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While the school health service is one of the key components of public health services in Israel, it has gone through a number of upheavals and changes over the past thirty years. On Monday, the Taub Center for Social Policy Studies in Israel published a study that discusses the fundamental problems of the school health service and presents five possible models for the service’s operation.

The findings of the study point to a chronic shortage of nurses in the service, a deterioration in the status of the nursing profession, and difficulties in measuring and evaluating the functioning of the service.

In addition, the researchers explain that the ongoing inconsistency in government policy toward the school health service and the lack of a uniform operating system on the national level has brought a lack of clarity regarding the most desirable model for the service. Thus, over the years, as a result of continuous planning failures, the school health services have been “balkanized,” with some districts of the country having a nationalized service operated by the Ministry of Health, while others operate through outsourcing to private companies.

The researchers express concern that the current situation – the result of a variety of circumstances, constraints, and conflicting forces – is likely to become permanent without proper professional or scientific justification.

The research was conducted by Dr. Baruch Levi, guest researcher at the Taub Center and a member of the Department for Healthcare Policy and Management, Ben-Gurion University of the Negev; Dr. Rami Adut from the School for Behavioral Sciences, Netanya Academic College and Ben-Gurion University of the Negev; and Prof. Nadav Davidovitch, Chair of the Taub Center Health Policy Program and Director of the School of Public Health, Ben-Gurion University of the Negev.

“A failure to make decisions about human resources and the budgets needed to operate the school health service is not new,” said Prof. Davidovitch. “During the time of COVID-19 in particular, we have seen the tremendous importance of the presence of a school nurse – a figure whose job is much more than simply giving vaccinations and carrying out periodic screening tests. The presence of a figure who has an important role in health education, who can assist the educational staff in identifying distress, and who can advance health by working with the students, the teachers, and the community, is a critical need that was only strengthened by the pandemic.”

The study highlights that while there is recognition of the school health service as an important public service, there have been years of uncertainty regarding both the operating model for the service and its adaptation in light of population increases and developments in the services offered. The school health service is nationalized in the Southern District, Ashkelon, and the North, while in the other districts and large cities (Jerusalem, Tel Aviv, and Haifa), the service has remained privatized, despite an agreement reached in 2015 between the Ministry of Finance and the Histadrut (General Federation of Labor) promising the direct employment of school nurses in the public sector.

According to Dr. Rami Adut, “Privatization of social services and outsourced service provision is a complex issue that has been around for over three decades. The school health service in its present form has many disadvantages, and it is to be hoped that lessons will be learned. The time period of COVID has demonstrated the extent to which preventive health services, which are considered less prestigious, are in fact essential.”

A low ratio of one nurse to 5,000 students in the school health service

The shortage of nurses in the school health service is essentially a reflection of the poor situation of general nursing manpower in Israel: The ratio of nurses to population in Israel is among the lowest in the developed countries. According to OECD data, in Israel, there are five nurses for every 1,000 population versus an OECD average of 9.5.

The Taub Center study paints a worrying picture of the school health service, which is characterized in part by a shortage of manpower and difficulties in filling nursing positions.

“The future of the school health service is dependent, first and foremost, on solving more basic healthcare problems related to manpower challenges, the definition of the role and professional standing of the school nurse, and more generally, the place of the public health services within the overall health system,” emphasized Dr. Baruch Levi.

The chronic shortage of public health nurses is also reflected in the number of students per nurse, with only one nurse per 5,000 students since 2010, as compared to one nurse per 1,600 students between 1997 and 2003. There has been an increase of about 400,000 students nationally in Grades 1-9 in the past 20 years, and in the nationalized districts, the number of job positions has not kept pace with this population growth.

The school health service neglects important areas like health education

The school health service rests on two principal pillars: preventive medicine and health promotion. The preventive medicine component, which includes vaccinations, developmental tests, and screenings, is easily quantifiable. By contrast, the health promotion component includes “softer” elements that cannot be easily quantified or evaluated over the long term, including providing advice and guidance to students, parents, and educational staff, identifying risky behavior, and running school programs to promote healthy living.

Quantitative evaluations of the student health service’s preventive medicine component provide the Ministry of Health with data regarding the service’s performance, while the less easily evaluated field of health promotion has been pushed aside.

For example, even for the single annual health education lesson per class that is included within the student health basket, there are substantial differences between districts. In Ashkelon and the Southern district, health education is covered in only 33.6% and 11.4% of classrooms, respectively, compared to a national average of 75.5%. In the Southern district, where the numbers are particularly low, it seems that for grades 5 and 6, there is almost no activity in health education. The same holds for the Northern district. All three of these districts receive the student health service as part of the nationalized program and are located in the geographic periphery.

The desirable model for school health services must also consider the needs of the school nurses and their professional stability

One of the most striking findings of the study is the abundance of opinions regarding the most appropriate framework for operating the service. Today, in certain districts, the school health service is nationalized and run directly by the Ministry of Health, while in others, it remains privatized and operated through public licensees.

Dr. Levi explained, “The question of how the service is provided – whether it is outsourced or supplied directly by the state – is an important question, but when choosing the most appropriate operating model, it is important to bear in mind equally important factors such as the job description of the school nurse, their professional affiliation, terms of employment, gaps in the level of service provided by the different districts, and methods of evaluation and measurement of the service.”

The study presents five possible operating models: a model based entirely on outsourcing, a decentralized model (outsourcing or operated by the government), the “schools promoting health” model, service provided through a nationalized and uniform model, and health services operated by local authorities. Each model has its own characteristics with regard to service provision, the place of the nurse within the service, and its integration with Tipat Halav (public health mother and child wellness clinic service).

Prof. Avi Weiss, President of the Taub Center, added, “There is no doubt that within the school health service there is an important opportunity to advance public health. Regardless of the service model that is ultimately chosen, optimal advancement of the health of students and their families in Israel requires a comprehensive approach to the issues and smart planning.”