Inequalities in use of health services among Jews and Arabs in Israel

Health Services Research, June, 2007 by Orna Baron-Epel, Noga Garty, Manfred S. Green

Low socioeconomic status (SES) has been associated with poorer health in developed countries (Haan, Kaplan, and Syme 1989). Poorer health could be a result of inadequate use of health care services. Factors, such as type of insurance, culture, and behavior are associated with inadequate use of health care services (Mayberry, Mili, and Ofdi 2000). Among lower SES groups, it has been reported that there is higher use of the primary physician's services, even after adjusting for health, and that populations with higher SES in developed countries visit a specialist more often (Roos and Mustard 1997; Schoen et al. 2000; van Doorslaer et al. 2000; van Doorslaer, Masseria, and Koolman 2006). More hospitalizations were also reported in lower SES populations within developed countries (Roos et al. 2005). Droomers and Westert (2004) reported that respondents with lower levels of education, indicating SES, used multiple health care services more often and so did those with higher prevalence of comorbidity. This study indicated that the higher use of health care among lower educated respondents was only partly explained by more illness. It has been suggested that utilization of health care does not always reflect the level of health need (Field and Briggs 2001). All these studies were performed in North America and Europe.

Moreover, utilization of health care services has also been associated with ethnicity--government subsidies reduces the difference but do not eliminate them (Mayberry, Mili, and Ofili 2000; Scott, Marwick, and Crampton 2003; National Center for Health Statistics 2004). This subject has not been reported on in Israel.

The population in Israel consists of two major population groups, Jews and Arabs. In 2003, there were 6,600,000 Jews and Arabs. Arabs comprised 19.2 percent of the population. These two population groups differ in their background, culture, and language. Health indicators in Israel present a picture of poorer health along with lower socioeconomic levels in the Arab population compared with the Jewish population (Israel Center for Disease Control 2005). For example, life expectancy in 2002 was about 3 years less for Arab Israelis compared with Jews (Central Bureau of Statistics 2004).

Ten years ago, a National Health Insurance Law (NHIL) was enacted providing health care services for all Israeli residents. The aim of the law was to provide equal health care services for all, with the expectation that adequate use would decrease the differences in health status between the two population groups in Israel. In a survey studying patterns of health care use in Arabs and Jews, before and after the enactment of the NHIL, Farfel and Yuval (1999) reported that in 1997 almost all Arabs (99.1 percent) and most Jews (88.3 percent) had a regular family physician. This represented an increase since 1995. They also reported that in 1997 42 percent of Jews reported visiting a specialist during the last 3 months compared with 30 percent among Arabs. The change from 1995 was not significant. Elnekave and Gross (2004) examined Arab Israeli women during 1998 following the implementation of the NHIL and reported that Arab women more often than Jewish women reported foregoing medical care and visiting a specialist. They suggested better adaptation of the primary health care services to the needs of the Arab community. The aim of this study was to compare the levels of utilization of physician's services and hospitalizations in Jews and Arabs taking into account differences in levels of SES in the two populations.

METHODS

The Israel National Health Survey is a telephone survey based on the EUROHIS (European Health Interview Survey) project, led by the World Health Organization Regional Office for the European region. This is an international project to develop common instruments for health surveys, for international comparisons of health data (Nosikov and Gudex 2003). The Israeli component of this survey was conducted between April 2003 and October 2004 at the Israel Center for Disease Control.

Study Population

A random sample of telephone numbers was drawn from a computerized list of subscribers to the national telephone company. Most Israeli households (Jews and Arabs) have telephones (94.4 percent) (Central Bureau of Statistics 2001). From these numbers, the fax numbers, disconnected numbers, commercial numbers, and households without a resident 21 years of age or over were deleted, leaving a total of 21,326 eligible households in the sample. There were 4,980 households (23.4 percent) that could not be located, leaving 16,346 households that were contacted. A total number of 9,512 respondents, men and women, completed the questionnaire, yielding a response rate of 58.2 percent. Nonresponses due to refusal included outright refusals (29.4 percent), partially completed interviews (2.2 percent), and repeated postponements (10.2 percent). The current analysis was performed with 9,352 due to 160 missing data on ethnicity. Of them 7,682 (81 percent) were Jews and 1,800 (19 percent) were Arabs.