Background
Ever since the 1995 National Health Insurance Law was passed, the Myers-JDC-Brookdale Institute (MJB) has been monitoring the health system’s performance from the point of view of the service recipients using biannual surveys. According to the law, every Israeli resident is entitled to quality health services within a reasonable time and at a reasonable distance from their place of residence. Nevertheless, there remain gaps in the deployment of health services between Israel’s center and its periphery that may affect those three dimensions of care.
A peripheral area is defined by the Central Bureau of Statistics (CBS) as one that is distant from opportunities, activities, or assets available in all of the areas, including its own area. The CBS’s Peripherality Index of Local Authorities (PILA) is structured based on this definition and is designed to characterize localities and local authorities (hereinafter, localities), based on their geographic location, from most peripheral to most central.
Objective
The objective of the analysis was to assess the differences between Israeli residents living in peripheral, middle-ranking, and central localities (clusters 1-4, 5, and 6-10 on PILA, respectively) in a variety of health system-related aspects: patterns of health service usage, forgoing medical care, voluntary health insurance (VHI) coverage, satisfaction with the health plan and health system, and trust in the health system.
Method
A secondary analysis of MJB’s “Level of Service and Health Care System Performance” public opinion surveys carried out in 2021-2022 was conducted to assess the differences in the respondents’ answers to selected survey questions across the three levels of the PILA index (peripheral, intermediate and central localities). For those survey questions where significant differences were found between those living in peripheral and intermediate localities and those living in central localities, multivariate logistic regression analyses were conducted to control for gender, age, population groups (Jews and others, Arabs), health status, income level and health plan membership.
The findings regarding differences between groups in the population presented in this paper were significant at a level of 95% and above. The study examined the differences between residents of peripheral and central localities, as well as between residents of intermediate and central localities. No statistical tests were conducted to identify significant differences between residents of intermediate and peripheral localities.
Findings
Compared to their counterparts in central Israel, more residents from peripheral and intermediate localities reported high satisfaction with their health plan and high trust in the health system. It was also found that, compared to residents of central localities, residents of peripheral and intermediate localities use hospital emergency departments more often than community emergency centers in cases of emergency; fewer of them use remote health services and have VHI coverage; and more of them forgo health services due to the distance of the service from their homes. No differences were found in the rate of those reporting forgoing medical services and medicines due to cost or waiting times, in the use of primary and secondary care, or in waiting times for specialist physicians.
A multivariate analysis found that the differences in socio-demographic characteristics of residents of peripheral and intermediate localities such as population group, age, income level, health status and health plan membership explained most of the variance in patterns of service use, satisfaction with and trust in the health system, and VHI membership. Conversely, even after controlling for socio-demographic variables, differences remained in the following four parameters:
- The likelihood of residents of a peripheral locality to be highly satisfied with their health plan was 1.4 times higher than that of residents of a central locality.
- The likelihood of residents of peripheral and intermediate localities to forgo a service because of distance was 2.0 and 1.6 higher, respectively, than that of residents of central Israel.
- The likelihood of residents of the periphery to turn to a hospital for a medical emergency was 1.8 higher than that of residents of central Israel.
- The likelihood of residents of the periphery to view personal information on a website or application was 0.6 times lower than that of residents of central localities.
Discussion and Recommendations
The findings help understand which gaps in the accessibility of health services are due to geographic peripherality and which are more related to social peripherality. Such understanding brings us closer to improving access to health services throughout Israel.
It was found that forgoing health services due to distance was more common in peripheral and intermediate localities. This suggests lower accessibility and availability of medical services in these localities compared to central Israel. We therefore recommend improving the supply of accessible health services to ensure greater equality across geographic locations.
The differences found in the frequency of visits to emergency centers in the community and hospital emergency departments in times of emergency can attest to the relative unavailability or inaccessibility of emergency medical services in the community or to their lower quality in peripheral and intermediate localities. The multivariate analysis suggests that the low rate of use of emergency services in the community found in peripheral and intermediate localities can be explained by the lower likelihood of Arabs and ‘Clalit Health Services’ health plan members to use these services compared to Jews and members of other health plans. Accordingly, we recommend that emergency centers in the community improve their accessibility to Arabs, and that Clalit expand its emergency services in peripheral localities.
The use of remote healthcare services is less common in the periphery, although most of the differences found may be explained in terms of the users’ background characteristics. To reduce service gaps, we recommend making those services more linguistically and culturally accessible for Arabs, as well as working to increase the awareness of those services in peripheral localities more generally.
Citing suggestion: Fialco, S., Laron, M., & Maoz Breuer, R.(2024). Health Service Use, Attitudes and Perceptions Towards the Health System: A Comparison of Residents of Israel’s Periphery and its Center. S-226-24. Myers-JDC-Brookdale Institute. (Hebrew)