health and welfare agencies or taxation-and less than one-fifth directly by the patient, at the time of hospitalization.

All this refers to hospitalization in public or non-profit hospitals The situation differs in regard to private hospitals (as profit-making hospitals are called in Israel). The number of private general hos pitals is small, and they are used mainly by those who can afford the fees. In maternity cases, patients have to supplement the fees over and above the National Insurance grants. The same applies to members of Sick Funds for whom, in certain cases, the Sick Fund pays the fee acceptable in other public institutions, while the patient pays the rest. The situation differs again in private hospitals which admit chronic, TB, mental and mentally retarded patients. Most of these patients are of the less affluent social strata and, because of the length of hospitalization, are unable to pay for it. The institutions are, therefore, usually paid either by the Government or by local welfare authorities. But many long-term cases are also hospitalized in Government institu tions, where there is either no fee, or only a token fee is collected to keep the family of the patient aware of its responsibility towards the hospitalized member.

PLANNING OF HOSPITAL SERVICES

A ten-year plan has been evolved in answer to expected hospitaliza tion needs in the near future, taking into account forecasts for the total population and for its regional distribution. Details have already been authorized for the construction of general hospital facilities; schemes for psychiatric and chronic disease hospitalization are still under discussion. The plan aims at rationalizing existing services, and at achiev ing adequate regional distribution. It will be effected by building hospitals and by extending existing ones.

It is intended to reach the following bed rates by 1974:

RATES AND EXPECTED RATES PER 1,000 POPULATION, ACCORDING TO CATEGORY OF BEDS, BY 1974

new

These rates are not considered optimal, but they represent what is feasible within the limits of the national economy.

To realize the plan means adding about 3,500 general beds and replacing about 1,500 existing unsuitable ones. It also entails the supplementation of many auxiliary medical services, apart from beds, to ensure better bed-utilization and maintain a few highly specialized

centers.

It is hoped to continue to confine to an absolute minimum the number of patients requiring to go abroad for medical care. This makes flexible planning imperative, in order to keep abreast of constant medical advances.

It will be necessary, moreover, to build about 3,000 psychiatric beds and to replace about 2,500 existing ones. New concepts of psychiatric care are being incorporated into the programmes for the new hospitals. Some 1,850 beds will have to be added for rehabilitation and hospitalization of patients with chronic diseases, and some 600 beds of that type to replace those that are unsuitable.

Most of the capital investment burden will fall on the Government, with the Histadrut's Kupat Holim in second place. It is hoped, howver, that the municipalities will increase their share. Other public and private bodies will also contribute their share. The national lottery, the expectation is, will greatly increase its allocations to hospital building.

BIBLIOGRAPHY

Gilliland, I. C., The Medical Services of Israel," The Lancet, March 13, 1971.

Grushka, Theodor, "Health Services In Israel," Jerusalem, 1968. Halevi, M. S., "Health Services in Israel: their organization, utilisaion and financing. Medical Care 2:231-42, Oct.-Dec. 1964.

Health Sciences in Israel: institutions and scientists. Ed. by Betty Davis. Jerusalem, Israel Journal of Medical Sciences, 1971. 285 p. Publication supported under the Special Foreign Currency Program of the National Library of Medicine.

Johnson, R. H., "The Health of Israel." The Lancet, Oct. 23, 1965. Lotan, Giora, "National Insurance In Israel," Jerusalem, 1969. Mann, Kalman J., "Visits To Doctors," Jerusalem, 1970.

Medalie, J. G., DeVries, A. and Shachor, S., "Family medicine at the Tel Aviv Medical School," The Lancet 1:979-81, May 10, 1969. Sheperd, Naomi, "Health and Medical Care," Jerusalem, 1966.

Shuval, Judith T., "Social Functions of Medical Practice," San Francisco, Calif., 1970.

Silberstein, J., Zeltzer, M., Rossovsky, R., and Pinkerfeld, C., 'Causes of Admissions to Nursing Homes in Israel," Medical Care, Vol. VIII, No. 3, May-June, 1970.

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APPENDIX A

DEVELOPMENT OF THE HEALTH SERVICES UP TO THE ESTABLISHMENT OF THE STATE OF ISRAEL

Prior to the period of the British Mandate, Palestine was one of the most backward provinces of the Ottoman Empire. Its physical and cultural resources were extremely limited and its health conditions correspondingly bad. Wide areas were malaria-ridden; enteric fever and dysentery caused a large number of deaths every year; trachoma and ringworm of the scalp were rife, and the infant mortality rate was very high.

The Jewish residents lived mainly in Jerusalem, Yafo, Hebron, Zefat and Tiberias, with only a few in farm villages (Petah Tikwa, Hadera, Rishon LeZion, Gedera, Rosh Pina and Zikhron Ya'akov). In the towns, sanitary conditions were appalling, in Jewish no less than in Arab quarters.

With the establishment of the British Administration, a new phase began and the health conditions of the population gradually improved. The pace was slow at first, but it quickened after voluntary social services were provided for the Jewish community, increasingly composed of European immigrants.

Owing to serious budgetary restrictions in the earlier years, the Mandatory Administration concentrated its efforts on malaria control and on the establishment of elementary preventive and curative health services, intended mainly for the Arab population. Little systematic effort could be made to combat endemic and epidemic diseases other than smallpox and malaria. Even the antimalarial services of the Government had to be supplemented by a separate Jewish service.

With little encouragement or guidance from the Government, and with hardly any financial assistance, the Jewish community had to build up its own health, education and social services. The rising standard of living of the Jewish population and the intensive activities of their health services led to a marked improvement. By the 1940's, trachoma and ringworm of the scalp had almost disappeared; malaria and enteric fever became less frequent. The decrease in infant mortality and the increase in life expectancy allowed Israel in 1948 to rank with the more developed nations.

Yet, during the Mandatory period, health conditions grew steadily better in the Arab community as well. The rates of infectious disease and infant mortality fell and life expectancy rose. Even though the improvement was less marked than in the Jewish community, conditions were ahead of those in the neighbouring Arab countries.

The progress in the Jewish community was effected by the activities of the Hadassah Medical Organization and other voluntary organizations. These included the comprehensive health insurance scheme based

on voluntary contributions by members of the General Federation of Jewish Labour (the Histadrut).

The Hadassah Medical Organization was founded immediately after the end of World War 1. From the very start, it provided curs tive and preventive services, successfully adapting American methods to the special needs of this country. The eradication of trachoma and ringworm of the scalp was mainly due to the systematic efforts of the Hadassah school health services. Public health education was one of Hadassah's foremost concerns, with the public health nurse playing a most important role, mainly due to Henrietta Szold's undaunted efforts.

At the same time, curative services were developed by Hadassah and by the Sick Fund (Kupat Holim) of the General Federation of Jewish Labour. Hospitals and clinics were established in all parts of the country. Hospital and preventive health services in Tel Aviv, in the beginning maintained by Hadassah, were taken over by the municipality and were enlarged and adapted to the growing needs. In contradistinc tion to the purely philanthropic societies which established and maintained hospitals and clinics on a charitable basis, the Hadassah Medical Organization based its medical work on the principle that responsi bility for the services which it initiated must gradually be taken over by the local authorities. Thus the Hadassah general hospital in Tel Aviv was transferred to the municipality in 1931, the Hadassah hos pital in Haifa to the Jewish community of that town in 1932, and the Hadassah hospital in Tiberias to the National Council of the Jewish Community in Palestine (Vaad Leumi).

Zionist policy aimed at creating a strong agricultural sector within the Jewish community, seeing in the return to the soil one of the cornerstones of national regeneration. An integral part of this policy was the provision of medical care for the rural population, and this has always been one of the characteristics of the Jewish health services in Pales tine. The high cultural standards of the Jewish agricultural pioneers required highly developed health services, and also offered favourable conditions for health education among the rural population. The Hadassah Medical Organization and Kupat Holim (which is responsible for the health services in all cooperative and collective villages) have from the beginning aimed at providing preventive and curative services for every Jewish village, irrespective of its size or accessibility. To serve small-holders and farmers not eligible for the workers' health insurance schemes, the Hadassah Medical Organization founded the Rural Sick Fund (Kupat Holim Amamit) in 1931; and a network of clinics was set up in the rural districts. The results of this combined care for the rural population have been most gratifying. Today, ma ternal and child mortality rates are extremely low among the settled population in the rural areas, considerably lower even than those in

the towns.

Kupat Holim has played a vital role in the development of the Jewish medical services. This voluntary health insurance scheme today covers about three quarters of the Jewish population. Its funds are spent almost entirely on services, and only a small percentage is used for cash benefits. It has thus been possible to organize a service of