delsa/gov 3rd health meeting - arnon afek
DESCRIPTION
This presentation by Arnon AFEK was made at the 3rd Joint DELSA/GOV Health Meeting, Paris 24-25 April 2014. Find out more at www.oecd.org/gov/budgeting/3rdmeetingdelsagovnetworkfiscalsustainabilityofhealthsystems2014.htmTRANSCRIPT
Challenges in the wage negotiation in Israel
• Universal coverage by The National Health Insurance law since 1995
• Bismarckian system – 4 HMOs, capitation formula
• Hospital sector includes 24 general hospitals
• System is highly controlled, under-budgeted and subsidized by MOF• National health expenditure – 7.7% (stable since 1995) • Acute care beds – 1.9 (OECD avg. – 3.4), per 1,000 pop., year 2011
• Medical graduates – 4.9 (OECD avg. – 10.6), per 100,000 pop., year 2011
• Physicians – 3.3 (OECD avg. – 3.2), per 1,000 pop., year 2011
Israeli Healthcare System at a Glance
“Israel has established one of the most enviable health care systems among OECD countries…”
OECD Reviews of Health Care Quality: Israel 2012
Medical Education in Israel
• 5 medical schools
• 700 medical students (in the past only 400)
• 2 medical programs: 6 year & 4 year
• Mandatory rotational internship
Source: OECD DATA
Physicians in Israel (1)
Source: OECD DATA
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
1000
2000
3000
New Licensed Physicians in Israelyears 1985-2012
Physicians in Israel (2)
Source: OECD DATA
Source: MOH
Israeli Medical Association (IMA)• Acts as an independent, apolitical, professional organization
• The official physician workers union
• Negotiates with employers and signs physicians perennial collective agreements
• Multiple roles: Union Scientific-professional (ethics) Medical association Advisory – Scientific board
IMA’s vision:not only to act as a union,but as Israel’s medical system protector
Summary
In the last decade the Healthcare System resources are highly regulated and limited by the MOF in order to maintain low national health expenditures.
This led to a shortage of medical graduates, physicians, hospital beds, nurses.
Physicians are represented by a powerful union.
Physician’s Strikes in Israel - History
• 1976 - lasted 58 days, first strike
• 1983 - lasted 117 days, hunger strike, physicians left hospitals
• 1994 - lasted one day
• 2000 - lasted 217 days, collective agreement for 10 years
• 2011 - lasted 242 days
(1950 - 1990: IMA declared on 20 strikes and labor disputes)
Physician’s Strike in 2011 (1)
• The beginning: Expiration of labor agreement from last strike (2000) Negotiation for a new labor agreement failed
• The players : Employers: Clalit HMO, Government, Hadassah Medical Org Employees representative: IMA with powerful leaders,
hospitals department heads, (residents?) Consultation with experts (Deloitte)
• High expectations
Physician’s Strike in 2011 (2)
• The longest strike
• Acting on the edge - partial work sanction, threats to abandon hospitals
• Hunger strikes
• Israeli Labor Courts were highly involved
• Extensive supportive media coverage
• Publicized march to Jerusalem
The unique agreement included:
• Major increase in salary (avg. increase 47%)
• Major increase in salary of professions in need (up to 67%)
• Physicians in periphery were highly recompensed (up to 67%)
• Additional staff (1000)
• Report to work (“clock” ; serving vs. working)
• Major changes in working hours (a change of life style)
• The balance between physicians in leading central Hospitals vs peripheral Hospitals.
• The agreement was signed for 9 years
• Hospital Directors were not a part of the agreement
signed & shattered)) 2011 The First Agreement
Orthopedics Internal General Surgery Intensive Care0
2,000
4,000
6,000
3,3333,926
3,333
4,4214,416
5,547 5,5476,040
Center
Orthopedics Internal General Surgery Intensive Care0
2,000
4,000
6,000
3,5674,183
3,567
4,6785,126
6,366 6,3666,859
Periphery
Aug 2011 Dec 2018
Salary of Young Specialist (Israel)Before the agreement (2011) vs. final step of the agreement (2018)
in EUR/month
Residents, 2nd stage of the Strike
• Shortage of medical school graduates led to a heavy burden on existing residents
• Changes in the power of the leaders of the IMA (Physician guild)
• Public & media support
• Demonstrations, rallies
• Reopening a wage agreement, first time in history
• Israeli Labor Courts
• During negotiation almost all residents resigned
• Dead-end
• Mediation
A new agreement for residents: Major increase in salary
Grants with a low tax rate (150 M EUR)
Decrease of working hours - max 26 hours per shift, 72 hours per week
Short shifts
Max 6 shifts per month
Reevaluation of the agreement in 2015
Residents, 2nd stage of the StrikeResults
Residents’ Salary (Israel)Before the agreement (2011) vs. final step of the agreement (2018)
in EUR/month
Orthopedics Internal General Surgery Intensive Care0
2,000
4,000
6,000
3,2613,667
3,2613,914
4,2204,901 4,901 5,175
Center
Orthopedics Internal General Surgery Intensive Care0
2,000
4,000
6,000
3,3243,740
3,3243,988
5,0535,835 5,835 6,109
Periphery
Aug 2011 Dec 2018
Specialist physicians salaryOECD countries
(2006=100)
ISRAEL
Source: OECD DATA
ISRAEL
Specialist physicians salaryrelative to the avg. salary
(2006=100)
Source: OECD DATA
The Agreement led to major improvements But All sides felt defeated (1)
• Strengthening peripheral parts of Israel
• Massive addition of beds and staff in hospital
• Some physicians earn twice as much as Israel’s Prime Minister
• Major benefits to residents (grants, decreased working hours)
• Specialist physicians salaries were highly increased
• Increase of physicians working in periphery
• Increase of physicians working in professions in need
The Agreement led to major improvements But All sides felt defeated (2)
• Discontent about having to report to work ( the clock)
• Agreement signed for 9 years – No strikes!
• Deficits in Healthcare budget due to high salary payment
• Rising opponents against the union (IMA)
• A few residents filed a spiteful lawsuit
The Future
• A change in the leadership of the IMA
• New struggle in 2015?
“Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.”
From the Oath of Maimonides