 Research, 1995 (in ). implementation of the National Hearth Insurance Law. Jerusalem: 8 Farfel M, Rosen B. Differences in the health and hearth JDC-Brookdale Institute, 19%. care of Arabs and Jews prior to the implementation of the National Hearth Insurance Law. Jerusalem: JDC-Brookdale Recaved 3 February 1998, accepted 17 February 1999 Institute, 1996.