Clinical health services in East Jerusalem

The franchise model was approved by the Ministry of Health as a temporary solution to problems encountered by the HMOs when attempting to operate clinics in the eastern part of the city. Among the main problems were difficulty in finding land for construction and buildings for rent, cultural barriers and lack of trust by the residents of the Israeli establishment. Despite the model’s many shortcomings, it obtained approval of the High Court of Justice in 2005 “due to the concern that no alternative service exists in the area”. Over the years, problems with quality of service provided by the franchise clinics were reported time and again. Consequently, Government Resolution 3790 set a goal to transfer the East Jerusalem medical services to direct operation by the HMO itself. In practice, four years after that decision, the transfer has not yet taken place (with the exception of a small number of Kupat Holim Leumit clinics), and only 10% of the allocated budget has been utilized.

This study, conducted in collaboration with the Ministry of Jerusalem and Heritage, sought to examine the impact of the franchise model on quality of services rendered to HMO members in East Jerusalem, to identify the central problems that exist in the model, and to examine feasibility of transferring all East Jerusalem clinics to direct operation by the HMOs (in accordance with the goal set by the government resolution).

Current status

The study showed many aspects of impaired quality of service, breadth of service and accessibility to service for HMO members in East Jerusalem. Findings included a severe lack of medical specialist services in the clinics operated by the franchisees; problems related to level of training and professional standard of the medical and administrative staff; serious faults in Ministry of Health and HMO oversight; and arrangements in practice that violate explicit Ministry of Health guidelines

On the other hand, the findings showed that the franchise model resolves certain challenges faced by East Jerusalem residents who seek medical services. For example – the franchise clinics remain open for longer hours than typical clinics, sometimes even 24 hours a day, and thus provide a solution to the lack of urgent care (emergency rooms) in the eastern part of the city. Moreover, many of the franchise clinics provide members with special “mediation services”, such as making appointments at the clinic offices (as a solution to lack of digital literacy and barriers of culture and language).

As far of feasibility of transitioning all East Jerusalem clinics from the franchise model to the direct operation model – the study shows that this is in fact an ideal goal, but its implementation is not realistic. The fact is that most of the challenges faced by the HMOs in 1995 (after enactment of the National Health Insurance Law) that led to the development of the franchise model in East Jerusalem – still exist. A total transition to direct operation is thus not feasible at this time.

Policy recommendations

Due to the findings, recommendations have been formulated to aid in improving quality of medical services for East Jerusalem residents, with a gradual transition to direct operation of the clinics by the HMOs. The expected outcome of implementing the recommendations is building a combined model of clinics run by the franchisees, with increased involvement of Ministry of Health via oversight and control, and with an increase in HMO control over decisions that impact the quality of medical service provided at the clinics.

Recommendation for gradual transition from the franchise model to the direct operation model

1. Ceasing approval of opening additional clinics via the franchise model, such that any new clinic will be operated directly by the HMO itself.
2. Developing a control and oversight mechanism for the Ministry of Health and HMOs suited to the provision of medical services by the franchisees with increased involvement of the Ministry of Health.
3. Increasing HMO involvement in the franchise clinics by transitioning to direct employment of doctors and nurses by the HMO itself (instead of by the franchisees).

Recommendation for the next five-year-plan in East Jerusalem: Change to the model of clinic operations

1. Setting a numerical goal for the number of new clinics that each HMO would be permitted to open each year.
2. Setting a numerical goal for transferring clinics to direct operation, while setting agreed-upon criteria. The first priority would be to transfer the lowest quality service franchise clinics to direct operation.
3. Integration of strong franchisees into the system (franchisees who provide good quality service to HMO members), while increasing involvement of the HMOs in their operation.

• Doctors, paramedical personnel and nursing staff in the franchise clinics should be employed directly by the HMOs (and not by the franchisee).
• A medical director and an administrative director should be appointed in each franchise clinic, employed by the HMO.
• Addng the role of a rights coordinator, to be employed by the HMO.
• Space rental, medical equipment procurement, clinical management and recruiting members – will continue to be carried out by the franchisee.

Recommendation for the next five-year-plan in East Jerusalem: Reducing gaps in provision of services

1. HMOs will be obligated to providing urgent care in East Jerusalem, a service that does not exist today at all. In parallel, franchisees will be obligated to operate the clinics in accordance with the agreement with the HMOs and without overtime hours.
2. HMOs will be obligated to address the shortage in child development, mental health and medical specialty services, and to reduce the gap in provision of these services between the eastern and the western parts of Jerusalem.

This report has been published in coordination with Ministry of Jerusalem and Heritage.