From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

View original post

HEPL blog series: Country Responses to the Covid19 Pandemic

 

Israel’s Response to the Coronavirus Pandemic – the August update (2020)

Ruth Waitzberg, Moriah Ellen

This piece is based on the work done for COVID-19 Health System Response Monitor, Israel country-page. Available at: https://www.covid19healthsystem.org/countries/israel/countrypage.aspx

 

Israel has faced an increased first wave (some are calling it a “second wave”) of COVID-19 since June, yet the epidemiology differs. The number of daily tests and confirmed cases have increased immensely.  Now, many of the infected individuals are young, asymptomatic or mildly ill and the number of severely ill and deaths have remained relatively low.

Education system

The education system resumed in early May for kindergartens and lower grades. Schools fully reopened on May 17^th. The only requirements for returning to school were use of masks and daily health declarations signed by parents.

Workplaces

Public and private workplaces reopened on May 3^rd. Conditions for re-opening (“purple badge” conditions) include wearing masks, adherence to strict hygiene rules, screening of employees and customers for COVID-19 symptoms, regulation of customer entry and site occupancies. Workplaces must self-identify as meeting conditions and appoint an individual responsible for monitoring and complying with “purple badge” requirements.

Public spaces

Public transportation, gyms, restaurants and other leisure activities returned in mid-May. The use of masks is mandatory in all places, including open areas, and violators are subject to fines.

Testing and contact tracing

As of June 1^st asymptomatic individuals who were in contact with confirmed cases are eligible for testing (this has since been reversed). The number of tests has increased significantly since then and so has the incidence of disease. Throughout this period, the legality of involuntary tracing by the Mossad was debated and banned by the government but was ultimately reintroduced two weeks later.

Data dashboard

On June 22^nd the MoH launched a new online dashboard tool, which is updated 3 times daily with epidemiological data on COVID-19 in Israel. The dashboard contains detailed data such as number of daily and total cases, active cases, daily tests, cases by location, age, and gender. Prior to this dashboard, daily data was published via online platforms.

Re-implementation of restrictions

The number of infected COVID-19 individuals reached similar numbers of daily new cases in late May to those of the March-April outbreak, and were consistently increasing. By the end of June the government began re-imposing lockdowns in selected neighborhoods where incidence rates were particularly high.

As of July 3^rd, the government reinstated restrictions on mass gatherings. Up to 50 individuals were allowed to gather in places of worship, bars, weddings and clubs, and no more than 20 people were permitted in other closed areas, excluding workplaces, shops and malls.

In mid-July daily new cases averaged 1,700/day and the government approved further restrictions:

• Gatherings limited to 20 individuals in open areas, 10 in closed spaces
• Restaurants and gyms closed until further notice
  • Food deliveries are permitted
  • Hotel cafeterias may open with up to 35% occupancy
  • Swimming pools in hotels may continue to operate
• Schools and day camps up to 4^th grade may remain open
• Government offices and services may only operate online. Only 50% of public employees may go into the office
• On weekends, malls, shops, markets, pools, hairdressers, salons and other businesses will be closed, essential services such as supermarkets may remain open. (Initially beaches were to be closed, yet this decision was overturned).

Economic Relief

Due to the persistence of high unemployment rates and socio-economic uncertainty, a new “safety net” was announced on July 9^th. The main goal is to provide immediate income by providing monthly monetary grants until June 2021. Eligibility criteria for unemployment benefits will be loosened, and full unemployment benefits will be available until June 2021 or until the unemployment rate drops below 10%. Grant amounts for businesses and the self-employed will depend on annual turnover and percentage loss of income.

Reflections:

The government did not respond systematically to the increase in identified cases. Restrictions were declared and cancelled often and it is unclear how decisions were made, based on what data or criteria, what the ultimate objective was, which stakeholders were involved and whether public health physicians or epidemiologists were involved in decision making.

The incoherence of measures along with a poorly managed economic crisis have generated mass confusion among the population, distrust and anger towards policy makers.

There has been great debate on how to respond to COVID-19. Initially, lockdowns were imposed in specific neighborhoods then imposed on weekends and further modified. The high stringency with which Israel responded to the first wave (severe lockdowns, restriction of movement, local curfews) when morbidity was not high relative to other countries makes it difficult for policy makers to impose a second lockdown, even though the numbers are higher. There has been an attempt to tailor responses to the situation and the incidence of COVID-19 in different areas, but as of July 29^th, responses have not succeeded in reducing the spread. Recently a new Coronavirus-cabinet has been developed and the hope is that decisions will be more evidence-informed and accepted by the public.

 

Israel’s response to the coronavirus pandemic – Update (May 2020)

Ruth Waitzberg[1][2][3], Moriah Ellen²⁴⁵

 

1. Lockdown

On April 1^st, the Israeli government approved emergency regulations to implement stricter measures in cities with high rates of Coronavirus and set a lockdown, which was at times extended. Jerusalem, for example, was divided into four areas and residents could not leave their area.

Holidays (Passover, Easter, Memorial and Independence Day)

In order to avoid family gatherings during holidays, individuals residing in Jewish majority cities were forbidden to leave their homes, and checkpoints restricted movement between cities. Bereaved families were not permitted to visit cemeteries on Memorial Day and ceremonies were held without an audience.

Ramadan

The MoH launched a national campaign calling to only celebrate Ramadan (April 23^rd-May 23^rd) with family members living in the same household. Religious leaders requested followers to pray at home and avoid in-person celebrations. Shops in mostly Muslim settlements had to be closed daily from 18:00- 03:00 the following day (except pharmacies).

2. Easing the lockdown (aka “The Exit”)

On April 19^th the government declared alleviations of the March 25^th orders. Individuals were still urged to stay home, required to wear masks in public spaces, maintain hand hygiene, and 2m distancing. Updates included:

• 30% of the workforce returned to work
• Street shops reopened
• Individual sport activity – in open spaces, up to 2 people within 500m from home
• Worship and prayer – in open areas with up to 19 people within 500m from home
• Special education services with up to 3 children and distancing between groups

Businesses returned without government authorization under certain conditions:

• Up to 2 employees per 20-sqrm; 8 people per meeting
• Body temperature checked prior to entering office
• Work within fixed groups of colleagues, employees aged 67+ work from home
• Appointment of an employee responsible for maintaining COVID-19 measures

As of April 25:

• Hairdressers, cosmetologists and all healthcare services returned to work
• Travel permitted, yet not recommended. Individuals entering the country were still required to self-quarantine for 14 days
• Religious events, funerals, and marriages were permitted in open spaces with up to 19 people

The regular education system started reopening on May 3rd, with lower primary education and 11^th & 12^th grades. Certain precautions have been implemented such as classes are limited in size, recesses are at different times and social distancing measures are in place.

3. Economic relief

In mid-March, The Bank of Israel announced plans to purchase 50 trillion shekels (approximately 3.5% of GDP) of government bonds to help Israelis cope with pandemic repercussions.

On March 31st, an 80 billion NIS incentive package was announced for businesses, health system investments, enhancing economic ‘safety nets’ and assisting the market.

On April 3^rd, holiday allowances of 500 NIS/child (maximum 2000 NIS/family) and 500 NIS for elderly, were given.

4. Long-Term-Care Facilities

On April 12^th a centralized national response plan was launched addressing the spread of COVID-19 in long-term care facilities (LTCF) including:

• Centralizing all offices involved in LTCF services and/or funding
• Establishing COVID-19 care units
• Expanding eligibility for COVID-19 testing
• Clarifying work regulations and recruiting additional staff
• Providing residents with mental health and well-being support
• Immediate quarantine of any LTCF with a positive COVID-19 case

5. Case tracking

Initially, district public health professionals used traditional contact tracing. Due to an influx in cases, tracing moved to mobile phone tracking by the Israeli secret service (the Shabak) and getting information from mobile companies. The MoH also developed a voluntary application called HaMagen.

6. Reflection on COVID-19 response in Israel

Israel had a rapid response to the pandemic and the health-related outcomes regarding the pandemic are exceptional, with low mortality rates. The leadership in Israel has been criticized for numerous reasons such as a lack of transparency in the decision-making process, a lack of inclusion of necessary stakeholders and the public, limited data sharing, and extremely centralized decision making. Furthermore, the digital tracing has been strongly criticized for breach of privacy, being less reliable and potentially misleading due to its reliance on confirmed cases. Israel is currently shifting the balance between epidemiological and economic considerations in its COVID-19 related policy, prioritizing the latter, opening up the economy and carefully easing restrictions. Going forward, Israel needs to have proper management, monitoring and measurement in place to properly manage the second wave.

[1] The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Israel;

[2] Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

[3] Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Germany.

⁴ Institute of Health Policy Management and Evaluation, Dalla Lana School Of Public Health, University of Toronto, Canada

⁵ McMaster Health Forum, McMaster University, Canada

 

Israel’s response to the coronavirus pandemic – Original post (April 2020)

Ruth Waitzberg[1][2][3], Moriah Ellen²⁴⁵

 

1.     Prevention and containment

The prevention phase in Israel started during the early stages of the pandemic in China. The Israeli MoH issued official advice on how to reduce the risks of infection with COVID-19. The advice was disseminated in 10 languages, through media and social media platforms, and was culturally adapted to a variety of publics such as the ultra-orthodox and the Bedouins.

From February 28^th, the MoH published epidemiological reports including flight details and places that each infected person was until diagnosis, and called on all individuals who were in touch with a diagnosed person, or were in the same places, to self-quarantine for 14 days.

As the number of cases increased and individual epidemiological investigations were no longer possible, the MoH started using big data and technological means to improve and expedite investigations (as of March 25^th). The MoH has been contacting individuals who have been in touch with an infected person via SMS and alerts them to self-isolate.

Borders were controlled and partially closed at a relatively early stage of the pandemic. On March 9^th, the country partially closed its borders:

• Residents returning to Israel from any country were required to self-quarantine for 14 days from the date of return;
• Tourists already in Israel were given time to leave the country over the following days.

2.     Mitigation phase

The mitigation phase started in March and included many physical distancing measures. These are updated frequently. Education facilities were closed on March 12^th, with very few exceptions.  Education continued through digital platforms. Public transportation has been discontinued on evenings and weekends, and day-time services have been reduced by 75%.

The Government declared a lockdown starting March 25^th (when there were about 2,500 cases). The lockdown added several restrictions and legal sanctions to the former guidelines and urged people to stay at home, reduce the number of workers at work, prohibited individuals from walking more than 100 meters from their home, and prohibited mass gatherings of over 10 people. Individuals not adhering to these regulations are fined.

Testing for COVID-19 has been made available for symptomatic individuals who: (1) had close contact or (2) were in touch with, or in the same place as, a diagnosed patient, or (3) arrived from abroad in the past 14 days, or (4) are in a severe health condition. Some hospitals have started periodically testing their staff.

Since mid-March the government has attempted to increase the treatment capacity for COVID-19 patients by converting geriatric hospitals and specialty units in hospitals into internal medicine (IM) wards while also increasing the number of ICU beds. The MoH has rented empty hotels to care for mild patients.

There was a shortage of nurses in Israel, even before the pandemic. To maintain an adequate supply of health care professionals (HCPs) to treat COVID-19 patients, on March 4^th the MoH prohibited HCPs from leaving the country. Apart from that, no logistical support has been given by the government, and no financial incentives have been provided to maintain the availability of HCPs.

No formal or centrally-led reorganization of hospital HCPs has been made, and this has been left to the hospitals’ discretion. In some instances, interns have been relocated from surgical wards and trained to help in medical wards with the COVID-19 treatment. This is necessary both because the patient volumes increased and because some of the HCPs get ill or are quarantined.

Elective hospital, diagnostic, and primary care were reduced significantly. Telemedicine is used for primary care purposes.

3.     Economic responses 

The government has approved an economic program for COVID-19 relief to support hospitals and HCPs which will cost millions of shekels and has already transferred some of the funds to hospitals to help them procure medicine and equipment. In a second stage, the plan is to have the Ministry of Finance (MoF) provide special funding to the HCPs.

Currently, the funds used to diagnose and treat COVID-19 come from HCP’s savings from their usual budget due to a large reduction in other services e.g., elective procedures.

As with any other health service funded by the NHI, diagnostic exams and hospitalizations related to COVID-19 are publicly provided without user chargers. Uninsured individuals such as non-residents or undocumented immigrants, receive screening and treatment free of charge on the basis of the Patient’s Rights Law.

Between March 1 and March 29, 764,165 citizens became unemployed. About 90% of them are on ‘unpaid leave’. The unemployment rate has risen from 3.4% in February to 22% by early April.

The Bank of Israel has announced plans to purchase Israeli government bonds to the sum of 50 trillion shekels (approximately 3.5% of GDP) to help Israelis cope with the economic repercussions of the pandemic.

4.     Reflection on COVID-19 response in Israel

All ministries have been working simultaneously to try and mitigate the impact of this virus on Israel (e.g., the MOH in addressing healthcare needs, MoF in developing economic relief packages, Ministry of Defence in protecting the citizens and assisting in implementing regulations, Ministry of Education in closing educational institutions). All these regulations and efforts have been implemented swiftly and with the purpose of minimizing the loss of life and “flattening the curve”.

Israel entered the pandemic with a robust economy, a good community and primary health care system, but an acute hospital system which was stretched, crowded and suffering from lower rates of hospital beds and nurses, compared to the OECD average. As the COVID-19 spread, the Israeli system started lacking resources specific for COVID-19 (e.g. appropriate protective gear, testing equipment, ventilators).

Israel’s overall response to the pandemic has been rapid. The prevention phase of the pandemic included closing its borders relatively soon after the outbreak in China and sending passengers coming from high risk areas to quarantine. The containment phase included quarantine of diagnosed individuals, but the capacity for testing suspected cases (in order to quarantine them) took longer to develop and is still not at the ideal strategy or capacity. The mitigation phase is being implemented with rapid and severe measures, almost on a daily basis, and includes social distancing, and a lockdown. Moreover, Israel has an incredible logistics “know-how” through its defence and Military system, that is able to mobilize fast and contribute to the implementation of social distancing measures.

There are certain less accessible populations due to language or cultural barriers, who were not properly reached by the prevention and containment efforts (e.g. ultra-orthodox Jews and Arabs). Cities majorly populated by these groups became the outbreak focus that require a different approach for mitigation of the disease. Israel is implementing tighter physical distancing measures in these cities, and its experience with special populations can be a good example of how to adapt responses to excluded populations such as low socioeconomic groups or immigrants.

The mortality rate in Israel is currently relatively low (0.5%) and this can be attributed to the rapid and extensive response from the Israeli government. The outcomes of these measures on other areas such as patients suffering from other conditions who had to delay treatment or the financial burden on small businesses, will be evident in the coming months and years.

 

[1] The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Israel;
[2] Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
[3] Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Germany.
⁴ Institute of Health Policy Management and Evaluation, Dalla Lana School Of Public Health, University of Toronto, Canada
⁵ McMaster Health Forum, McMaster University, Canada

 

Health Economics, Policy and Law serves as a forum for scholarship on health and social care policy issues from these perspectives, and is of use to academics, policy makers and practitioners. HEPL is international in scope and publishes both theoretical and applied work.