healthcare in israel healthcare in israel healthcare in israel is universal and participation in a medical insurance plan is compulsory. all israeli residents are entitled to basic health care as a fundamental right. the israeli healthcare system is based on the national health insurance law of 1995, which mandates all citizens resident in the country to join one of four official health insurance organizations, known as kupat holim (קופת חולים - "sick funds") which are run as not-for-profit organizations and are prohibited by law from denying any israeli resident membership. israelis can increase their medical coverage and improve their options by purchasing private health insurance. in a survey of 48 countries in 2013, israel's health system was ranked fourth in the world in terms of efficiency, and in 2014 it ranked seventh out of 51. in 2020, israel's health system was ranked third most efficient in the world. in 2015, israel was ranked sixth-healthiest country in the world by bloomberg rankings and ranked eighth in terms of life expectancy. beilinson hospital in petah tikva, israel history ottoman era during ottoman rule, health care in the region of palestine was poor and underdeveloped until the 19th century. healthcare was largely provided by traditional healers, amateur druggists, and experts in medicinal herbs. modern medical institutions began to be established in the 19th century. three jewish hospitals were founded in jerusalem: bikur cholim (1826), misgav ladach (1854), and ezrat nashim (1895). christian missionary organizations also set up medical facilities. the british consulate in jerusalem established a clinic providing free medical care in 1838, which was turned into a hospital run by a missionary organization in 1844. the communal leadership of the haredi jewish community was opposed to the establishment of jewish medical institutions until the mid-19th century, fearing that the influence of jewish doctors trained in secular universities would disrupt the religious life of the jewish community of ottoman palestine. after the establishment of the missionary hospital in jerusalem, the haredi communal leadership dropped its objections to jewish medical institutions, as the influence of missionaries was seen as a greater threat than that of jewish doctors trained in secular institutions. in 1872, max sandreczky, a german christian physician, settled in jerusalem and opened the first children's hospital in the country, marienstift, which admitted children of all faiths. in 1891, a jewish hospital was opened in jaffa. scores of clinics managed by jewish doctors were also opened. in the late nineteenth century, as the yishuv, or pre-state jewish community, began to grow in the wake of the first aliyah, medical systems were set up in the emerging jewish agricultural settlements, or moshavot. financially backed by baron edmond de rothschild, the settlers hired physicians and medical assistants. a sick room was built in rishon lezion and a fourteen-bed hospital was established in zikhron ya'akov. towards the end of the 19th century and into the early 20th century, the medical system in the moshavot was expanded, initially under baron rothschild and then under the auspices of the jewish colonization association. nurses and midwives were hired and apothecaries run by trained pharmacists were established. primary care was provided in the moshavot with serious cases referred to the hospitals and in some cases abroad for treatment. in 1902, another jewish hospital in jerusalem, shaarei zedek, was opened just two miles from the old city. the expanding medical system of the moshavot was designed primarily for the residents of those settlements. jews who worked as ordinary laborers and were not members of a moshava were consequently forced to pay for medical care or rely on the benevolence of doctors to treat them. in large moshavot such as rishon lezion petah tikva, and rehovot, partial medical assistance was extended to jewish laborers, but this sometimes relied on the goodwill of the baron's clerks, and in petah tikva a clause in the local charter stipulated that a non-resident in need of medical assistance must pay. in the jewish agricultural training farms at ben shemen and hulda, established by the jewish colonization association to train laborers, insufficient medical care was one of the most common causes of conflict between the workers and foremen. in 1911, the judea worker's health fund, which later evolved into clalit health services, was established to cover jewish laborers and their wives, becoming the first zionist health insurance fund in the country. it began operations in 1913. jewish laborers in the galilee and samaria subsequently established their own sick funds in 1912, which began operations in 1915 and 1916 respectively. during world war i, the ottoman authorities closed the jewish hospitals in jerusalem and jaffa. the ottoman army seized the medical equipment and drafted most of the doctors. with the war's end and the british conquest of palestine, the yishuv was left without an effective hospital system. in 1918, the hadassah women's zionist organization of america established the american zionist medical unit (azmu) to rebuild the yishuv's medical system. with assistance from the azmu and foreign contributions, the jewish hospitals were reopened, and a new one was established in jaffa. in 1919, hospitals were opened in safed and tiberias, and a hospital was opened in haifa in 1922. the azmu was turned into the hadassah medical federation, which oversaw the yishuv's health system. british mandate pharmacy in petah tikva, 1930s with the start of british rule, measures were taken to improve public health in the area. they began during british military rule, and continued to grow with the establishment of the british mandate in 1922. in jerusalem, accumulated refuse heaps were removed, public rubbish bins were installed; the entire population was vaccinated against smallpox, and pools and cisterns were covered with mosquito repellent as part of the campaign to eradicate malaria. family health centers known as "tipat halav" (from hebrew: a drop of milk) were founded for the care of newborns, child development and vaccinations. in 1929, the zionist commission and the british authorities sent the jewish epidemiologist gideon mer to rosh pinna to establish a laboratory for malaria research. mer's laboratory was instrumental in eradicating the disease. the campaign against malaria was headed by hadassah until 1927, when the organization turned responsibility over to the authorities. the mandate administration founded a health department that operated its own hospitals, clinics, and laboratories. the health department primarily cared for british personnel stationed in mandatory palestine and provided health services to the arab population. little was invested in healthcare for the jewish population, as it was assumed that the yishuv was capable of managing its own healthcare system. with the expansion of the yishuv through the third and fourth aliyah, new jewish medical facilities were established and the number of hadassah hospital beds tripled. new jewish health insurance funds were also formed. the other major provider of healthcare aside from hadassah was the histadrut labor federation, which established its own sick fund, kupat holim clalit, and by 1946 operated two hospitals and hundreds of clinics and health centers. in addition, some private medical centers and health funds were also established. the yishuv's health insurance and medical services organizations, known as kupat holim (pl. kupot holim) were modeled after the medical mutual-aid societies that were formed in germany following otto von bismarck's social legislation of the late 19th century. the term kupat holim is a literal hebrew translation of the german word krankenkasse. although they have undergone significant reform since, to this day they are an integral part of israel's universal healthcare system (as they are in present-day german-speaking countries). state of israel hadassah nursing students, 1948 magen david adom ambulance, 1948 the yishuv's health system formed the basis of the israeli healthcare system with the establishment of the state of israel in 1948. the israeli government replaced the british mandate's health department with a ministry of health, and established regional health bureaus and an epidemiological service. hospital facilities formerly run by the british authorities were taken over by the state, and new hospitals and clinics were established. at the end of 1948, only 53% of israel's jewish population was insured, about 80% of them by clalit, with a few small health funds insuring the remainder. throughout the following years, israel's healthcare system was expanded, and within a decade, about 90% were insured. according to a 1994 study, "israel maintains a comprehensive health sector that is practically a universal coverage system, without being formally defined as such." until the enactment of the national health insurance law in 1995, the israeli healthcare system was based on voluntary membership of israeli citizens in one of the kupot holim, which were responsible for providing medical care to their members. there were initially six kupot holim, though the number was reduced to four in the 1970s after two of them merged. the kupot holim operated independently but were subsidized by the government. the largest kupat holim was clalit health services, which was owned by the histadrut labor federation. in the mid-1980s it was estimated that about 70% of the population was insured by clalit. there were a number of government-owned hospitals; in 1987 the government ran 11 general hospitals, 10 psychiatric hospitals, and 8 geriatric hospitals. clalit owned several hospitals and ran clinics in virtually every city, town, village, and kibbutz. there were other organizations which maintained some of their own medical facilities and funded the hospitalization of their clients in government hospitals. for health insurance, people had to pay premiums which varied according to income. finally, there were some private doctors and very few private hospitals, and some highly expensive health plans covered private healthcare. the level of health coverage provided varied among kupot holim. furthermore, clalit was the only one not to restrict entry to new members based on age, pre-existing conditions, or other factors, although membership in the histadrut labor union or being a dependant of a member was a pre-condition for membership with clalit. this meant that people who did not (or could not) have such an affiliation with the histadrut and were unable to join another sick fund lacked health insurance coverage. nevertheless, by the early 1990s approximately 95% of the population was insured by the four funds. in 1973, a law was enacted which legally obligated all employers to participate in the medical insurance of their employees by means of a direct payment to their employees' insurance plans. the duty of participation was eventually changed and diminished in 1991. in 1988, the government appointed a national commission of inquiry to examine the effectiveness and efficiency of the israeli healthcare system, headed by shoshana netanyahu. the commission handed in the final report in 1990. the main recommendation of this report was to enact a national health insurance law which would streamline the management, delivery and public financing of medical services in the country and guarantee a minimum health coverage level to all citizens. the recommendation was promoted by health minister haim ramon and the national health insurance law was passed by the knesset in 1994 and came into effect on january 1, 1995. after enactment of the 1995 law, membership in one of the four kupot holim became mandatory while acceptance into any of them was legally guaranteed, clalit's linkage with the histadrut was severed, and israeli residents became entitled to the same minimum basic basket of services regardless of which fund they belonged to, and were permitted to switch between funds once a year. health insurance framework national health insurance law health care spending in israel as a percentage of gdp