Israel’s School Health Service (SHS) is the vital institution in which public health nurses and some physicians provide vaccinations for schoolchildren; monitor their general health, vision, dental status, orthopedic condition, and psychological strengths, in addition to educating them about relationships with the opposite sex and the dangers of smoking, drinking alcohol and taking drugs. 

Thus, while the SHS is one of the key components of public health services throughout the country, it has gone through a number of upheavals and changes over the past three decades and declined due to Health Ministry negligence and the desire to save money and handing numerous services over to private providers. 

Jerusalem’s Taub Center for Social Policy Studies in Israel –and independent, non-partisan socioeconomic research institute that provides decision-makers and the public with research in the areas of education, health, welfare, labor markets, and economic policy – has just published a study that zooms into the fundamental problems of the SHS and presents five possible models for its 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. The researchers also note that the ongoing inconsistency in government policy toward the SHS and the lack of a uniform operating system on the national level has created confusion regarding the most desirable model for the service. 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 Health Ministry, 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, a guest researcher at the Taub Center and a member of the department for healthcare policy and management at Ben-Gurion University (BGU) of the Negev; Dr. Rami Adut from the School for Behavioral Sciences, Netanya Academic College and BGU; and Prof. Nadav Davidovitch, an epidemiologist, chairman of the Taub Center Health Policy Program and director of the BGU’s School of Public Health. 

“A failure to make decisions about human resources and the budgets needed to operate the school health service is not new. 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 education 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,” said Davidovitch.

The study highlights that while there is recognition of the SHS 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 SHS was 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 Finance Ministry and the Histadrut (General Federation of Labor) promising the direct employment of school nurses in the public sector.

“Privatization of social services and outsourced service provision is a complex issue that has been around for over 30 years. The SHS in its present form has many disadvantages, and it is to be hoped that lessons will be learned. The time period of Covid-19 has demonstrated the extent to which preventive health services, which are considered less prestigious, are in fact essential.” According to Adut, who is responsible for coordinating the public potline of the Association of Civil Rights in Israel (ACRI) in Jerusalem and for developing a new interdepartmental project designed to promote the right to health. 

There is a very low ratio of only one nurse to 5,000 students in the SHS. This shortage is essentially a reflection of the poor situation of general nursing manpower in the country, wrote the authors. The ratio of nurses to the population in Israel is among the lowest in the developed countries. 

The Taub Center study paints a worrisome picture of the SHS, 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 public health services within the overall health system,” declared Levi, is a postdoctoral fellow and a teaching fellow at BGU. 

Between 1997 and 2003, there was one SHS nurse per 1,600 pupils in the period. There has been an increase of about 400,000 pupils nationally in grades one to nine in the past 20 years, and in the nationalized districts, the number of job positions has not kept pace with this population growth.

The SNS focuses on vaccinations, developmental tests, and screenings that are all easily measured and evaluated but neglects important areas like health education. It rests on two principal pillars: preventive medicine and health promotion. The preventive medicine component is easily quantifiable. In 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. 

As the quantitative evaluations of the SHS’s preventive medicine services provide the ministry with data regarding the service’s performance, 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 Northern district and the Southern district, where the numbers are particularly low, it seems that for grades five and six, there is almost no activity in health education. All three of these districts receive the SHS 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, they wrote. 

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 SHS is nationalized and run directly by the ministry, while in others, it remains privatized and operated through public licensees. “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,” said Levi. 

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 regarding service provision, the nurse’s place within the service, and its integration with Tipat Halav (public health mother and child wellness clinic service).

Taub Center president Prof. Avi Weiss concluded: “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 comprehensive thinking of the issues and smart planning.”