This paper reviews the state of research on health inequality between Jews and Arabs in Israel in order to develop a comprehensive research program that will contribute to the understanding of the factors leading to inequality.
Most social scientists who study inequality between Arabs and Jews in Israel generally address issues of education and employment. Very few studies have been dedicated to other topics, including health care. The present paper seeks to examine the state of research on the topic of health inequality between Jews and Arabs in Israel and to identify the lacunae in the research knowledge in order to develop a comprehensive research program that will contribute to the understanding of the factors leading to inequality. Understanding the background of the disparities in healthcare will enable us to learn from international studies and to propose ways to decrease the gaps. The paper is divided into four sections. Part one provides background information, defines inequality in health, and describes factors that cause this inequality. Parts two and three relate to health inequality in Israel. These sections provide historical background, along with up-to-date data and explanations of inequality found in the literature. In part four, we present our research proposal, which is based on the existing literature and aims to fill in the gaps in the research on health inequality in Israel between Jews and Arabs.
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This paper examines the state of the research on health inequality between Arabs and Jews as well as the academic knowledge on the topic, in order to build a comprehensive research project that can contribute to a deeper understanding of the factors that lead to inequality in health between Jews and Arabs in Israel.
In defining inequality in health, it is important to distinguish between “inequality” and “inequity.” Health “inequality” refers to the existence of differences—which may not be possible to change—between individuals or groups with regard to their health; for instance, the health of young people versus the elderly, or illnesses that are unique to one sex. In contrast, “inequity” is broader than just the quantitative difference measured. An awareness of the characteristics of the disadvantaged groups in society—such as women, the indigent, those with less education, and ethnic and national minorities—makes it possible to assess the differences in their level of health (inequality) on the basis of these characteristics (inequity), and hence to draft a suitable plan of action. The explanations and factors generally associated with inequality include: income inequality, social capital, socioeconomic status, gender, and ethnicity, on the level of the individual and on the level of the community.
In Israel, the basic principles of the Compulsory Health Insurance Law, which took effect in 1995, reflect the notion that healthcare is a resource to which all members of society are entitled, in accordance with their medical needs and regardless of their ability to pay. The three principles essential for exercising this right are: equity, accessibility, and state of health (equality).
By law, compulsory health insurance applies to all citizens and entitles them to a defined “basket” of services. The law guaranteed the insured person the right to choose an HMO and to change HMOs. It also modified the bureaucratic procedures for allocating public funds to the HMOs in a way that weakened the incentive for them to cherry-pick their members. The combination of these principles was thought to harbor great promise for generating public involvement and solidarity in the healthcare system; it was no coincidence that this law was seen as one of the major social revolutions in Israeli history. However, various amendments made over the years eroded the law’s achievements. These amendments, which were introduced in 1998, were ostensibly meant to “increase the flexibility, authority, and responsibility of the HMOs.” Instead, they merely increased the HMOs’ dependence on the State budget (in part due to the abolition of the “parallel tax”) and created incentives for them to increase their revenues from members (in the form of supplementary insurance). Alongside the trend toward privatizing the sources of funding for the healthcare system, a similar trend emerged in the provision of healthcare, in the form of private medical services. The combination of these two factors undermined the public nature of the healthcare system and weakened the notion that the right to health is a social right in Israel.
Background factors leading to inequality in health in Israel include differences in the healthcare infrastructure (which influence accessibility), developments and changes in how the system is funded (which influence the economic ability of citizens to pay for healthcare), and the system’s cultural incompatibility with Israel’s diverse populations.
In Israel, there are disparities between Jews and Arabs in all aspects of health. These gaps are reflected in life expectancy, general mortality, infant mortality, and morbidity. Over the years, there has been an increase in the life expectancy of the population as a whole, but the gap between Jews and Arabs has not only persisted but has even grown. In addition to the gaps measured by the basic, “objective” measures of health, there is also evidence of gaps in self-assessment of health, of physical and psychiatric morbidity, of utilization of healthcare services, and of health-related behaviors.
A review of studies on health-related inequality between Jews and Arabs in Israel reveals that the vast majority of them focus on determining the size of the gaps between the two groups in this area. The most prevalent research topics in this field include smoking and lung cancer, breast cancer and mammography, obesity, cardiovascular disease, and depression. In all of these, significant gaps have been found between Israel’s Jewish and Arab citizens.
Studies that attempt to explain the inequality in the health of Jews and Arabs in Israel explain that the differences stem from cultural differences—different perceptions of illness and disease, social capital, social support, and socioeconomic status. Another set of studies examines the utilization of healthcare services. It appears, however, that accessibility and the quality of services have not been studied sufficiently. Similarly, few studies explore multiple factors and examine the possible reasons for inequality using complex models. Moreover, it seems that the link between the sense of discrimination and inequality in health in Israel has not been researched adequately. Studies conducted in England, for instance, have emphasized this unique factor.
For this reason, the remainder of the research project is comprised of two stages, which will be carried out gradually:
- An analysis of SHARE data, including subjective self-reports of personal health by Arabs and Jews in Israel
- The construction and distribution of a questionnaire for a comparative study of the two populations—Jewish and Arab.
The objective is to examine a complex model that takes into consideration all of the factors that may produce inequality in health: income, occupation, education, social capital, social support, and, as mentioned above, a sense of being a victim of racism and discrimination.
In light of our study of this subject, we recommend:
- Relevant government officials should organize extensive campaigns of public and formal education in all the following areas:
- The damage caused by smoking
- The importance of examination for early detection of breast cancer in women
- The importance of exercise for a normal and healthy lifestyle
- Proper nutrition
- The dangers of obesity.
- Long-term studies, including tracking the trends mentioned above, should be conducted in order to identify undesirable developments and deal with them as early as possible and to examine the impact of the public campaigns and educational efforts both during and after the intervention.
- Various services should be made more accessible to the population. For example, mammography compliance rates for Arab women should be increased; raising awareness among Arab women of the importance of this exam and of early detection of breast cancer is important, but not enough. It is also essential that the exam be available in the localities where the women live, or at least in nearby localities, so they do not have to travel long distances.
About the Authors
Dr. Nabil Khattab is head of IDI's Arab-Jewish Relations project. Shlomit Kagya is a researcher at the Israel Democracy Institute, conducting research as part of the same project.