3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
Rosen, B., Waitzberg, R. & Israeli, A. Israel’s rapid rollout of vaccinations for COVID-19. Isr J Health Policy Res 10, 6 (2021). https://doi.org/10.1186/s13584-021-00440-6
As of the end of 2020, the State of Israel, with a population of 9.3 million, had administered more COVID-19 vaccine doses than all countries aside from China, the US, and the UK. Moreover, Israel had administered almost 11.0 doses per 100 population, while the next highest rates were 3.5 (in Bahrain) and 1.4 (in the United Kingdom). All other countries had administered less than 1 dose per 100 population.
While Israel’s rollout of COVID-19 vaccinations was not problem-free, its initial phase had clearly been rapid and effective. A large number of factors contributed to this early success, and they can be divided into three major groups.
The first group of factors consists of long-standing characteristics of Israel which are extrinsic to health care. They include: Israel’s small size (in terms of both area and population), a relatively young population, relatively warm weather in December 2020, a centralized national system of government, and well-developed infrastructure for implementing prompt responses to large-scale national emergencies.
The second group of factors are also long-standing, but they are health-system specific. They include: the organizational, IT and logistical capacities of Israel’s community-based health care providers, the availability of a cadre of well-trained, salaried, community-based nurses who are directly employed by those providers, a tradition of effective cooperation between government, health plans, hospitals, and emergency care providers – particularly during national emergencies; and support tools and decisionmaking frameworks to support vaccination campaigns.
The third group consists of factors that are more recent and are specific to the COVID-19 vaccination effort. They include: the mobilization of special government funding for vaccine purchase and distribution, timely contracting for a large amount of vaccines relative to Israel’s population, the use of simple, clear and easily implementable criteria for determining who had priority for receiving vaccines in the early phases of the distribution process, a creative technical response that addressed the demanding cold storage requirements of the Pfizer-BioNTech COVID-19 vaccine, and well-tailored outreach efforts to encourage Israelis to sign up for vaccinations and then show up to get vaccinated.
While many of these facilitating factors are not unique to Israel, part of what made the Israeli rollout successful was its combination of facilitating factors (as opposed to each factor being unique separately) and the synergies it created among them. Moreover, some high-income countries (including the US, the UK, and Canada) are lacking several of these facilitating factors, apparently contributing to the slower pace of the rollout in those countries.
The agreement between Pfizer and Israel
On January 17, the MoH published in full the “REAL-WORLD EPIDEMIOLOGICAL EVIDENCE COLLABORATION AGREEMENT” signed on January 6, 2021, between the Israeli Government and Pfizer. This is a standard agreement for clinical trials between hospitals or health plans and research entities, where health providers provide anonymized medical records. The agreement is used in general for clinical trials organized between a commercial/industrial sponsor and a research institution (e.g., a hospital). The agreement follows all regulatory requirements of the health system:
1. The Israeli Patient’s Rights Law, 1996, as amended;
2. The Israel Privacy protection law, 1981, as amended;
3. the Israel Public Health Ordinance, 1940, as amended;
4. the Israeli Pharmacist Regulations (Medical Preparations), 1986, as amended;
5. the Israeli Freedom of Information law, 1998, as amended;
6. anti-bribery laws including the U.S. Foreign Corrupt Practices Act 1977, as amended; and
7. Global Trade Control Laws.
The objective of the collaboration agreement is “to measure and analyze epidemiological data arising from the product’s (the vaccine) rollout, to determine whether herd immunity is achieved after reaching a certain percentage of vaccination coverage in Israel. According to the agreement, MoH will provide Pfizer with epidemiological data. Data will be aggregated and anonymized.
Besides the data that will be provided at the end of one year, the MoH will provide Pfizer with weekly epidemiological data transfers that include the following information:
• Confirmed COVID-19 cases / week
• Confirmed COVID-19 hospitalizations / week
• Confirmed COVID-19 severe/critical cases / week
• Confirmed COVID-19 ventilator use / week
• Confirmed COVID-19 deaths / week
• Symptomatic cases / week
• Weekly numbers of vaccinees, as total and by age and other demographic subgroups.
• Number of cases per week by age groups, and other demographic factors.
Both parties will provide each other with Ancillary Documents regarding the data such as documentation of statistical programming algorithms, methodologies used, analysis assumptions or plans etc., as needed. Any analysis and results thereof that Pfizer may perform will be shared with the MoH to discuss and finalize jointly.
No funding will be provided under this agreement. Project data is collected on a routine basis by MoH for epidemiological, logistical and oversight purposes to monitor pandemic and vaccination statuses.
Vaccine administration and rollout updates:
As of December 11, the Minister of Health has instructed the Pharmacy Department in his office to review FDA approval and submit recommendations going forward. This included the creation of a “prioritization plan for the vaccine”. The tentative plan is to first vaccinate medical staff in Israeli hospitals, and about a week later, to start the full vaccination campaign. About a week or two before the vaccines are given to the public, an information campaign will be launched due to the public's concern and uncertainty regarding the vaccines. The Ministry of Health also decided to grant a "green pass" to the vaccinated a week after receiving the second dose of vaccine, in order to motivate the population to get vaccinated. The "green pass" will grant its holders mitigations from restrictions of movement, isolations and gatherings. The current daily target for vaccinations is 60,000, but it is possible that this target will increase in the near future as the number of vaccines that have arrived in Israel so far exceeds expectations (about half a million). In the first stage, people suffering from allergies, lactating women and pregnant women will not receive the vaccine.
The MoH determined (on December 16) that the initial target groups for vaccination would be medical personnel and soldiers suffering from background illnesses. Then, medical staff and front-line health care workers, residents of mental health care facilities, nursing home residents, people aged 60+, and other people with severe immunosuppression such as organ transplant recipients. On second priority were additional groups at risk (diabetes, morbid obesity, significant lung disease, etc.), and high-exposure groups such as schools and kindergarten teachers, prisoners and wardens, and first-response services. The basis for these decisions was the protection of at-risk population, and of groups of highest exposure to the virus. The IDF and other security services received a separate allocation of vaccines, and were eligible to receive a vaccine with no relation to other criteria of eligibility.
Access to vaccines is granted free of charge also for some uninsured populations such as foreign workers and asylum seekers. Although, the access is not entirely universal, as there are still populations that are not eligible to be vaccinated at the vaccine center for foreign population. For example: international students, diplomats, uninsured "returning residents" and more. Those who wish to get vaccinated need to schedule an appointment on a dedicated website and are asked to come with a passport or a visa.
20.12.20 – COVID-19 vaccinations have started in Israel
Israeli residents began to receive the Pfizer/BioNtech COVID-19 vaccine on 20 December, 2020. The vaccine is being given by hospitals and health plans' primary care clinics. Residents eligible for the COVID-19 vaccine at present are heath care workers and individuals over the age of 60. There is no need for a referral from a doctor.
Healthcare workers are being vaccinated by their employers or contractors, either hospitals or health plans. Individuals can schedule an appointment for the vaccine directly with their health plans. Health plans have arranged and converted ambulatory clinics into vaccine stations. This implies an organized and decentralized logistical approach, with a broad availability and accessibility to residents throughout the country.
Long-term care institutions and nursing homes are the main focus of the vaccination strategy, and teams of the MoH have been vaccinating all residents and workers of these institutions. By mid-January all nursing homes and LTC institutions will be vaccinated. The vaccination policy aims at vaccinating the entire adult population before summer. Special rights will be granted for vaccinated individuals such as permits to enter public closed areas as well as exemption from quarantine.
10.01.21 – Update on Israel's vaccination operation
The Ministry of Health is the body responsible for the vaccination policy. The operating bodies in principle are hospitals, HMOs and Israel's national emergency services (MDA).
The MoH formed a monitoring committee on the vaccination campaign; collects data on side effects, immunization rates, morbidity, and mortality; and conducts effectiveness tests which are a measurement of the risk for illness for people who have been vaccinated in two doses compared to people who have not been vaccinated at all. Comparisons are also made via a division to groups based on number of days elapsed after the reception of the 2nd dose of the vaccine (7 or 14 days).
HPs are also conducting studies comparing vaccinated with of non-vaccinated groups, with hundreds of thousands of participants in each group, to examine the effectiveness of the vaccine after the 1st, and the 2nd dose of the vaccine.
In addition, Pfizer, which receives data from the Israeli government in accordance with the agreement signed with it, (see above) also conducts research on the effectiveness of the vaccine in preventing infection, asymptomatic infections, symptomatic morbidity, serious illness and death. Pfizer publishes a summary of the data of the vaccination campaign in Israel.
In cases in which not all of the defrosted vaccines are used for the priority groups (either because of no-shows or because too many doses were defrosted), HPs were also calling on non-priority individuals to get vaccinated, to avoid the wasting of the doses.
Implementation and Administration of COVID-19 vaccines:
For the implementation, Israel opted for simplifying the eligibility criteria and called for all residents aged 60+ and all health workers to get vaccinated in the first phase of the distribution process (from December 2020 to February 2021).
Going forward: The expectation is that after February 2021 the eligibility to the vaccines will be open to all residents, who will be able to make an appointment through their health plans, just as for a regular flu vaccine.
The responsibilities for vaccinating each population group were also clearly defined:
• The responsibility for vaccinating the general population over the age of 60 and individuals with comorbidities was assigned to the four health plans
• Responsibility for vaccinating nursing home residents was assigned to Israel’s national emergency services organization
• Responsibility for vaccinating front-line health workers was assigned to the hospitals and health plans employing them
There are no private providers involved in the vaccination process. All vaccines are provided by the statutory health system free at the point of care. HPs invite the eligible population under their responsibility to get vaccinated via SMS messages, and offer to book appointments independently by phone or digitally via the HPs’ portal. Individuals then can schedule an appointment for the vaccine directly with their health plan. Scheduling of 2nd dose appointment is done automatically to three weeks after receiving the 1st dose of the vaccine. Israel’s national emergency services are the ones responsible for vaccinating nursing home residents, and the responsibility for vaccinating front-line health workers was assigned to the hospitals and HPs employing them.
Nurses are authorized to administer vaccinations without physicians being present. Since most of the outpatient nurses are employed by HPs, nurses were able to be rapidly deployed to the vaccination campaign. Hence, the vast majority of vaccines were administered by nurses.
The vaccines were initially administered in designated complexes that have been either established or converted for the purpose of the vaccination campaign, led by the control center of the MoH and with the assistance of the Home Front Command of the army, and in cooperation with the local authorities. Portable immunization stations were set up in remote areas and in places where there is difficulty in building orderly immunization complexes. In addition, a focus was put on long-term care institutions and nursing homes during the vaccination strategy. Teams of the MoH have been vaccinating all residents and workers of these institutions. During a second stage, on January 2021, less than a month after the vaccination campaign has started, the HPs moved the vaccination sites from big complexes to their primary care clinics spread in the community. This allowed a better access to vaccination sites, particularly in the periphery and remote areas.
Supply chain management and logistic issues
"Pfizer" is responsible for transporting the vaccines from the US to the logistics centers in Israel. From there, the vaccines are collected by the logistics company of the pharmaceutical company "Teva" and of another private logistics company, and distributed to HPs (Health Plans) throughout the country. From the moment the vaccines packages leave the US factories, and until they land and are distributed in Israel, they are under electronic surveillance, to make sure that the vaccines are kept under the required conditions, particularly temperature. The HPs, which are the bodies responsible for the administration of vaccines to all residents, oversee and monitor expiry dates of the inventories they receive.
Repackaging for the purpose of vaccine doses mobilization: the Pfizer vaccines come in pallets of 1,000 vaccines, and once they come out of a deep freeze they must not be transported. Thus, it was not initially possible to mobilize the vaccines to remote places in the countryside. As a result, Israel received permission from the manufacturer to repackage the doses into tens and hundreds per shipment, thus obtaining a solution for the safe mobilization of fewer vaccines that allows for vaccinations in small and remote places as well as nursing homes - and without losing vaccine doses.
The Minister of Health instructed the director general of his office to work to provide vaccinations 24/7, to recruit manpower for this purpose and to reach a rate of more than 100,000 vaccinations per day. Health plans deployed their employed nurses to administer the vaccination. They have been working extra-hours, and have reduced their non-COVID19 duties (e.g. monitoring chronically ill, pregnancies etc).
13.01.21: Vaccination Rollout – second dose started, all nursing homes vaccinated, eligibility broadened for residents aged 55+
As of January 7, approximately 1.5 million people had already received their first vaccination dose. Second doses of the vaccine began being administered on January 10. By January 11, Israel had vaccinated 1.8 million, including 72% of the elderly and all members of nursing homes and long-term care institutions and thus began vaccinating residents aged 55+.
26.01.21: Vaccination operation updates
On January 19, the MoH determined that the vaccine could be given to residents aged 40+. On January 23, some HPs also began vaccinating 17–18-year-olds, to allow them to return to school and so that they can sit for the matriculation exams at the end of the lockdown. As of January 25, Israel has administered approximately 2.7 million first-dose vaccinations, and 1.25 million second-dose vaccinations.
03.02.21: Vaccination operation updates
The criteria of eligibility for getting the vaccine were broadened and included more age groups every week or so, until determining that all residents aged 16+ are eligible since February 3. This decision follows the decrease (by nearly 50%) in the number of new vaccinations in the current recent week.
As of February 3, Israel has administered approximately 3.2 million first-dose vaccinations and 1.9 million second-dose vaccinations, about 35% and 20% of the overall population, respectively. Among the eligible population (residents aged 16+, excluding those who have previously been diagnosed with COVID-19), the vaccination coverage is currently over 52%. The vaccination coverage is particularly high among older population groups: 93% of those aged 70-79 and 86% of those aged 80-89 have received at least one dose so far. Israel has the capacity to vaccinate about 250,000 people daily.
21.02.21: Vaccination operation expands beyond health plans’ clinics
Several efforts are employed to speed up the vaccination campaign: For example, the opening of vaccine-designated areas, the sending of mobile vaccination units to remote places, nurses have been working extra-hours and have reduced their non COVID-19 duties, and the campaign for vaccinating people confined to their homes. Further, there is a social incentive in the form of the green pass initiative (see below) which allows those who have been vaccinated with a 2nd dose to enter entertainment venues such as hotels and guesthouses, restaurants, concerts, and sporting events. There were also plans to provide financial incentives to HPs for excellence, and to pay a bonus to doctors for vaccinating people from certain age groups (50 and older) to speed up the vaccination campaign. Although, these financial incentive plans have not yet been implemented, and it is not at all certain that they will be implemented.
On February 21, universities started to collaborate with the health plans and launched vaccination days inside the campi for students and employees – for members of all health plans. These vaccination days will be held for both doses. Moreover, manufacturers associations have agreed on a national vaccination campaign in collaboration with the MoH, Home Front Command and Israel's emergency services (MDA). This campaign aims to promote vaccination among workers. Many of the leading companies in the Israeli economy immediately responded positively to the campaign. Most of them are supporting the general vaccination campaign with information and health communication among their employees. Some brought vaccine mobile units to factories and workplaces, and some are offering encouragement gifts and even a day off as a gift for employees who suffer from side effects from the vaccine.
21.02.21: The vaccine "green pass" – getting back to routine in the midst of the vaccination campaign
In order to allow a return to routine of life in a responsible and controlled manner, from Sunday, 21.02.21, businesses and public leisure, culture and sport places will reopen for vaccinated or recovered individuals only.
Individuals willing to enter these spaces/ business have to present a "green pass". The document is scanned by the business, along with an ID card. Individuals and business who use these spaces without a "green pass", are subject to a fine.
As of February 21, it is no longer possible to present a negative COVID-19 test result to enter places that require a green pass, as well as for children under the age of 16, except for hotels and accommodation complexes.
The green pass is currently available only under the following cases:
• Having a valid vaccination certificate – People who have completed two vaccine doses and at least one week has passed from the date of receiving the the second dose.
• Recovered, with a certificate of recovery – whether they were confirmed patients or received a positive result in a serological examination.
The types of businesses, institutions and events that can only be entered with the green pass:
• Cultural and sports events - with prior reservations, seating only and without breaks, dancing or eating. Up to 75% occupancy; up to 300 people indoors and up to 500 people in open spaces.
• Gyms, studios and swimming pools: one person per 7 square meters or up to 10 people in a building, and up to 20 people in an open space, while maintaining a distance of 2 meters from other people (unless there is a partition), and without the use of Jacuzzi or a sauna. Number of people in the pool is restricted to one person per 6 square meters.
• Exhibitions - with prior reservations. One person per 7 square meters, up to 300 people indoors and up to 500 people in an open space.
• Hotels, guest complexes and B&Bs that operate 6 accommodation units or more – without the operation of dining rooms. Children up to the age of 16, who received a negative result in a COVID-19 test performed up to 48 hours before arrival at the hotel – are allowed in.
• Areas declared as a special tourist area ("tourist islands") - can be entered by presenting a green pass or a vaccination/recovery certificate, or by presenting a negative result in a COVID test performed up to 72 hours before arrival.
• Worship houses that choose to operate under the green pass - up to 50% occupancy, up to 300 people indoors and up to 500 people in open spaces.
Issuing of the green pass
The pass can be issued in Hebrew Arabic, Russian and English, in one of the following ways:
• MoH website – issuing and printing a “green pass”.
• MoH “traffic light” application – after the pass is issued, it can be displayed in the app.
• Call center – the certifiacte can be requested by e-mail, fax or mail, using the MoH’s voicemail. The certiicate will be printed on paper and a barcode will be embedded inside.
On March 7, a vaccination campaign began for Palestinian workers holding a valid employment license in Israel and in the settlements, in accordance with the approval of the political echelon and with the aim of maintaining public health standards and the functioning of the economy.
MoH has launched a vaccination campaign for people confined to their homes. The vaccination was administered by joint teams of the HPs' nurses and Israel's' emergency services (MDA), who were mobilized to reach the homes. The teams either move from home to home to administer the vaccinations, or carry confined people to vaccination complexes by ambulances.
The government has decided on an outline that will allow entry for vaccinated tourists from foreign countries in groups, beginning May 23, 2021. Entry will be allowed based on a quota to be determined at a later time (see “Borders” in Section 6.1 for further details).
27.04.2021 Further relaxation of public health restrictions
Occupancy restrictions for places that are part of the green pass initiative will be abolished beginning May 6, 2021. Children and people who cannot be vaccinated are able to access amenities currently restricted to green pass holders via speedy PCR tests (relaxations subject to government approval and morbidity and mortality rates; see “Israel’s third lockdown” in Section 1.2 for further details).
16.5.2021 - Vaccination of children aged 12-15
The manufacturer Pfizer has already given permission to vaccinate this age group, and the FDA has also given its approval. However, MoH is still discussing the need to vaccinate this population, given the already high vaccination rate in Israel, accompanied by very low rates of morbidity. There is still no sweeping approval or an outline for vaccinating 12–15-year-olds. Nevertheless, an exceptional authorization was given to vaccinate children aged 12+ who belong to higher risk groups, including conditions such as obesity, lung injury, diabetes and those undergoing chemotherapy.
At the beginning of the outbreak in Israel, all patients were taken to hospitals to limit the spread of the virus. Once the virus had continued to spread, it was no longer possible to hospitalize all patients. As of March 30, severe patients were being taken to hospitals where the most intensive treatment of COVID-19 is provided. Mild cases are sometimes placed in geriatric hospitals or empty hotels that have been converted into internal medicine (IM) wards in order to ensure that they do not infect other household members. Yet, patients with mild cases stayed at home, where they are monitored by HP professionals. However, the current policy is to encourage them not to stay at home (in order to not infect other members of the household) and instead to move to care facilities. Patients do not always comply with this recommendation; apparently this is due in part to fear of not being treated properly and/or fear of leaving the family. Elective procedures have been reduced to a minimum, to enable the medical staffs to focus on the treatment of COVID-19 cases and reduce spread of the virus.
Outpatient health professionals, including those involved in primary care, are mostly treating COVID-19 patients remotely because they do not have proper protective equipment, and the MoH wants to avoid spread of the virus in outpatient facilities (e.g. in the waiting rooms). Primary care physicians were involved when hospitals were already crowded, and they are now helping with initial screening, particularly to rule out individuals with similar symptoms and with monitoring diagnosed cases who stay at home. Another important role of primary care providers is to support patients through designated on-line and telephone centers. These centres provide medical information and mental health assistance as needed.
New and clear definition of COVID-19 illness severity and treatment guidelines
Different hospitals had different definitions of “severely” ill COVID-19 patients, which caused confusion in reporting to the ministry of health, and sometimes variations in treatment paths of patients. In order to harmonize the definition and set standard paths of care, and treatment guidelines, the ministry of health issued on July, 12th, 2020 a circular with clear definitions of “severely” ill COVID-19 patients. The definition is based on COVID-19 severity definitions from the American National Institute of Health (NIH), the WHO and other academic publications. Patients are to be classified as follows:
i) Mild illness – patients with COVID-19 symptoms: fever, cough, weakness, loss of taste and smell
ii) Moderate illness – patients with clinical or X-ray diagnosis of COVID-19 Pneumonia
iii) Severe illness – patients with COVID-19 symptoms and and one of the following:
1. Breathing shortage: faster than 30 breaths per minute
2. a saturation of oxygen (SpO2) ≥93% on room air at sea level.
3. PaO2/FiO2 ratio lower than 300
iv) Critical illness - Patients in need of mechanical breathing assistance (invasive or non-invasive) or Individuals who have respiratory failure, septic shock, and/or multiple organ dysfunction.
(General Medicine Division MoH, Unified definition of hospitalized COVID-19 patients, 294754420)