Policy responses for Israel - HSRM


Policy responses for Israel

5. Governance

5.1 Governance

The GOVERNANCE of the health system with regard to COVID-19 relates to pandemic response plans and the steering of the health system to ensure its continued functioning. It includes emergency response mechanisms, as well as how information is being communicated, and the regulation of health service provision to patients affected by the virus.

MoH circular 35/05 from 2005 specifies how Israel should prepare for a flu pandemic, based on WHO recommendations and on a MoH working document on preparedness of the Israeli healthcare system for an outbreak of pandemic influenza strain. It draws on data and experience from previous flu epidemics such as avian influenza from 1997.

The pandemic response plan includes directives to healthcare managers such as hospital CEOs, health plan directors and chief physicians to prepare detailed action plans for responding to pandemics at different levels. The response plan assumed that most of the care would be provided in outpatient settings. The document defines the conditions for hospitalization and the course of treatment, based on SARS disease, including isolation. It designates one special diagnostic laboratory in a hospital to test for SARS (although in practice currently 28 laboratories are diagnosing COVID-19), and mandates epidemiological research/tracking. In addition, the response plan includes guidelines for protecting workers in the poultry market against avian influenza. The response plan recommends to the MoH that it stock antiviral medications, build infrastructure in hospitals such as isolation rooms, low-pressure rooms, emergency rooms; and carry out simulations of responses to pandemics.

A report by the State Comptroller (ombudsman) from March 2020 (SC, 2000) showed that despite the pandemic response plan recommendations, few of the recommended actions had been implemented. According to the report, there are not enough antiviral medicines; the MoH had defined action plans for only a small number of selected diseases; and the MoH had not set guidelines regarding the vaccine stock required at the onset of various illnesses and how they should be stored. Moreover, there was no mechanism for updating the budget of the public health services (which are the responsibility of the MoH) including preventive medicine.

The MoH signed a decree of the Public Health Ordinance to expand its powers in dealing with the COVID-19 pandemics on 27.1.20. The Prime Minister and the General Director of the MoH have been leading the national response to COVID-19 since the beginning of the pandemic in January in China. Public health specialists at the MoH advise decision-makers, and decisions are made at the central level. The MoH also coordinates surveillance, communication and reporting: it periodically releases information about the outbreak severity (i.e., the number of diagnosed, severely ill, hospitalized, deaths). The MoH website provides an up-to-date interactive map with the precise locations of exposure to COVID-19 cases, with date and time (for example, a certain synagogue, or a grocery store), and another map with the number of individuals in home isolation, by city. Until mid-March, it also published all diagnosed cases with details of the places which the patient frequented, and flights or trains used, since the initial symptoms. This information was widely published by the local media (newspapers, television, radio). After that, there were too many cases to be followed individually, and the MoH moved to map based presentation of the data. There have been briefings, almost on a daily basis, by the Prime Minister, who appears alongside other relevant Ministers and selected experts. Many public health specialists and professors, from all universities, communicate information on a daily basis through the mass media and social media.

28.4.20: Data to support exit planning:
At the beginning of the pandemic, Israel was one of the first non-Asian countries to react with border and travel restrictions put in place in early February 2020. Israel was also one of the first countries to implement physical distancing measures in early March (see chapter 1.2 – physical distancing). Nevertheless, as the pandemics developed, many ministries studied and learned from COVID-19 responses in other countries, each from its perspective. Research teams at various ministries have searching other countries’ ministries websites and press. Regarding exit measures, Israel has been learning from the experience of early adopters of exit strategies such as the Czech Republic, Denmark and Asian countries. As other countries implement exit measures, Israel adds them to the list of learning cases.

The government has been making decisions regarding exit measures taking into consideration both the economic and the epidemiologic aspects of the lock-down. Regarding epidemiological aspects, the MoH has determined the responses to COVID-19 based on three main indicators: (1) number of available ventilators compared to the number of ventilated, and (2) the number of severely ill individuals, are the main reliable indicators of the development of the disease in Israel, as the screening of diagnosis was not uniform or regular. (3) Emergency care units are considered the main resource consumed by COVID-19 patients, and the main constraint of the Israeli healthcare system to cope with the disease. The mortality rate from COVID-19 in Israel has been relatively low, but it is not used as an indicator for decision making regarding exit planning.

Regarding the economic aspect, the Ministry of Finance (MoF) built various economic forecasts for the effects of the lock-down based on many scenarios. All forecasts concluded that the economy would not resist more than 5 weeks without activity, which influenced much of the COVID-19 responses, particularly the length of the quarantine.

Apart from exit strategies prepared by the MoH and MoF, various other organizations submitted exit plans to the government, such as schools of public health, research institutes, non-governmental organizations. The final outline is being decided by the government with fast developments on a daily base.

The main considerations for allowing the different activities to resume after the lock down are the risk of contagious and the contribution to the GDP

Measures in exit plans are not compulsory and there is no means to control it. However, most residents comply with the measures. After a long time of strict lock down, individuals are happy with exit measures, except some parents of children in special education settings. Special education schools are those for disabled children or children with learning difficulties. These were the first schools to reopen due to the extra services they provide to the children such as physiotherapy, speech therapy etc. parents were concerned that these schools were not adapted to COVID-19 and therefore were not happy to send their children right away

Preparedness for a potential second wave

The MoH announced the launch of a new operation center for COVID-19 on the 25th of May 2020. This center will be the professional body for monitoring, planning and dealing with a potential second wave of COVID-19 outbreak in Israel. The operation center is led by MoH, in charge of the governance, operations and decision making of COVID-19 since mid-May 2020. It also includes representatives from the army (IDF) and Ministry of Defense. The center will have around 200 employees (it's yet unclear how many of those positions are new recruitments and how many of existing employees). (doctorsonly.co.il, 25.05.2020)

Source: https://www.mevaker.gov.il/sites/DigitalLibrary/Documents/2020/70a/200-health-Taktzir.pdf 

23.7.20 – new project manager and director of the COVID-19 “control center”
In mid-July, the Prime Minister and Health Minister appointed a national COVID-19 project manager and director of the COVID-19 “control center”. This body is supposed to set short- and long-term health policies in order to tackle the spread of COVID-19 in Israel.
Apart from the COVID-19 control center, the Intelligence Division of the Israel Defense Forces (IDF) has established the Corona National Information and Knowledge Center to assist the Ministry of Health in systemic and medical research on the spread of COVID-19 in Israel and around the world. The National Security Council and other government ministries have information, data analysis, insights and recommendations designed to formulate national policies in government ministries to support health policy to mitigate the spread and negative outcomes of the virus.

The center's main goal is to conduct in-depth research on the spread of the pandemic to identify risks and opportunities for professionals and decision makers in the Ministry of Health, the National Health Service and the defense establishment. The center investigates the spread of the virus in countries around the world and in the Middle East, while also serving as a center of insights from leading medical research on testing methods, vaccines and drugs that have been shown to be effective in the global fight against COVID-19 (https://www.gov.il/he/departments/about/about-the-knowledge-center).

16.9.20 – Governance developments of responses to COVID-19

The administrative and governmental management of COVID-19 in Israel has evolved significantly since the initial outbreak in March 2020. Multiple stakeholders are involved, and it is not always clear where the boundaries of autonomy might result in overlap. Below is a clarification on the role of each body as well as their fields of action and the potential overlapping of responsibilities.

The 2007 Pandemic Preparedness Plan
In 2006, amid concerns about the spread of the bird flu, the Israeli government prepared a "Health System Preparedness Plan for Pandemic Influenza" with a team of more than 100 experts. The plan stipulated the division of labor between the Ministry of Defense and the Ministry of Health, with the former in charge of operating any state of emergency. Furthermore, in the event of a pandemic, the Ministry of Health should be the body to outline the public health policy, while the Ministry of Defense would be the operating body through a crisis management team and through the National Emergency Authority and Home Front Command. The program  was approved in June 2007.

The bodies involved in the COVID-19 pandemic governance, their roles and authorities

The Supreme Hospitalization Authority at the Ministry of Health
The Supreme Hospitalization Authority is the body within the Ministry of Health (MoH) in charge of health emergencies. It is headed by the Director General of the MoH, and consists of representatives of the MoH, the IDF Medical Corps and the biggest health plan (Clalit Health Services). Its purpose is to prepare the health system for responding to emergencies during routine and war, and to serve as an organizational and logistical infrastructure for managing emergency events. The 2007 Pandemic Preparedness Program assigns many roles to the Supreme Hospitalization Authority, such as performing administrative actions and setting policies on various health issues, writing designated action plans, making decisions on personnel and workload issues and the like - all while coordinating with various officials in the government and in the Ministry of Defense. This body was intended to be a major factor in the decision-making processes in the event of a pandemic; however, as per September 2020, it has had no voice in the media since COVID-19 started spreading in February 2020. It is possible that this body was indeed involved, but did not appear in the media coverage or in official government information sources.  On August 26, 2020, the MoH established the Corona Control Center, which is supposed to concentrate all efforts and responses to COVID-19 from the different divisions within the MoH.

The National Security Council
Instead of following the 2007 Pandemic Preparedness Plan during the early stages of the COVID-19 pandemic (February 25, 2020), the Prime Minister (PM) determined that the head of the National Security Council (NSC) would be responsible for the integration and coordination among the different ministries involved in controlling the outbreak. The NSC is an advisory body within the Prime Minister's office in charge of internal security and external relations. The head of the NSC is a direct subordinate of and reports directly to the PM. The PM also determined that COVID-19-related financial planning and actions were the responsibility of the Ministry of Finance (MoF).

According to the 2007 pandemic plan, neither the MoH nor the MoF have the capacity to integrate and coordinate such a complex undertaking, considered in Israel similar to the scope of war. Therefore, the PM decided that during COVID-19’s initial outbreak (February-May 2020), the NSC would not only advise, but would also become the executive body that supervises and coordinates the responses to the pandemic among all relevant ministries and other bodies such as the army (Israel Defense Forces, IDF) and the secret service (the Mossad). The NSC opened up an emergency management center with representatives from each of the government ministries, divisions of the army, police, and prison services and representatives from the national ambulance service, Magen David Adom (MDA), to centralize and optimize coordination.

The Army
During the early stages of the pandemic, the NSC and MoH decided gradually to delegate specific responsibility to the army. The army’s control center was sidelined on May 26, at the end of the first outbreak. Between May and the end of July (the time of the appointment of the Corona Project Manager), the various defense forces did not formally sit on the executive body of the pandemic response, and in fact it was not at all clear if and how it would be integrated in the future due to political and professional disputes.

The “Corona Cabinet”
The “Corona Cabinet” is a government body that was assembled on May 27 as a forum of 16 ministers to better manage the responses to the COVID-19 pandemic. Yet, this new cabinet’s duties were paused after a few weeks on the grounds that “a large forum complicates the decision-making process”. Two months later, on July 26, the government decided to cut the “Corona Cabinet” to 10 members (all male and all government ministers). The cabinet then included the PM and ministers of defense, internal security, health, finance, foreign affairs, sciences and technology, justice, economy and industry and interior.

This body operates according to the authorities defined in the newly passed “Corona Virus Law”. According to this law, the “Corona Cabinet” may impose significant restrictions on public life: from restricting the activities of commerce, recreation or leisure through restricting the activities of educational institutions and imposing local or general quarantines. Each decision made by the “Corona Cabinet” is subject to parliamentary overview, and the parliament can vote to overturn decisions by the “Corona Cabinet” seven days after the regulations are instituted. This body is supposed to coordinate among all government agencies involved in dealing with COVID-19 in order to optimize the government's actions regarding the effects of the crisis on health, social and economic aspects. It is supposed to consolidate the "Exit Strategy" out of the crisis in its various aspects as well as prepare for any recurrences of the virus. The “Corona Cabinet”, similar to the NSC, is also led by the PM. Upon the establishment of the “Corona Cabinet” as an executive authority, the NSC returned to function according to its original duty as an advisory body.

The "Corona Project Manager"
On July 23, 2020, a "Corona Project Manager" was appointed. Their task is to lead and manage the “national program to fight the COVID-19 novel coronavirus” by integrating professional and executive bodies. In effect, the Corona Project Manager took over some of the powers pertaining to the management of COVID-19 responses – particularly epidemiological testing and investigations. At the same time, the head of public health services at the MoH resigned on the grounds that the government was not implementing proper recommendations and was working to reduce her office’s autonomy and power.

The Corona Project Manager operates within the “Corona Cabinet” and advises on strategic responses based on data and evidence.
One of the first plans suggested by the Corona Project Manager was the "Israel's shield” (Magen Israel) program. This was approved by the “Corona Cabinet” and aims to systematically reduce the coefficient of infection (R0) and keep it below 1 in order to curb the spread of COVID-19. The coefficient of infection is used as the main indicator in this program., which also defines the capacity and occupancy of hospitals and outpatient clinics as an indicator for decisions regarding restrictions to public life and lockdowns. One of the main principles of the "Israel's Shield" program is to increase the public trust with decision makers, which has been undermined by governance that has lacked clarity and transparency.

The Corona Project Manager has acted with executive power to implement approved plans. For example: recruiting inspectors to enforce isolation instructions for foreign students, training local authorities’ employees for epidemiological investigations and appointing the Corona Chief responsible for the Arab population.

Besides the Corona Project Manager, the MoH’s Director General has the same authority to manage epidemics, based on the Public Health Ordinance Act 1940, though it is not clear what the relationship between the MoH’s Director General and the Corona Project Manager is and what, if any official authorities were transferred to the Corona Project Manager.

The PM stressed that the Corona Project Manager would be granted "all authorities" in three areas: testing, investigation and isolation. Nevertheless, the specific authorities of the Corona Project Manager are not yet detailed, and the extent of overlap with other bodies is still not clear.

Main objectives of the "Israel's Shield" national program to cope with COVID-19
• To create a uniform, up-to-date and permanent database that will serve as evidence for decision makers and the general public. The database will focus on three main topics: (1) combining several morbidity-prediction models based on variables such as the morbidity burden in the community, the total number of patients in hospitals and the number of severe patients hospitalized in order to create a unified model; (2) the measurement and display of the infection coefficient (R) on a regular basis; and (3) to make information accessible and transparent for decision makers.
o An effort will be made to create and provide uniform and clear principles for responses to COVID-19 such as the introduction and/or removal of physical distancing restrictions to the public.
• To establish a “Professional Corona Cabinet” composed of 14 expert medical professionals from the fields of public health, R&D, psychiatry, internal medicine, epidemiology and more.
• To establish a "barometer" team consisted of hospital managers, who are responsible for constantly updating the Corona Cabinet in real time about bed occupancy rates and alerting any possible insufficienies.
• To use the IDF's data-collection, investigation and execution capabilities by forming a mission-task force to curb the spread of the virus.
• To implement the "Traffic light" action plan. The plan decentralizes authority and autonomy from the central government to municipalities to self-manage responses to COVID-19. The plan sets four severity scenarios based on COVID-19 morbidity and the R0 coefficient and determines the responses needed for each scenario. (For example, a “green scenario” means a low morbidity with low levels of restrictions for gatherings). These scenarios range from green to red, and each municipality is supposed to constantly self-classify in each scenario and respond accordingly. This plan allows local restrictions instead of centralized, nationwide responses, as have been imposed so far.
• To survey public opinion and perspectives regarding the pandemic and the government’s response, and create advocacy campaigns that encourages the public to follow the governments’ guidelines.

The "Israel's Shield" national program's headquarters operates as a central integrative body, which will coordinate the following topics:
• An enforcement staff led by the Israeli Police, the Home Front Command and the local authorities – among its duties are enforcing the prevention of gatherings (OR physical distancing) and of wearing masks in public, investigations of positive diagnosed individuals, etc.
• A Health communication staff in charge of providing information regarding outbreak severity and campaigning regarding the importance of masks wearing, keeping personal hygiene and physical distance
• A staff of the "Protection of the Elderly" program, which serves the purpose of providing solutions to protect residents in senior care facilities.
• A staff of local authorities in charge of the coordination between themselves and operational and professional bodies at the local level.
• A General Health staff in charge of all things related to professional instructions and policy.

Residents medical records available for COVID-19 related research
In recent months, the MoH has begun to establish a database that will be used (initially only by Israeli researchers) for the research and development of strategies for defeating the COVID-19 pandemic. The database will contain all the statistical and clinical data from about half a million Israelis who have been infected with the virus since its outbreak. The planned database will be anonymous but will include information from the residents’ medical records (e.g., medical history, background illnesses and details on examinations), information on hospitalizations, contact tracing, epidemiological investigations, utilization of services and demographic information such as age and gender. As of January 12, the Helsinki Committee is expected to inform the MoH that it has decided on two conditions for the establishment of the database: obtaining an opinion from the Ministry of Justice, and individually informing each citizen included in the database via text message, with the option of self-removal from the database – all this in addition to publicizing it in the media.

Source: https://www.haaretz.co.il/tmr/.premium.HIGHLIGHT-1.9441522