Health Promotion and Preventive Medicine: A Revolution in Israeli Healthcare

Transcription

1 October 2007 No. 24 Executive Summary Health Promotion and Preventive Medicine: A Revolution in Israeli Healthcare Diana Zaks Koret-Milken Institute Fellow

2 About the Koret-Milken Institute Fellows Program The Koret-Milken Institute Fellows Program accelerates Israel s economic growth through innovative, market-based solutions for long-term economic, social, and environmental issues. The program focuses on connecting government, philanthropic, and business resources that are vital to national growth and development. Directed by the Milken Institute Israel Center, the Koret-Milken Institute Fellows Program awards annual fellowships to outstanding graduates of Israeli and international institutes of higher education. Fellows serve yearlong internships at the center of the nation s decision-making the Knesset, government ministries, and other Israeli agencies and aid policymakers by researching and developing solutions for various economic and social challenges. In addition, fellows craft their own policy studies aimed at identifying barriers to economic and employment growth in Israel. The fellows studies, carried out under the guidance of an experienced academic and professional staff, support legislators and regulators who shape the economic reality in Israel. The program offers the ultimate educational exercise, combining real-life work experience with applied research five days a week. Throughout the year, fellows receive intensive training in economic policy, government processes, and research methods. They acquire tools for writing memorandums, presentations, and policy papers, and they develop management, marketing, and communication skills. The fellows participate in a weekly workshop, where they meet senior economic and government professionals, business leaders, and top academics from Israel and abroad. They also participate in an accredited MBA course that awards three graduate-level academic credits that are transferable to other universities in Israel. The course, which focuses on financial and economic innovations, is taught at the Hebrew University of Jerusalem s School of Business Administration by Professor Glenn Yago, Director of the Milken Institute Israel Center and Director of Capital Studies at the Milken Institute in California. Fellows Program alumni can be found in senior positions in the public and private sectors. Some serve as advisers to government ministries while others work at private-sector companies or go on to advanced studies at leading universities in Israel, the United States, and Great Britain. Within the program s framework, more than 80 research papers have been published, catalyzing reforms, reducing barriers, bringing about economic growth, and improving the quality of life for Israeli citizens. The Koret-Milken Institute Fellows Program is nonpolitical and nonpartisan. It is funded by the Koret Foundation, the Milken Institute, and other leading philanthropic organizations and individuals in the United States and Israel. More about the program: Contact us: info@kmifellows.org

3 Health Promotion and Preventive Medicine: A Revolution in Israeli Healthcare Diana Zaks KIEDF Koret Fellow Over 60% of the annual deaths in Israel are attributable to diabetes, cancer and cardiovascular disease. 60% of these diseases are preventable. We recommend: Adopting international models by which the government, private sector and philanthropy cooperate in promoting health. Merging the various Health Ministry departments dealing with disease prevention and health promotion so there is a single responsible office. A gradual redirecting of Israel s expenditure on health so the focus is on prevention and early care. Introduction The chronic illnesses of diabetes, cancer and cardiovascular disease are the main cause of death in the world, and Israel is no exception. 1 In 2003, more than 60% of mortality in Israel was attributable to these three diseases, while deaths attributed to traffic accidents amounted to 1.3% of the total. Nonetheless, while the government established a national agency for road safety in 1997, and the war against traffic accidents has been on its agenda ever since, there is no national effort or plan to combat chronic disease. 2 Graph 1 shows the main causes of death in Israel in According to data compiled by the World Health Organization, a healthy lifestyle is capable of reducing premature mortality from these diseases by over 60%. 3 In addition to saving life, a decision to change Israeli health policy will also result in considerable budgetary savings. Investment in health promotion and removing obstacles preventing businesses from operating in the health sector would be a boon both to the budget and the lives of Israelis. The term health promotion refers to a process allowing people to increase control over their health and improve it 4 and includes both preventive medicine and early detection. The term preventive medicine is an activity usually promoted by the health sector that treats individuals and population groups with particular risks that are usually associated with risk-inducing behavior. 5 [ 1 ]

4 Graph 1: Main Causes of Death in Israel, 2003 Traffic 1.3% Diabetes, cancer and cardiovascular disease 62.2% Others 36.6% Source: Based on CBS, Statistical Abstract of Israel 57 (2006), table 3.29 (Jerusalem: SBS, 2006), www1.cbs.gov.il/shnaton57/download/st03_29x.xls (18 May 2007). Importance of Health Promotion An individual who develops a chronic disease becomes a burden to his environment until his death, as he is dependent on drugs and medical treatment and his quality of life drops. 6 The best cure for chronic disease is prevention or early detection. 7 Adoption of a healthy lifestyle at an early age impacts on later life and reduces the risk of developing chronic diseases. 8 Causes of Illness There is a small group of preventable causes responsible for much chronic disease. Nutrition, obesity, and the lack of physical activity contribute to 30% of cancers, 20% of cardiovascular disease, and 90% of diabetes. Smoking causes 17% of the instances of cancer and 20% of cardiovascular disease, and recent studies indicate that it also contributes to diabetes. 9 All of these behaviors may be categorized as unhealthy. The good news is that it should be easier to treat one problem unhealthy behavior than to treat many different problems. Health Promotion vs. Corrective Medicine The Israeli health system allocates most of its resources to corrective medicine (which provides care to patients already suffering or dying from an illness). In order to determine whether current state allocations are efficient, [ 2 ]

5 the influence of smoking can be considered: Smoking causes 71% of tracheal, bronchial and lung cancers. 10 An individual who stops smoking after five years or less of the activity reduces his risk of falling ill to that of somebody who has never smoked. 11 Quitting smoking between the ages of increases life expectancy by 120 months. In contrast, medicines such as Avastin and Herceptin, which are expensive and efficient treatments for cancer, usually contribute approximately no more than 4-5 months to life expectancy. 12 Avastin is included in the basic health basket in Israel, at a per-patient monthly cost of over NIS 20,000. This is in contrast to the cost of a smoking prevention workshop presented by one of Israel s Health Funds, at a cost of NIS 225 for an insurance holder or NIS 700 for someone not insured at that Health Fund. 13 Ironically, such workshops for prevention of smoking are not included in the basic health basket. While illness cannot be entirely prevented, early detection is of great importance in determining a patient s chances for recovery and reducing the cost of treatment. Table 1 compares the cost of corrective medicine and early detection. Heart disease Breast cancer Table 1: Efficiency of Early Detection and Late Detection in Treating Chronic Disease Early detection treatment cost ($) Corrective treatment cost ($) Difference 15,000 30,000-50,000 2x-3x 10,000-15,000 60, ,000 4x-9x Source: Joe Hogan, in The Future of Health Care (California: Milken Institute Global Conference, 2006) (DVD). Health Promotion in Israel Israel is not prepared today to offer health promotion on a national scale for several reasons, including: a lack of appropriate legislation; those who formulate health policy usually have clinical experience with chronic disease and thus gravitate to such treatment and policy; many doctors lack a professional background in health promotion; and hospitals are already overburdened and suffer from acute budgetary problems. Health promotion is simply not at the top of Israel s health priority list. The Ministry of Health does not have a national plan or an operative working program to combat chronic disease, official data to assess the economic burden caused by these diseases or the means to engage in health promotion. There are two departments in the Israeli Health Ministry dealing with preventive medicine: the Department of Health Promotion and Education, and the Department for a Healthy Future But the ministry neither engages in health promotion with the public at large, nor strives to make Israel s health system more efficient. The ministry, which administers state hospitals, actually prevents budgetary savings by prohibiting them from offering certain services, and imposing wage and [ 3 ]

6 price controls on these hospitals; it also limits competition between suppliers of community medical services. Use of the Internet for Health Promotion Since medical providers have began using the Internet, distance medicine technologies and telemedicine have proven very effective. Among the advantages to using these tools are increased transparency and validity of treatments, patient satisfaction, economic savings and more efficient treatments. Whatever deficiencies may be found in the use of these tools are easily resolvable: problems of data protection, technical limitations, remuneration for treatment, and legal and ethical bases for activities. International Experience Many countries have national programs for health promotion. Reducing the causes of risk brings speedy results. In China, the U.S. and Finland, studies have been conducted regarding nutrition and physical activity. Within one year, patients blood pressure and cholesterol level improved and these results held for six years. The number of patients developing diabetes among those studied dropped approximately 60% in Finland and the U.S. and 30% in China. 14 Finland s national program. The death rate from heart disease in Finland in the 1970s was among the highest in the world, probably a result of a high use of tobacco and diets rich in fats and low in fruits. 15 Finland developed a national program to combat chronic diseases that involved the public sector, hospitals, providers of communal health services, NGOs and private sector institutions such as food producers. The following steps were taken as part of the program: Setting goals, involving doctors and nurses in reducing the risks among their patients, places of employment were encouraged to engage in health promotion, national television broadcasts, contests to stop smoking, contests between cities to lower cholesterol levels among their residents, production of low fat products in factories producing frankfurters and cheeses and others. The rate of smokers among men aged dropped from 51% in 1971 to 31% in 1997, 25 years after the beginning of the program. There was also a drop in cholesterol levels and other health indices also improved. 16 The drop in deaths caused by heart disease and cancer naturally increased life expectancy in Finland. Male life expectancy rose by seven years and women s by six years. 17 Graph 2 shows the results of the Finnish program, beginning in North Karelia and six years later, across all of Finland. The graph shows the drop in male mortality rate between the ages of 35 and 64. Also in Finland, a study on the reduction of the incidence of diabetes found that increased physical activity and proper nutrition lowered the risk of diabetes by approximately 58%. 18 [ 4 ]

7 700 Graph 2: Male Mortality Rates, Ages in Finland and North Karelia Start of the North Karelia Project Nation wide activity North Karelia Finland Mortality per 1oo,ooo population Source: Pekka Pushka, Successful prevention of non-communicable diseases: 25 year experiences with North Karelia Project in Finland, Public Health Medicine (2002), 4(1):5-7, (9 May 2007). Year Recommendations The key to a successful national health program and preventing chronic diseases is the cooperation of all institutions on a national level. Therefore we recommend formulating a national program based on a coalition of the public, private and philanthropic sectors. The program should relate to all ages and include: nurseries, schools, places of employment, the community and more. This program should involve the following division of labor: The government: A portion of the basic health basket should be invested in preventive medicine and health promotion. Over the years, the chronic disease rate will fall and with it the budgetary allocations to corrective medicine and late term treatment. The Ministry of Health: The different departments and projects currently dealing with preventive medicine should be merged into one, able to provide scientific data necessary for health promotion in Israel. This one department should take an advisory position to those organizations dealing with health promotion or preventive medicine, oversee them and make recommendations as to changes in the health basket. Medical institutions: A patient s medical provider should provide him with advice and recommendations on leading a healthy life. Whenever a [ 5 ]

8 patient visits a medical institution, the medical professionals with whom he meets should initiate a conversation about the importance of proper nutrition, the dangers of smoking and the advantages of increased physical activity. Medical institutions should place special emphasis on high-risk segments of the population. Media: The media have the ability to reach large numbers of people and supply critical information about a healthy lifestyle; their readers and viewers would benefit if they would engage in dissemination of information, provision of explanations, and offering recommendations about such healthy lifestyles. The Internet should also be used for these purposes, as websites are easily available to most of the public and are a user-friendly and inexpensive means of providing contact between doctors and patients. Small businesses and philanthropy: Small businesses and philanthropic organizations can play a major role in a national health program, by financing health promotion or providing health-related services. Small businesses can easily provide targeted programs for specific segments of the population, such as children, smokers, nursery school teachers and teachers, as well as providing early detection services and followup for the chronically ill, especially on a local school- or communitybased level. Today, for all intents and purposes, the government sits idly by waiting for further increases in illness and mortality rates, while allocating increasing portions of state budgets year after year in a never ending attempt to satisfy the needs of a health system that is based on providing late term treatment to an ever increasing number of patients. It tries to satisfy patients demanding increases in the basic health basket, by providing expensive care to chronic and late term patients; but it does this for diseases that could originally have been prevented. The government s policymakers, together with those institutions operating in the field, should move towards health promotion. We should unite our forces, allocate the budgets, and set realizable and measurable goals for reducing the causes of chronic non-communicable disease and the rate of illness and mortality from diabetes, cancer and cardiovascular disease. Endnotes: 1 Chronic diseases are: cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, and others such as mental disorders, vision and hearing impairment, oral diseases, bone and joint disorders, and genetic disorders. WHO, Chronic diseases and their common risk factors, Facing the Facts #1, (19 March 2007). 2 The National Road Safety Authority, Welcome, (25 April 2007). 3 WHO, Solving the chronic disease problem, Facing the Facts #5, (19 March 2007); CBS, Statistical Abstract of Israel 2006, no. 57, table 3.1, www1.cbs.gov.il/shnaton57/download/st03_31x.xls (19 March 2007). [ 6 ]

9 4 The Israel Center for Disease Control, Knowledge, Position, Health Related Behaviors in Israel , publication 304 (Israel: The Israel Center for Disease Control, Ministry of Health, 2006), p The Israel National Institute for Health Policy and Health Services Research, The Seventh Dead-Sea Conference 2006, Healthy Behavior as a National Endeavour (Tel Hashomer: The Israel National Institute for Health Policy and Health Services Research, n.d.), p Naoki Ikegami, Merging of Primary and Tertiary Prevention in the Aging Society The Case of Japan, presentation, slide 2, (5 March 2007). 7 Ruth Weinstein, director of the Department of Health Promotion, Ministry of Health, interview with the author, 5 February J. Edward Hill, in The Future of Health Care (California: Milken Institute Global Conference, 2006) (DVD). 9 Judith Mackay, Ahmedin Jemal, Nancy C. Lee and D. Maxwell Parkin, The Cancer Atlas (Atlanta: American Cancer Society, 2006), pp. 30, 34-35, (19 February 2007); Judith Mackay and George A. Mensen, The Atlas of Heart Disease and Stroke (Geneva: WHO, 2004), pp , int/cardiovascular_diseases/en/cvd_atlas_07_tobacco.pdf, (19 February 2007); Delice Gan, Diabetes Atlas (Belgium: International Diabetes Federation, 2003), p. 18, (19 February 2007); Israel Diabetes Association, Diabetes prevention the future of the younger generation is in our hands, IDA Journal 85 (April 2007). 10 Mackay, Jemal, Lee and Parkin, The Cancer Atlas, pp , CancerAtlas05.pdf (19 February 2007). 11 Liora Valinsky, Community Health, Maccabi Health Care Services, interview with the author, 28 March Elliot Rosenberg, National Coordinator for Healthy Israel 2020, Ministry of Health, and Leah Rosen, Senior Consultant, Ministry of Health, interview with the author. 13 Valinsky, Rosenberg and Rosen, interview. 14 WHO, Preventing chronic disease: a vital investment, WHO global report (Geneva: WHO, 2005), p. 91, (19 March 2007). 15 Ibid., p Valinsky, Rosenberg and Rosen, interview. 17 WHO, Preventing chronic disease, p Diabetes prevention, IDA Journal. [ 7 ]

10 FELLOWS Koret PROGRAM Milken Institute תוכנית עמיתי קורת מכון מילקן בית מילקן, רחוב תל חי 13 ירושלים,