Passage of the National Health Insurance Law (NHIL) in 1995 marked a turning point in the history of the Israeli healthcare system, ensuring sustainable, high-quality medical care to all eligible Israeli residents. Over 100 amendments have been made to the law over the years, yet additional adaptations are required to ensure the law’s relevance in years to come. In honor of the 25th anniversary of the passage of the law, the 19th annual Dead Sea Conference brought together prominent figures in the Israeli healthcare system for a discussion on “25 Years to the NHIL: Suggested Changes and Adaptations”. Key topics discussed in the conference were regulatory aspects related to the healthcare system, administration of medical services, and financial aspects pertinent to the NHIL. The following meeting report summarizes the insights and recommendations from this conference.

Pharmaceutical drug shortages (DSs) are a global problem which presents challenges to countries around the world. Shortages of pharmaceutical products may have a direct detrimental impact on public health and patients’ wellbeing by causing delayed, or even lack of, treatment. Moreover, DSs may force both patients and caregivers to use unfamiliar drugs, which could lead to medication errors. The objective of our study was to analyze DSs in Israel during the years 2013–2015, assessing their etiology and exploring the steps taken for their mitigation and prevention. The database of the Israeli Ministry of Health (MoH) on drug shortages contains all the DSs recorded in Israel since 2013, detailing the cause of the DS, its duration, steps taken in its’ management and the availability of generic or therapeutic alternatives. Selected examples of DSs from the database are described in this paper in order to identify the causes of DSs, the scope of the problem and possible solutions. Additionally, we have reviewed the recent activities performed by European Medicine Agency (EMA) and the American Food and Drug Administration (FDA) in their efforts to minimize this problem. Several factors contributing towards DSs in Israel were identified, including quality problems in both the final drug product and in the raw materials, upgrades and improvements of the manufacturing process required by the MoH, manufacturing by a sole supplier, dramatic price decrease in off-patent medications causing the manufacturer to discontinue the distribution of the product in Israel, just-in-time inventory control, and others. One of the most important steps in managing drug shortages was identified to be early notification of the shortage by the Marketing Authorization Holder (MAH) to the MoH. In 2013, the Israeli MoH updated the regulation on drug shortages instructing MAHs on their obligation of early notification to the MoH. Furthermore, various steps dealing with marketing withdrawal of drugs and temporary drug shortages are being implemented in Israel, such as suspending any further reductions in drug prices below 17 new Israeli shekels, instructing all MAHs to maintain no less than 1 month supply of all registered and non-registered drugs in Israel and allowing an expedited registration pathway for well-established use/grandfather drugs. Drug shortages pose significant public health hazards worldwide. Early notification to the MoH and open dialog with MAHs are essential for managing DSs and mitigating their impact. Despite the efforts carried out by health regulatory authorities worldwide, DSs still pose a significant threat to public health.

Although a fourth dose of SARS-CoV-2 vaccine was shown to be effective, the immunogenicity of a fifth dose in immunocompetent individuals had not been well described. This was a prospective observational cohort study of previously vaccinated healthcare workers at a single tertiary hospital in Israel. Individuals were administered up to three booster doses of the BNT162b2 mRNA vaccine (i.e., up to five overall doses), during the period between July 2021 and January 2023. Immunogenicity was assessed using the SARS-CoV-2 IgG (sCOVG) semi-quantitative assay, performed at several time points. The cohort consisted of 162 individuals (median age 69 years, 62% female). Of these, 104 (64%) received four doses and 58 (36%) received five doses. Anti-SARS-CoV-2 antibody levels increased in all cases, regardless of the baseline levels. The fold-change increase in the mean sCOVG index was 29.2 (SD 2.6) after the third vaccine, 3.8 (SD 2.4) after the fourth vaccine, and 3.6 (SD 3.0) after the fifth vaccine. A waning effect over time was seen in 78% and 43% of participants for the third and fourth doses, respectively. Adverse events following the fifth dose were limited and mild. Similar to previous booster vaccines, a fifth dose of BNT162b2 is immunogenic and safe in healthy individuals, although the clinical implications remain unclear.

In 2011 the Israeli Ministry of Health (MOH) instructed hospitals to limit occupancy in the internal medicine wards to 120%, which was followed by a nationwide reduction in hospitalization rates. We examined how readmission and mortality rates changed in the five years following the changes in occupancy rates and hospitalization rates. All visits to the Tel Aviv Medical Center internal Emergency Medicine Department (ED) in 2010, 2014 and 2016 were captured, with exclusion of visits by patients below 16 of age and patients with incomplete or faulty data. The main outcomes were one-week readmission rates and one-month death rates. The secondary outcomes were admission rate, ED visit length & admission-delay time (minutes), and rates of admission-delayed patients. After exclusion, a total of 168,891 internal medicine ED patients were included in the analysis. Mean age was 58.0 and 49% were males. During the relevant period (2010–2016), total medical ED visits increased by 11% - 53,327, 56,588 and 59,066 in 2010, 2014 and 2016 respectively. Hospitalization rates decreased from 46% in 2010 to 35% in 2015 (p < 0.001), with the most prominent reduction in the elderly population. One-week readmission rates were 6.5, 6.4 and 6.7% in 2010, 2014 and 2016 respectively (p = 0.347 and p = 0.21). One-month mortality was similar in 2010 and 2014 (4.4 and 4.5%, p = 0.388) and lower in 2016 (4.1%, p = 0.048 compared with 2010). Average ED visit length increased from 184 min in 2010 to 238 and 262 min in 2014 & 2016 (p < 0.001 for both) and average delay time to ward admission increased from 97 min in 2010 to 179 and 240 in 2014 & 2016 (p < 0.001 for both). In 2010 24% of the admitted patients were delayed in the ED more than 2 h, numbers that increased to 53% in 2014 and 66% in 2016 (p < 0.001 for both). Following the 2011 MOH’s decision to establish a 120% occupancy limit for internal medicine wards along with natural growth in population volume, significant changes were noted in the work of a large, presumably representative emergency department in Israel. Although a steady increase in total ED visits along with a steady reduction in hospitalization rates were observed, the readmission and mortality rates remained low. The increase in the average length of ED visits and in the delay from ED admission to a ward reflects higher burden on the ED. The study was not able to establish a causal connection between the MOH directive and the subsequent changes in ED activity. Nonetheless, the study has significant potential implications for policy makers, including the presence of senior ED physicians during afterhours, creation of short-stay diagnostic units and proper adjustments in ED size and personnel.

Approximately 150,000 undocumented migrants (UM) who are medically uninsured reside in Israel, including ~50,000 originating from the horn of Africa (MHA). Free medical-care is provided by two walk-in clinics in Tel-Aviv. This study aims to compare the medical complaints of UM from different origins, define their community health needs and assess gaps between medical needs and available services. This cross-sectional study included a random sample of 610 UM aged 18–64 years, who were treated in these community clinics between 2008 and 2011. The study compared UM who had complex medical conditions which necessitated referral to more equipped medical settings with UM having mild/simple medical conditions, who were treated at the clinics. MHA were younger, unemployed and more commonly males compared with UM originating from other countries. MHA also had longer referral-delays and visited the clinics less frequently. UM with complex medical conditions were more commonly females, had chronic diseases and demonstrated longer referral-delays than those who had mild/simple medical conditions. The latter more commonly presented with complained of respiratory, muscular and skeletal discomfort. In multivariate analysis, the variables which predicted complex medical conditions included female gender, chronic illnes and self-referral to the clinics. The ambulatory clinics were capable of responding to mild/simple medical conditions. Yet, the health needs of women and migrants suffering from complex medical conditions and chronic diseases necessitated referrals to secondary/tertiary medical settings, while jeopardizing the continuity of care. The health gaps can be addressed by a more holistic social approach, which includes integration of UM in universal health insurance.

Response to and monitoring of viral outbreaks can be efficiently focused when rapid, quantitative, kinetic information provides the location and the number of infected individuals. Environmental surveillance traditionally provides information on location of populations with contagious, infected individuals since infectious poliovirus is excreted whether infections are asymptomatic or symptomatic. Here, we describe development of rapid (1 week turnaround time, TAT), quantitative RT-PCR of poliovirus RNA extracted directly from concentrated environmental surveillance samples to infer the number of infected individuals excreting poliovirus. The quantitation method was validated using data from vaccination with bivalent oral polio vaccine (bOPV). The method was then applied to infer the weekly number of excreters in a large, sustained, asymptomatic outbreak of wild type 1 poliovirus in Israel (2013) in a population where >90% of the individuals received three doses of inactivated polio vaccine (IPV). Evidence-based intervention strategies were based on the short TAT for direct quantitative detection. Furthermore, a TAT shorter than the duration of poliovirus excretion allowed resampling of infected individuals. Finally, the method documented absence of infections after successful intervention of the asymptomatic outbreak. The methodologies described here can be applied to outbreaks of other excreted viruses such as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), where there are (1) significant numbers of asymptomatic infections; (2) long incubation times during which infectious virus is excreted; and (3) limited resources, facilities, and manpower that restrict the number of individuals who can be tested and re-tested.