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Translated by Elisheva Hecht
Abstract
Significant disparities exist between the Periphery and the Center of the State of Israel in a number of areas. In the health field, this difference is articulated in the fewer number of available services, such as hospital beds, operating rooms, primary care and the ratio of doctors to patients. The implications of these disparities can be observed in the healthcare indexes in the north and south of the State, where residents are prone to higher morbidity and mortality rates.
This problem has been acknowledged and has been discussed in a number of governmental, research and journalistic frameworks. Various solutions were proposed over the course of the discussions, some taking place within the healthcare system and some outside of it. However, only a minority of the proposals attributed the problem to the shortage of medical manpower in these areas. Because of the correlation between the proportion of physicians in a specific place and heath index scores, it becomes clear that it is impossible to bring an end to the inequalities without a change in the proportion of physicians.
The placement of physicians in their workplaces is done independently by each physician, generally quite early in his or her medical career. The process begins towards the end of medical school, when the student prioritizes his or her choices for internship placement. The year of internship is a mandatory part of a medical degree, and only afterwards may the graduate obtain a license allowing him or her to practice medicine. The deliberations surrounding the choice of internship location – geographic, social and economic – result in a situation in which a majority of students choose Jerusalem or the Center of the State and avoid choosing the Periphery. Following their internship year, most graduates continue on to completing a residency in their chosen field. The selection of place of residency is done separately from the selection of place of internship, yet in many cases, there is a connection between the two, due to an already established familiarity with the hospital. Therefore, a large amount of young medical manpower becomes settled in the Center of the State.
In recent years, a lively debate has been stirring regarding the price of tuition in Israeli universities. The increase in tuition proposed by the Shohat Report will significantly raise the price of medical school tuition in Israel, thus preventing students from disadvantaged backgrounds from studying medicine. The committee proposed offering loans to these students to allow them to complete their studies, but these loans charge interest and must be repaid within the new physician's first few years of work. These conditions are not suited for students of medicine, as their first years of work are during their residency period. On the other hand, it is apparent that institutions of higher learning are in a state of budgetary distress, and therefore, we must find a way to increase the funding received by universities and colleges without challenging the ability of the students to study.
In the United States, medical school is privately funded, thus requiring a funding program to provide accessibility to the general population. One existing program provides reimbursement for loans for young physicians working in areas defined as needy by the United States Department of Health. Similar programs exist in Israel, wherein the Ministry of Education aids in the funding of teachers' training. The proposal presented in this paper is to merge the American medical model with the conditional loans model of the Israeli educational system. It is proposed that along with the expected increase in tuition, students will be able to partially cover their medical school tuition by means of a conditional loan, which is to be repaid over the course of several years of work, or alternatively will be converted into a grant in the case that the young physician chooses to complete his or her residency in a Peripheral hospital. This way, medical school will be accessible to the public as a whole, the loan reimbursement will serve as an incentive for young physicians to make their homes in the Periphery, and those graduates who complete their residency will serve as specialists in their fields in the Periphery. As long as this practice is in effect, hospitals in the Periphery will be able to advance in terms of academics, research and technology, thus drawing additional students to the Periphery, where they will work as specialists in their fields, etc. The expected cost of this program is NIS 5 million per year, a sum that may be funded by the budgets of the Ministry of Health, the Ministry of Education or the Ministry of Development of the Negev and the Galilee. Increasing the number of physicians in the Periphery will bring an end to the current health disparities, in addition to the existing proposed solutions.
This program, which seemingly concerns the healthcare field only, may also be applied in other fields affected by Center-Periphery disparity. The primary goal of the program is improve the standards of healthcare services in the Periphery, yet it also strives to strengthen the Periphery on demographic, economic and social levels. In this manner, the proposal puts significant Zionist and strategic axioms into effect on behalf of the State of Israel.
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