Trends in the Employment of Medical and Nursing Manpower under the National Health Insurance Law

The past decade has seen a dramatic increase in the physician to population ratio, as well as a very modest increase in the nurse to population ratio. This increase was partly a result of the employment of physicians and nurses who came to Israel during the recent wave of immigration from the former Soviet Union. However, this extensive employment of immigrants, especially physicians, was surprising, given the relatively large number of physicians in Israel prior to the wave of immigration, the low estimate of jobs available, the sharp rise in physician salaries between 1990 and 1995, and the budgetary pressure arising from implementation of the NHI Law.

The study, which is based on the analysis of data from numerous existing data bases for 1990-2000, as well as on interviews with key people in the health system, provides a comprehensive picture of trends in the employment of physicians and nurses over time. The timing and composition of these changes are examined in depth. This study also examines several possible explanations for the changes in employment levels. The following are among the study’s principal findings:

  • The rate of increase in the employment of physicians was particularly high between 1995 and 1997, hile the rate of increase was much lower after 1998. This finding is consistent with the intense competition among the health plans and service expansion that occurred immediately following the introduction of national health insurance, and the greater budgetary pressure that began in 1998. The increase occurred in both hospitals and the community, though the percentage of increase was greater in the community.
  • Only a small part of the absorption of physicians into employment can be explained by a decrease in their weekly work hours. In addition, their absorption into employment in the periphery explains only a small part of the total increase in the number of physicians employed.
  • It appears that in both hospitals and the community, the bulk of expansion in physician employment was accomplished through channels of employment not governed by quotas, such as health trusts, as well as through non-health plan community frameworks.
  • During the period examined, the proportion of immigrants, younger professionals, and women – who are less expensive to employ – increased in the total medical labor force.
  • The increase in the ratio of nurses to the population during the same period was very moderate. While there was a significant increase in ratio of nurses per thousand population in the hospital system, there was a notable decrease in the community. The primary change in the structure of nursing manpower was in the addition of nurses who were immigrants from the former Soviet Union.
  • The finding that, during the same period, there was an increase in the ratio of physicians to the population in the community, and a decrease in the ratio of nurses to the population in the community, suggests that there was a certain substitution between the employment of physicians and that of nurses in the community.

The information in this report is designed to assist policymakers in planning policy regarding manpower in the health system. Recently, the recommendations of the “Committee to Examine Public Medicine” (the Amorai Committee) were presented to the government; these concern the structure, employment, and salaries of physicians in the public system. Implementation of the committee’s recommendations, and its funding will be informed by a detailed understanding of the development of medical manpower.

This study was funded with the assistance of the National Institute for Health Services and Health Policy Research.