The State audit of social services in Israel is conducted in the Ministries responsible for those services-the Ministry of Education and Culture, the Ministry of Health, the Ministry of Labour and Social Affairs, certain departments in the Ministry of Construction and Housing, and the National Insurance Institute. Since certain services, especially in the field of education and welfare, are administered by the local authorities, audit in these authorities regularly includes the inspection of those fields of activities too.
In state audit of social services, there are two basic concepts. One is the traditional audit concept, which requires that operations, and in particular their financial side, be inspected from the standpoint of the Treasury in order to check the regularity and legality of payments (and eventual receipts), the quality of accounting, the due maintenance of property, the elimination of waste, etc.
The other concept is relatively modern and sometimes called "social audit". Inspection is not intended to serve the Treasury but the ordinary citizen: to find out whether he gets what is legally due to him, what is the quality of the services he receives, whether he suffers from inefficiency, prejudice, favoritism, bureaucratic obstacles or perhaps from illogical or outdated legal and administrative rules.
The aspiration of Israel's State Comptroller to improve the services rendered by the authorities in the social as well as in other fields led from the routine inspection of administrative practices to the audit of policy: the critical evaluation of arrangements which even when embedded in law gave rise to results which did not conform to equitable norms.
An example of this attitude can be found in one of the earlier reports of the State Comptroller of Israel.
In a chapter dealing with the inspection of old age and survivors' insurance in the National Insurance Institute, several recommendations were made to change the law, and to introduce new procedures in order to remove hardship caused in particular cases by the existing arrangements. For instance, the curtailment of benefits
because of arrears in payments to the Institute by the insured could cause particular hardship to dependents of a deceased breadwinner. One of the recommendations was to set up a special fund for insured persons or their dependents, who were ineligible for benefits under the law, because of circumstances which arose through no fault on their part.
Another recommendation of the State Comptroller referred to a special allowance paid to recipients of old-age insurance, who had no additional income. Since this payment was not founded in law, labour tribunals did not deal with appeals against the decisions of the Institute in this matter. As a result of the Comptroller's recommendation a procedure of appeals was adopted.
Because of the growing awareness of the public, the media, the parliament and the government to problems of this kind-undoubtedly, in part, as a result of the State Comptroller's attention to them-and because since 1971, the State Comptroller has also acted as Commissioner for Complaints from the Public (Ombudsman^ there have been fewer recommendations of this kind in; recent annual reports.
This is one of the reasons, that the case study brought hereafter deals with a different aspect of auditing policy in the social services: the inspection of the institutional setting in which services are delivered according to government policy.
As an illustration of the way in which the State Comptroller examines such subjects, the following excerpts have been chosen from an Annual Report of the State Comptroller which summarize an audit of hospitalization in the Jerusalem district, conducted in the Ministry of Health.
At the end of 1981 there were 26,703 hospital beds of all kinds in Israel (6.8 beds per 1000 inhabitants); Of these, there were 11,630 general hospital beds (2.9 per 1000 inhabitants); 8,619 for mental illness, excluding institutions for the retarded (2.2 per 1000 inhabitants); 5,832 in hospitals for chronic illnesses, including
tuberculosis (1.5 per 1000 inhabitants); and 622 in rehabilitation centers (0.2 per 1000 inhabitants).
There were 145 hospitals in Israel-35 run by the government, 2 run jointly by local and national government, 14 by the Labour Federation's General Sick-Fund, 32 by other organizations, 7 by Christian churches, and 55 under private ownership. During 1981 620,000 patients used these hospitals.
At the end of 1981 there were in the 31 hospitals in Jerusalem 3,866 beds of all kinds (8.3 beds per 1000 inhabitants). Of these, there were 1, 871 beds for general patients, 1,301 for mental illness, 549 for chronic illnesses or geriatric disabilities, and 145 for rehabilitation. Fourteen of the hospitals were owned by public organizations, 7 by the government, 6 by private owners, 3 by churches and 1 by the General Sick Fund.
From July to September 1982, the State Comptroller's Office inspected the hospitalization system in Jerusalem with the aim of determining its suitability to the needs of the population it serves. The activities of the Ministry of Health, which is responsible for the supervision of the hospitalization system, was also examined. The inspection was conducted in the Ministry's head office and in its Jerusalem district office.
1. In 1982 there were 16 general hospitals in Jerusalem. The number of Ministry authorized beds in these institutions, as of 1.4.81 included 1, 841 general beds, 110 beds for chronic and geriatric diseases, 22 day care beds, and 30 beds for the treatment of Hansen's disease (leprosy).
In the fiscal years 1977-1980 there had been 3.2 general beds per 1000 people in Israel, but there were great differences between different parts of the country; while Jerusalem and the central district of the country had 4.2 beds per 1000 inhabitants, the south, the north and Tel Aviv had only between 2.2-2.8 beds per 1000 inhabitants. In 1980 the Ministry decided that the rate of general beds in the country should be 3 per 1000 inhabitants. With respect to Jerusalem, the Ministry endeavored to reduce the number of general beds and to increase the number of beds for chronic and geriatric diseases, which were lacking in the district.
In fiscal year 1982 the Ministry authorized an additional 25 general beds for Jerusalem, and thus set the complement at 1, 866 general beds for Jerusalem and its environs. The population in the district of Jerusalem was 448, 200 as of 31.12.80. According to the complement of beds for the fiscal years 1981 and 1982 the quota was thus set at 4.1 general beds for 1000 inhabitants. Accordingly, the 11.4% of the country's total population which resided in the district of Jerusalem received 15% of the total general hospital beds in the country. In addition to the district populace, in certain fields of medicine the hospitals in the city serve the rest of the country as well, and tourists who come for treatment. This additional population to be served explains part of the added load on the general hospitals in Jerusalem. Since Jerusalem has up to 60% more general beds than the Southern and Northern Districts, it might be expected that there would be a relatively lighter load on the hospitals. However, this is not the case. The occupancy of the large hospitals in Jerusalem is similar to that of other hospitals in the country, and in certain departments is even greater by 150% (as in the neurological department, general intensive care, and cardiac intensive care at Shaarei Zedek Hospital) and by 120% (as in the gynecology department at Hadassah Ein Karem; special infants' care and urology departments at Shaarei Zedek Hospital, and special infants' care department at Bikur Cholim Hospital). The reasons for this phenomenon were not investigated sufficiently by the Ministry. It might be conjectured that among the reasons for this additional load are the standing and reputation of the large hospitals in the city and the country-wide functions they fulfil.
2. In Jerusalem there are new medical centers which do not operate at full capacity. Hadassah Hospital on Mt. Scopus was built for approximately 400 beds and uses only 285; Shaarei Zedek Hospital was built for some 500 beds and uses only about 300. Also, the new building of Misgav Ladach hospital planned for 60 beds for infants and women, uses only 30 beds.
The relatively large number of general beds and of insufficiently-utilized hospital facilities in Jerusalem, represents investment in building and maintenance that could have contributed more in terms of medical services if invested in other parts of the country or in hospital beds of a different sort which are lacking in Jerusalem. The Ministry has been aware of the situation for some years, but only since 1980 have realistic efforts been made to reduce the number of general beds in Jerusalem.
At the end of 1981 there were 5,812 beds in the country for chronic/geriatric illness, and-20 additional beds for tuberculosis patients. Most of the hospitals in Jerusalem are owned by various public bodies; only one, whose complement is 66 beds, is in government ownership. The General Sick Fund does not maintain a hospital for chronic/geriatric illness in the city. In Jerusalem, a complement of 549 beds was set for ten hospitals, but in mid-1982 there were only 491 beds of this type in use.
The population of the country is aging fast. The percentage of residents aged 65 years and older rose from 4.8% in J955 to 6.8% in 1970, and at the end of 1981, 8.6% of the population in the country were 65 or older. In Jerusalem, 8% of its Jewish residents and 4.2% of its non-Jewish residents were 65 or older.
The Ministry proposed in 1975, that the new Misgav Ladach Hospital, which was about to be erected, should merge with a geriatric hospital in a large complex of 400 beds, financed and operated by the Ministry, but it has not yet been implemented. Towards the end of fiscal year 1981 the Ministry had reached agreement with Hadassah and Shaarei Zedek Hospitals on the use of 50 geriatric hospital beds in each of them, the expense to be borne by the Ministry. Hadassah Hospital actually put into use only 28 geriatric beds, at low occupancy rates. There is no information at the Ministry concerning the occupancy of the geriatric beds at Shaarei Zedek Hospital inspite of the fact that they have been in use since July of that year. A private hospital in the Jerusalem area, that had 50-geriatric beds in use, was in the process of closing down, and in August 1982 had only 14 patients .
Most of the admissions to geriatric hospitals are made through the district health office. The data gathered by the State Comptroller's Office attest to the fact that in August 1982 there were 442 residents of Jerusalem in hospitals in the city, and 71 of its residents were hospitalized, through the district office, in hospitals in other cities. Hospitalization outside the city is extremely burdensome on both the patient and his family. In addition to those referred to the geriatric hospitals by the district office, private patients are admitted to these institutions as well. Their number is not known to the district office; in its opinion, there exists over-admission in most institutions, an undesirable situation especially with regard to chronic illness.
At the time of the audit, in September 1982, the district office had' a list of about 200 patients waiting for admission to hospital, of whom about 70 were urgent cases; however, the lack of beds both in and outside Jerusalem prevented a solution to the problem. Keeping at home a sick, elderly person in need of constant attention is burdensome and likely to be, in many cases, destructive to the family, and not infrequently the patient is not cared for properly.
Those hospitalized through the district office are entitled to support from the Ministry, depending on the economic situation of the patient and of his family. In the fiscal year 1981, the Ministry's support for geriatric and chronically ill patients from Jerusalem, whether hospitalized in the city's institution or elsewhere, came to IS 58.8 million, about a fourth of the total support of IS 219.1 million given to patients of this kind, for the whole country. For fiscal 1982 IS 582.1 million was budgeted for the entire country.
Hospitalization in Jerusalem is characterized by the fact that there are no general hospitals owned by the government or by the General Sick Fund, and that, basically, medical services are given by hospitals under other kinds of public ownership. The number of general beds in the city, relative to the size of the population, is significantly larger than the maximum set by the Ministry of Health, and larger than the national average. On the other hand, the city has a serious shortages of beds for geriatric and chronic illness and the number of sick people awaiting hospital admission-including some needing urgent hospitalization-is ever increasing as a result of the aging population.
In spite of the fact that the number of general beds relative to the population is large in Jerusalem, the occupancy in the city's large hospitals is full and even higher. This points to the importance of reducing the occupancy rate, and the length of stay of patients in the general hospitals. In the opinion of the Comptroller, an arrangement should be made similar to the one temporarily adopted by General Sick Fund and public hospitals, aimed at reducing the number of days of hospitalization for each patient and thus lowering the occupancy rates of the hospitals.
This would make it possible to convert the beds freed to other types of hospital use, and a more efficient use of the resources of the system.
Notwithstanding the not insignificant support the state gives to the public hospitals in Jerusalem through the Ministry of Health, and inspite of the Ministry's responsibility for the planning and supervision of the whole hospitalization system, a lack of balance has been created in the hospitalization system in Jerusalem-an excess of general beds and a scarcity of geriatric beds.
The Ministry must tighten its supervision of the hospitals in order to attain co-ordination between the hospital services in Jerusalem and the needs of its population, including a change in the assignments of unused facilities. Also the Ministry must encourage the initiatives of other institutions, and initiate ways to reduce the need for the large number of days of hospitalization in the general hospitals-steps it has refrained from taking so far-in order to lessen it at least to the national average. Steps such as these should halt the phenomenon of overload in the general hospitals.