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Shifra Shvarts, Health and Zionism: the Israeli health care system, 1948–60, Rochester Studies in Medical History, Rochester, NY, University of Rochester Press, and Woodbridge, Suffolk, Boydell and Brewer, 2009, pp. xxi, 322, illus., £45.00, $80.00 (hardback 978-1-58046-279-2).
In this major new contribution to health systems history Shifra Shvarts sets the making of health services in Israel against the coming of statehood. The time frame of the book is short, but of fundamental significance to the form the Israeli health system was to take. Her earlier work has already laid the foundations, with a study of Kupat Holim, the workers’ health insurance fund which dominated the financing and provision of Eretz Israel's health care in the interwar period. In the introduction she recapitulates these findings before proceeding to an account which charts the failure of policy-makers to push through their preferred model of health service organization. The result, she stresses, was to leave Israel with its pluralist structure, which satisfied some interest groups but delayed universal coverage and instilled enduring “performance problems” (p. xii).
By necessity health care before 1948 had been the remit of civil society organizations, Kupat Holim, the minor sick funds and Hadassah, a provider financed by American philanthropy. However, statehood, war and mass immigration pushed the government into the field, with a military medical service and a new Ministry of Health. The policy question was therefore whether to nationalize the pre-existing services, as was done with education, or to embrace a mixed economy combining public and third sectors. The champion of the state as principal agent was Chaim Sheba, who, as director general of the Ministry of Health in 1950, advocated a service “based on the British system” (p. 148). David Ben-Gurion was also supportive, regarding pluralism as financially wasteful and inefficient, in that it separated preventive and curative efforts.
In explaining why the mixed economy persisted, Shvarts begins by outlining a bitter dispute between doctors and managers of Kupat Holim over pay and conditions. The personal animosities this inspired then carried over into the early involvement of the state, when dissatisfied doctors abandoned the sick fund for public sector employment, and on into the nationalization debate. The central section of the book details the politicking following the Kanev Plan, a loose blueprint which could have been the basis of a comprehensive service. This was opposed by Kupat Holim, which exploited its affiliation to the Federation of Labour to marshal support from the Left, arguing that its demise would undermine the broader labour movement. Thus in alliance with the middle-class Progressive Party, representing hostile doctors, the plan was scotched. The closing sections detail the consolidation of Kupat Holim's position, and by extension, of the pluralist structure. The crucial issue was the insufficiency of the state in tackling the medical needs of new immigrants, many of whom, including Holocaust survivors, were in desperately poor health. In describing the response of the various agencies Shvarts provides an essential context for the insights into early public health in Palestine/Israel which scholars like Nadav Davidovich and Rakefet Zalashik have recently begun to produce.
The method is principally documentary analysis of material from government, professional associations and the insurance funds. This is presented as detailed narrative, with only occasional pause for conceptual discussion. However, in a key analytical passage Shvarts argues that the heightened conflict between the different players was essentially a legacy of abrupt colonial withdrawal and the power vacuum which ensued, generally at odds with “a Jewish political culture … remarkably free of violence” (p. 168).
Despite this reading, comparative health systems historians will find much which is familiar. For labour mobilization theorists who stress the role of the organized working class in encouraging social democratic welfare states, Israel provides a particularly interesting variant. Here labour's fissure, between the centrists and socialists, actually impeded the adoption of a comprehensive, universal system. Israel also adds a classic case study for those whose explanatory framework foregrounds the power of the medical profession, the capacity of governance structures to facilitate or frustrate change, and the scope at key junctures for forging solidaristic alliances favouring reform. From this perspective the obstructionism of the doctors’ lobby seems less exceptional, despite Shvarts’ emphasis on the importance of personalities. Similarly the polity-based analysis would surely predict that the odds of major reform were never good: Israel's political system accommodated diverse parties founded on political or religious beliefs and its coalition governments depended on fragile compromises between them. Indeed in the pivotal phase, 1950–55, government changed hands six times, with the turmoil providing plenty of veto opportunities for opponents.
The broader health systems perspective also directs attention to issues Shvarts raises but leaves unresolved. Kupat Holim had envisaged coverage for all citizens regardless of race and creed, and the Kanev plan would also have included Arab citizens (p. 112), but what was the result for non-Jews in practice? This question is not addressed, despite the presentation of data on differential health outcomes according to religious background (p. 160), which show that during the 1960s from a poor start Jewish mortality indicators became markedly better than those of Moslems and others. Similarly, the focus on “health and Zionism” by necessity excludes the larger regional context. This is frustrating, since Shvarts’ “decolonization” observations beg the question of how services developed in the West Bank and Gaza, especially given that under the mandate Britain had concentrated on Arab needs (p. 16). The impact on Palestinian health provision of the political and military pressures described in the book thus remains a pressing historical problem.
Finally, the publishers may note the slapdash quality of the copy-editing. “Pommel” for Rommel (p. 72) and “public hearth” (p. 183) are two egregious examples. This reader would also have preferred a copy whose binding did not shed black ink all over his fingers!