Community Paediatrics in Israel: the 'goshen' Model for Change

Child health services in Israel have focused historically on three areas. Preventive services have been delivered in maternal child centres; these originally belonged exclusively to the Ministry of Health, and subsequently expanded into services provided by local municipalities, and new centres were established by the health funds, following the National Health Insurance Law in 1995. The paediatric departments of hospitals were responsible for managing serious paediatric pathology, with increasing numbers of subspecialties developing over the years. The hospitals have also held the exclusive right for accrediting paediatric training. The management of paediatric problems in the community is done by paediatricians who had not completed subspecialty training and by family practitioners. Three service models exist in community paediatrics in Israel. The first model is a long-standing one, involving salaried paediatricians working in primary care clinics together with general practitioners or specialist family physicians or internists. In the second model, groups of primary care paediatricians work in comprehensive paediatric service centres, where various paediatric subspecialists are also available. Third, a large body of independent paediatricians work on a modified fee-for-service basis for one or more number of health funds, with many working in solo practise. The remuneration of independent physicians is based on the volume of children seen, which may be seen as a disincentive for proper assessment and management of non-acute developmental, behavioural and well-being problems, which almost invariably are more time consuming. While the paediatric services as described seemed to cover adequately the needs of children and their families, it has become apparent that the sorts of conditions described by Haggerty1 as comprising the ‘new morbidity’, especially developmental, behavioural and psychosocial problems, have not been appropriately managed. As parents began turning increasingly to paediatricians for concerns about their children's development and behaviour, as well as chronic illnesses, paediatricians found …