This article describes a systematic process of strategic planning for healthcare services, as part of a national development plan, using the Galilee’s plan as a case study.
Healthcare strategic planning as part of national and regional development in the Israeli Galilee: a case study of the planning process.
Regional development usually involves population growth and changes in population distribution. This process occurs in tandem with the availability of health, social and other community services, and has the potential to significantly affect the health and wellbeing of communities, both existing and new (McMicheal & Powles1999; Parliament of Australia House of Representatives 2005).
In March 2005, the Israeli government declared a national plan for its northern region, theGalilee. The region was to become an advanced, established and competitive society, economically strong, attractive to new residents and sustaining a civil society with a high quality of life. The plan’s goals were to consolidate a perennial strategic plan encompassing economic, social and infrastructure factors, with the aim that these plans would be be adapted and considered by policy makers. From the beginning of the process, the plan’s taskforce recognised the significant role the healthcare system plays in the region. The healthcare delivery system is a major employer of high quality manpower, and has a significant impact on the wellbeing of existing and new populations. Thus, the aim of the healthcare strategic plan was to suggest initiatives and actions to be taken in order to improve healthcare supply and the health and wellbeing of all local residents.
This article describes a systematic process of strategic planning for healthcare services, as part of a national development plan, using the Galilee’s plan as a case study.
Background: the Israeli Galilee
The Galilee is the northern region of Israel, comprises 1,185,000 inhabitants
, and spreads over 4,474 square kilometres (22% of national land) (Central Bureau of Statistics 2007). According to
demographic analysis, the population is expected to expand in the next decade (i.e. until 2020) by up to 1,558,500 due to natural growth and by up to 1,756,000 according to the national plan authorised by the Government.
For many years the region has experienced inequities and inequalities in the availability and accessibility of healthcare services as well as in health and welfare indicators, which have been well documented in Israeli studies (Nirel et al. 2000; Horev & Epstein 2007; Ministry of Health 2008). These studies indicated that in only 20% of the region’s households are all adults employed, 43% of whom earn only the minimum national wage. The average number of persons per household is 4.01, in comparison with a national average of 3.3 (Central Bureau of Statistics 2007).
Infant mortality rates for the years 2003-2005 averaged 4.1 deaths per one thousand live births, compared with a national average of 3.3. The rate for birth malformations was 20 per thousand live births in 2005, compared with a national rate of 16. Mortality due to cardiac and cerebralvascular diseases were higher in the Galilee compared with the national average; only cancer mortality rates were lower in comparison with national figures (Central Bureau of Statistics 2007). Nine percent of the adult population in the Galilee reported in 2003-2004 that a physician diagnosed them as having cardiovascular disease
compared with 7%- 8% in other Israeli regions. Forty-eight percent evaluated their personal health status as being ‘very good’ compared with 60% in other regions. Only 60% evaluated their mental health as ‘very good’ compared with 70% in other regions across the country (Ministry of Health n.d.). Physicians and hospital bed rates in the Galilee region are the lowest throughout the country (Nirel et al. 2000; Horev & Epstein 2007; Ministry of Health 2008). These figures probably indicate poor access to healthcare services or presence of pre-conditions, which significantly affect adequate use of healthcare services.
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The planning process
Johnson (2005) describes organisational strategic planning as a cyclical
process with three dimensions:
a) Assessment of needs and demands. For assessing the needs and demands of an organisation, in our case, of a regional health care delivery system, we need information about the existing resources and the external forces that should be considered during the planning process.
b) Prioritisation. The prioritisation phase adds value to the planning process by asking why and how one solution or project will be initiated before the others.
c) Scheduling. The scheduling phase takes theoretical priorities derived in the assessment phase and introduces them to reality.
These three stages are essential especially when the planning process is aimed to ultimately allocate scarce resources among competing demands (Johnson 2005).
Figure 1 illustrates our planning cycle, which is based on data acquisition and analysis, prioritisation among all demands raised from data and experts opinions, and scheduling initiatives according to priorities: that is, what should be done in the immediate time and along the coming years up to 2020.
When assessing the area’s healthcare needs, services were analysed according to the three levels of the Israeli healthcare system:
* primary services, which are community services provided by four Israeli Health Maintenance Organisations (HMOs) (under a National Health Insurance Law), and by public health services via regional officers
* secondary services, which are expert and consultant medical services, provided byHMO
specialists and outpatient clinics in local hospitals
* tertiary services, which are provided by five public and three non-profit hospitals.
Primary and secondary services
Data about primary and secondary services including manpower, workforce needs, infrastructures and existing facilities, were gathered by open and deep interviews with medical officers and other decision- and policy-makers. Figures on quantitative questions, such as the number of doctors in each specialty available in the region, were obtained from the Israeli Medical Association (Israeli Medical Association 2008).
The results show that physician numbers in Galilee are very low compared with national figures, as well as those of specific regions in Israel (Figure 2). The information obtained revealed a shortage in high quality and well-trained manpower, especially in community and family medicine and paediatrics. All of the HMO management boards emphasised the difficulties they face to convince skilled and well trained physicians to move their practicesnorthward
from established practices in central Israel.
Data concerning tertiary services were gathered from national registries, and focused mainly on hospital bed numbers and regional and national bed rates, in addition to activity indicators for each local hospital, such as average length of stay (LOS), occupancy percentage and bed circulation (i.e. number of hospitalisation days in a specific period multiplied by occupancy rate divided by LOS) (Ministry of Health 2008; Central Bureau of Statistics 2007). The calculations of present and future hospital bed needs were based on national bed rates for seven selected wards (Internal Medicine, ICCU
, NICCU, Paediatrics, General Surgical,Rehabilitation, Obstetrics) and demographic forecasts with activity measurements taken into consideration.
Situated in the nearby region is Haifa, the third largest Israeli city which is located on the coast south of Galilee. In Haifa there are three general hospitals with a total of 1741 beds. All our calculations for hospital bed needs took into account the possible contribution of Haifa’s beds to the figures for the Galilee. It does not mean that beds will necessarily be allocated to Galilee, but services could potentially be provided to the Galilee population if required.
Needs for diagnostic and treatment technologies and infrastructures, manpower, relationships between providers, HMOs and the population, other special needs and major problems were thoroughly discussed with all eight hospital management boards. The information about incremental hospital beds was analysed separately for the region and with respect to bed needs and those that exist in a neighboring
region (Haifa district). During the planning process, it was hypothesised that:
* The Israeli mean for bed rates will stay constant (more or less) for the next decade.
* The age distribution for the region will not change dramatically in the coming years.
* The hospital length of stay will decrease, especially in surgical wards, due to innovation in sophisticated surgical techniques.
Throughout our discussions with the Israeli Ministry of Health, all of our analyses were compared with records of the analyses performed by the Ministry.
Results for Stage One
The results suggest a need for an additional 1,158 hospital beds by the year 2020. This comprises 377 additional beds that are needed immediately for closing gaps and addressing inequalities, 512 beds by the year 2020 due to natural growth and 269 additional beds by the year 2020 due to the national plan to increase the northern population.
All health providers’ boards–hospitals, HMOs and social and community organisations–noted an urgent need for the following:
* Rehabilitation. For a population of more than a million inhabitants there is no rehabilitation facility available within reasonable distance and traveling time. Thus, the Galilee inhabitants are in urgent need of two rehabilitation centres for cardiology
, neurology and orthopedic rehabilitation.
* Neurosurgical wards. None of the eight hospitals in the Galilee have neurosurgical services. Patients with trauma and other acute and non-acute conditions travel 30 to 90 minutes to Haifa in order to obtain neurosurgical treatment. Our analysis revealed an urgent need for at least one neurosurgical service, especially for trauma patients. There is professional capability and willingness to operate neurosurgical services in few of the northern hospitals. They all lack the appropriate licence which we suggest, should be urgently provided to at least one of them.
* Radiation therapy. Oncology patients need to travel two hours each way to receive radiation therapy due to the absence of this type of service in the Galilee. None of the eight northern hospitals has radiation therapy services because of budget insufficiency and absence of licenses. All medical boards stated the need of at least one radiation therapy centre for the benefit of the northern population.
* Long-term care. Our analysis revealed sufficient nursing bed rates for ageing patients, most of them located in rural settlements (kibbutzim
and moshavim). The northern rates for long-term beds are 8.5 per 1,000 inhabitants aged 75+ years compared with a national mean rate of 6.8. However, there is a shortage in complicated long term care beds for chronic illnesses. The northern rates are 2.5 beds per 1,000 inhabitants aged 75+ compared with a national mean rate of 7.7 (Table 1) (Ministry of Health 2008).
* Mental care. Both community and inpatient psychiatric care are provided by one psychiatric hospital located near the city of Acre (in the western part of the Galilee). This is a very old facility built in the beginning of the 20th century. It is generally accepted that this hospital should be rebuilt; however, the different approaches to this plan are under dispute. We evaluated objectively all alternatives for rebuilding this hospital based on economic, professional and good practice measurements and judgment (see the suggestions in the next section).
Primary and secondary services
The need for highly skilled physicians to relocate their practices to the northern region will be met only if robust and bold regulation measures are taken by the government in several areas:
* Skilled physicians will relocate their practices to the Galilee, if they are given the opportunity for private practice in addition to their public service: most Israeli physicians work in public hospitals or HMOs as their main practice, but are allowed to conduct some private practice as specialists and/or surgeons. This is a result of the fact that most Israeli public hospitals are not licenced to provide private health services. We suggest therefore that northern hospitals should be uniquely licenced to allow for inclusion of private practice as a means of attracting skilled practitioners to the region. This step would need active regulation which could only be decreed by the Ministries of Health and Law.
* We recommend that the Ministry of Health and HMOs offer economic incentives for skilled physicians who relocate their practices to the north, These incentives could include cheaper housing, tax reduction and attractive specialising programs.
As stated, 1,158 additional hospital beds for short-term care are needed in the Galilee by the year 2020. Given scarce resources and the fact that the number of Israeli public hospital beds has not increase in many years, we suggest an urgent and immediate supply of 134 hospital beds in addition to the contribution of another 243 beds by the Haifa district. An additional 287 hospital beds should be added by the year 2020 to meet the population’s natural growth. By 2020, according to the national plan, another 269 beds should be added to the region. In this phase, Haifa will contribute 278 beds (see Table 2).
The cost of providing a new bed in an existing facility in Israel (2007-2008) is US$100,000, in comparison with US$250,000 for one in a new facility. We suggest that the additional hospital beds by the year 2020 be provided in existing facilities and not in new ones, thus saving resources, empowering northern hospitals, and creating centres for excellence.
Rehabilitation and long-term care
In Israel, rehabilitation and long-term care facilities are not economically viable, and hospitals are confronted with financial difficulties in operating these wards for the benefit of the population. As there is no rehabilitation facility in the north, there is a shortage in high dependency care beds. We suggested that regulatory measurements and actions should be taken in order to support rehabilitation and chronic care services.
Our suggestions included dramatic changes in fees and the pricing method: currently Israeli public hospitals charge fixed prices set by the Ministry of Health. These prices, in some cases, do not cover actual costs. However, a funding method using diagnosis related groups (DRG
), for instance, could be one of the solutions to this problem. However, such a solution, which would involve changes in national health insurance and pricing methods, is in the hands of the Ministry of Health.
The Israeli Neurosurgical Society insists on high surgical volumes in order to sustain high performance, and, for many years objected to the opening of new neurosurgical services in the north, arguing a lack of sufficient patient volumes. Taking into consideration these arguments, the following solutions were suggested:
* Assigning one of the neurosurgical wards in Haifa as a superior ward to a new ward that will be opened in one of the northern hospitals, with the roles of supervision, support and training of new staff.
* Staff from the northern hospitals will rotate service with Haifa neurosurgical professionals. In this case, Haifa hospitals will respond to elective procedures while the northern staff will respond to trauma and acute events.
We offered two solutions to the need of rebuilding an old psychiatric hospital in Acre. The first was to retain the independence of the hospital and the existing hospital board. The second one was to finance a new facility as part of Naharia medical campus (situated close to neighbouring Acre), through assigning part of the expensive and valuable real estate and land they own. This solution would create a large health campus with significant centres of excellence. The Ministry of Health support the second solution but unfortunately local political issues presented serious obstacles to the plan.
The scheduling phase takes theoretical priorities derived in the assessment phase, and introduces them to reality (Johnson 2005). The worst-case scenario for us in this project was that our plan would remain unimplemented. It was realised that for such an ambitious plan traditional scheduling is not enough, especially where many public arms need to become involved, including central government, philanthropy, non-governmental organisations (NGOs), local municipalities, community leaders with different interests and public agendas, and other public representatives. Therefore, while focusing on this phase we decided to schedule three operational steps.
The first step was to validate the plan’s conclusions and suggestions, its analysis and results. To achieve this, we were introduced to a panel of major caregivers and policy makers who had been invited to an open discussion. By the end of this intensive discussion, most of the suggestions were approved and priorities were scheduled. The scheduling process assisted in developing a compromise between conflicting needs; for example, the recommendation to add 1,158 hospital beds was primarily constructed as a suggestion for a new hospital located in the centre of the Galilee; however, the panel insisted on the distribution of these additional beds between eight existing public and private hospitals. By the end of the process, this suggestion was accepted by the planners.
The second step was to publicise
the plan. A book, describing the planning process, results and recommendations in detail was published and distributed among a wide range of professionals. A short summary of the main conclusions was prepared and presented to governmental decision makers – the Prime-Minister’s Chief of Staff, the Ministry of Health’s General Director, the Minister for Regional Development and, finally, to the President, the former Minister for Regional Development, Mr. Shimon Peres, who has been a strong promoter of the development of the Galilee.
The third step was to create a coalition and a taskforce to lobby for the plan. This group included leaders in the region’s healthcare system, including hospitals, HMOs, public health services and academics. This group’s role was to coordinate the implementation of the plan, and work with governmental ministries on the proposed solutions, especially where regulatory measurements are needed. In order to accelerate the process, the planners initiated the taskforce activities; however, the goal was to eventually hand over all project responsibilities to the taskforce within a year.
Conclusion: lessons learned
Strategic planning achieves optimal allocation of scarce resources by proper execution of three phases: the assessment phase which encompasses the needs of the entire region and its environment; the prioritisation phase, where priorities are established; and the scheduling phase where an implementation timeframe and actions are assigned. Collectively, these tasks comprise the planning cycle (Johnson 2005).
Our planning process, especially during Phase One, explored a wide range of needs for a well-functioning healthcare delivery system. These needs range from broad system changes to local issues such as reductions in local taxes, employment of additional technology and upgrading certain infrastructures. The plan’s mission was to evaluate each need and each demand from a broad perspective, taking into consideration spatial, political and regulatory issues, costs, cost benefit diversity and inequalities into considerations The result of this process is a reasonable and achievable list of five main suggestions as described earlier.
A number of preconditions are necessary to influence policy: political will, sustained funding to encourage methodological rigour
and build decision makers’ confidence, and the development of sufficient capacity and skills (Hall & Viney 2008).
Political will is crucial, implying both receptiveness to new ideas and readiness to change thestatus quo. This must be combined with an appropriate and sustained level of investment over time, and a time frame that allows for the development of rigour and confidence from policymakers and players in the health system. In order to achieve the political will, the plan has to be available, acceptable and affordable by all key political players, and this is the main reason why they all should take part in the planning process. They should be heard, and their visions, needs and perspectives should be taken into consideration while decisions are made. In addition, planners should be aware of political sensitivities and conflicts of interest, and address them professionally.
Half of the Galilee population is made up of Israeli Arab citizens, who conduct a lifestyle that is different from that of the Jewish population. Therefore, it is crucial to approach the planning process with an open heart and mind, especially if the region is ethnically diverse. During the planning process we made a point of analysing special health and morbidity data concerning the Israeli Arab population, and were in close discussions with its community leaders in order to remain sensitive to the region’s diverse needs.
Lobbying activity should occur on behalf of, and in collaboration with, service users and providers equipped with the skills necessary to do so (Cutcliffe & Hannigan 2001). In regional planning, adequate lobbying activity, carried out by professional lobby groups and political activists working in the parliament, is of great help in ensuring political and budgetary support.
Another critical precondition
is that there should be sufficient capacity among independent academic researchers to provide the evidence-base that supports and informs the policy initiatives of government (Hall & Viney 2008). From our long years of experience, we know that if a regional healthcare plan consists of good evidence-based research and is supported by validated data analysis, decision makers are more likely to support the plan.
The regional healthcare strategic plan for the Galilee is now in a stage of political and governmental approval. It is our hope that the plan will be confirmed and implemented and that an equal healthcare system will soon be created for all Israel: The north and the south thou hast created them: Tabor and Hermon shall rejoice in thy name (Psalms 89.12).
The authors would like to thank Ms. Ayala Peled Ben-Ari for her contribution to this article.
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Horev, T. and Epstein, L. (2007). Inequality in health and in the health system. Taub Institute for Social Policy Research in Israel. Available at: http://www.taubcenter. org.il/publications.asp?ID=2007
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Nirel, N., Pilpel, D., Rosen, B., Zmora, I., Greenstein, M. and Zalcberg, S. (2000). The accessibility and availability of health services in the south of Israel: has the gap between the south and other regions in Israel been reduced in the wake of the national health insurance law? Brookdale Institute Jerusalem. Available at: http://brookdale.jdc. org.il/category/ByYear2000
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Ronit Peled MPH PhD
Faculty of Health sciences
Department of Health Systems Management
University of the Negev
Jerry Schenirer LLB
Tzafona Idan Ha Galil
PO Box 12
Table 1: Long term care:
bed rates regional comparison
MEAN GALILEE CENTRAL JERUSALEM
Long-term care 68.1 85.0 99.4 66.7
Geriatric rehabilitation 2.8 0.5 6.6 0.8
long-term care 7.7 2.5 8.3 4.9
Long-term geriatric 48.8 69.6 65.4 47.1
Table 2: The need for hospital beds in selected wards
BED NEEDS BED NEEDS
NATIONAL PLAN NATURAL
DEPARTMENT 2020 GROWTH 2020
Internal Medical 1,001 888
ICU 70 62
Cardiology ICU 70 62
Pediatrics 263 234
General Surgical 421 374
Obstetrics 351 312
Rehabilitation 228 203
Total 2,404 2,135
Aggregated Bed needs 1,158 889
Bed needs in Ranks 269 512
Haifa Contribution 53 225
Total need in accordance with Haifa 216 287
CLOSING GAPS EXISTING BEDS
DEPARTMENT 2005 2005
Internal Medical 676 506
ICU 47 26
Cardiology ICU 47 28
Pediatrics 178 217
General Surgical 284 165
Obstetrics 237 257
Rehabilitation 154 47
Total 1,623 1,246
Aggregated Bed needs 377
Bed needs in Ranks 377
Haifa Contribution 287
Total need in accordance with Haifa 134
Internal Medical 0.57
Cardiology ICU 0.04
General Surgical 0.24
Aggregated Bed needs
Bed needs in Ranks
Total need in accordance with Haifa
Figure 2: Physician rates (per 1,000 population)
for the Galilee region compared with
National rates and rates for Tel-Aviv
Tel Aviv 4.7
Note: Table made from bar graph.
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