Lessons In COVID-19 Vaccination From Israel
Israel is the world leader in vaccinating its population against COVID-19. As of March 15, 50 percent of Israel’s population had been fully vaccinated, and 60 percent had its first dose. The comparable figures for the United States were 12 percent and 21 percent, respectively. Among Israelis ages 70–79, 91 percent had been fully vaccinated, and 96 percent had received a first dose.
Every country is unique and has singular features that characterize its geography, population, health care system, and thus impact vaccine delivery. Israel is a small country in population and geographically compact. In size and population, it is often compared to New Jersey. Its population skews younger than many other economically advanced countries. The share of population older than age 65 in Israel stands at 12 percent compared to 23 percent for Italy, 28 percent for Japan, and 16 percent for the United States.
This past December when the vaccine rollout began, the weather in Israel was unusually mild, even for a country that typically has relatively mild winters. Israel also does not shut down for Christmas. These are unique advantages, not easily adopted by most other countries. Israel, however, also concurrently faced challenges similar to other countries. It was and still is facing its third surge in infection rates, with about 6 percent testing positive overall, and some communities posting infections rates up to 25 percent. Israel is still in the middle of a fraught political campaign and, like the US, has subpopulations and ethnic minorities, some of whom live in very dense conditions, tend to distrust government and science, flout various social distancing policies, and are slower to get vaccinated.
For all of these reasons, it is no surprise that Israel has performed comparably well in a vaccine rollout. Even so, these factors alone did not portend that Israel would be the world leader it is today. So, what additional factors that have contributed to Israel’s success?
Central Planning And Guidance
In a recent article in the Israel Journal of Health Policy Research, Bruce Rosen, Ruth Waitzberg, and Avi Israeli discussed 12 factors that have led to Israel’s rapid rollout of the vaccine. Some of the factors, such as geography and population size have been noted above. Additional factors that have helped Israel achieve relatively high rates of vaccination include early access to a steady supply of vaccines, a tradition of periodic emergency preparedness exercises that included well-trained community-based health care providers, and highly developed electronic health records systems capable of both identifying high-risk persons and reaching out to them in a seamless fashion. While these factors are not universally shared, they are not unique to Israel.
On December 16, 2020, Israel’s Ministry of Health decided that the initial target groups for vaccination would be people ages 60 and older, nursing home residents, other people at high risk due to serious medical conditions, and front-line health care workers. The responsibility for vaccinating each of these groups was also clearly defined at that time. Israel’s four competing nonprofit health plans were assigned the primary responsibility for vaccinating the general population older than age 60 and people at risk due to preexisting medical conditions. Responsibility for vaccinating nursing home residents was assigned primarily to Israel’s national medical emergency services organization—Magen David Adom. Responsibility for vaccinating front-line health workers was assigned to the hospitals and health plans with whom they work.
Consequently, everyone in the target groups knew exactly who was responsible for vaccinating them. While in the initial rollouts some websites for making appointments crashed, people were not trapped in a digital loop of trying to log onto multiple sites to obtain a vaccination from providers they did not know. This, alas, was an all too common experience in the United States. Many states (for example, Maryland, California, and Florida) in the US seemed to put residents through scenarios akin to the Hunger Games to obtain a vaccination. Only those who were most computer literate and fast on the draw—a survival of the fittest drama, testing one’s computer skills—were able to obtain a coveted vaccination slot from an array of providers, all with different websites and requirements. The takeaway lesson here is that a lack of clearly communicated standards for vaccine eligibility, and the dispersal and diffusion of responsibility for vaccinations, creates massive confusion and inequity.
One of the other takeaways is the importance of central planning and guidance in pandemic response. In Israel, the state has central authority on health care policy making (especially on vaccine policy and prioritization), and delivery and local authorities play only a limited role. Historically, delivery of health care in the United States has been a state rather than a federal responsibility. The Trump administration continued that tradition in allocating vaccine doses to the states to administer. Belatedly, under the Biden administration, there have been some federal efforts at vaccine “last mile” distribution and administration, with announcement of vaccine allocations to federally qualified health centers and pharmacies.
More recently, federal efforts have helped boost US vaccinations to over 2 million a day now reaching over 20% of the population. Teachers have been prioritized in all 50 states and members of the military and National Guard have been deployed to help establish mass vaccination sites.
Could states have taken on a more central planning role during initial vaccine distribution under the Trump administration? West Virginia is one state that did. The state adopted a centralized state-run registration system that has contributed to its success and also established priorities for vaccination instead of leaving it up to the 55 counties in the state, which could have led to 55 different sets of rules. Confusion about eligibility, particularly the categories of essential workers or which comorbidities put a person in a higher-risk category, has characterized the rollout in other states. Even within the same state there are contradictory rules about teachers and other essential workers.
Other factors described by Rosen and colleagues are more pertinent or transferable lessons for other countries, rather than US states. Two of the factors were the rapid mobilization of special government funding for vaccine purchase and distribution and timely contracting for large amounts of vaccines relative to Israel’s population. These two factors also speak to decision making on a national level that understood that dedicated resources had to be set aside and plans needed to be implemented once the vaccine became available to immunize the country.
Cross-National Learning
In the wake of Israel’s impressive roll-out experience, the Israel Journal of Health Policy Research (co-edited by Rosen, who is one of the authors of this blog post) launched a rapid cross-national learning effort inviting health policy experts from other countries to weigh in on what ideas their countries could absorb from Israel.
Sherry Glied, dean of New York University’s Wagner School of Public Service, responded with a US perspective and advocated for the federal government to adopt an urgent, united response to the COVID-19 pandemic as a clear national emergency.
Greg Marchildon, professor of health policy at the University of Toronto, noted that Canada started with some structural disadvantages relative to Israel. These included less centralized and coherent emergency planning and a more challenging geography. Nonetheless, Marchildon took the position that Canada could benefit from Israel’s example through a more strategic deployment of national leadership in the vaccination campaign and the greater use of primary care resources and providers.
Martin McKee and Selina Rajan, at the London School of Hygiene and Tropical Medicine, saw a useful lesson for the United Kingdom, noting that Israel went one step further than many other countries by linking each priority group to a different delivery system. Thus, each priority group and each delivery system had a clear understanding of who was responsible for their care.
McKee and Rajan also noted the smooth operation of Israeli health care information systems and the existence of a comprehensive population-based childhood web-based immunization registry. That platform of the national registry was adapted for the COVID-19 vaccine campaign and used for monitoring adverse events and population-based research on vaccine effectiveness.
McKee and Rajan noted that many interconnected steps had to be taken to turn plans for successful vaccine purchase, cold-chain storage, delivery logistics, accurate population register, and a cadre of vaccinators into actual immunizations. It’s not a system that self-organizes on its own. Ultimately, as they and Glied recognized “Somebody needs to be in charge with a clear vision of what they want to achieve. While this seems to be the case in Israel, it appears to have been lacking in many other countries.”
Challenges Remain
By moving ahead more quickly than others with vaccinations, Israel has not only been a source of ideas regarding what has gone well. It also is generating advance warning signals for other countries about challenges that become more prominent once a significant proportion of the population has been vaccinated. In recent weeks, Israel’s vaccination campaign has moved from an initially smooth opening game into a more challenging middle phase. The challenges include relatively low vaccination rates among Arabs and the ultra-Orthodox, two groups that are also more resistant to social distancing rules. For example, according to statistics provided by the Ministry of Health, as of February 27, it was estimated that among Israelis age 50 or older, 68 percent of Israeli Arabs and 62 percent of Israel’s ultra-Orthodox Jews had been vaccinated at least once, compared with 89 percent among other Israelis.
The relatively high rate of vaccine hesitancy among the ultra-Orthodox population has been attributed in part to a general distrust of the government and incomplete understanding of the vaccine’s risks and benefits in general (as promoted by some well-known radical anti-vaccination rabbis). Moreover, as a population that places great weight on having large families, some of the ultra-Orthodox have also expressed a particular concern about the potential—although unfounded—fertility risks of vaccination. The government, health plans, and public health community have responded to this by hesitancy targeting fake news stories such as those related to fertility. This is being done through the ultra-Orthodox media (ranging from pamphlets, radio, podcasts, and social media) and leading rabbis (who are the de facto community leaders). Health system professionals are also working together with ultra-Orthodox municipalities such as Bnei Brak to improve access and encourage vaccinations.
Vaccine hesitancy is also prevalent among Israel’s Arab population. There, too, it is often related to misinformation around vaccine benefits and risks, as well as issues of trust in government. Public health professionals are addressing these issues by engaging Arab religious and other leaders, and showcasing them in various communication venues, from traditional to social media.
Residents of smaller Arab villages and Bedouin encampments also had suboptimal vaccine access during the early roll-out phase. In response, Israel focused on improving physical access—especially in the country’s peripheral regions (the Galilee in the north and the Negev in the south). Health professionals are also working with local organizations, such as the Arab Bedouin Physicians Organization, to improve access and uptake.
The challenges in communication and access to minority communities are not dissimilar to those in the United States. While the populations and groups might differ, widespread distrust, particularly in minority communities, exists. Even among nursing aides, the majority of whom are people of color and who have experienced first-hand the devastation wrought by COVID-19, large percentages of the work force have hesitated to get vaccinated. Social media has been replete with similar stories as in Israel’s ultra-Orthodox communities falsely claiming that the vaccine would change one’s DNA or cause infertility. Rural Black communities in the South face daunting logistical challenges in obtaining vaccinations.
While all countries face challenges, viruses do not respect borders. Until we are all free of the virus, no one will be free of the virus. In an effort to promote global consensus on vaccine policy, Israel, the United Kingdom, and Canada joined the COVAX initiative in September 2020, to support global equitable access to a vaccine. The United States joined in January 2021.
The drawing of lessons and ideas from health care developments in other countries is particularly valuable in times of shared global challenges. Both the successes of the Israeli rollout and the challenges it is currently encountering can illuminate the path forward for other countries. Cross-national learning in many forums needs to be done promptly, with appropriate caution that countries also differ in significant ways. Health policy journals, such as Health Affairs and the Israel Journal of Health Policy Research, should play vital roles in sharing experiences and best practices across countries.
