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Maccabi Healthcare Services (MHS), the second largest HMO in Israel, has chosen to implement a multi-annual strategy to promote equality and equity in healthcare. Within the strategy's framework, MHS will maintain an ongoing process of studying the variability of its members characteristics for the purpose of adjusting service provision and improving health outcomes. MHS has recently published its first Equality Report, dedicated to defining the observed associations between its members demographic and socioeconomic characteristics and their health measures. The report identifies those sub-groups belonging to Israel's geographic and social peripheries that require focused interventions. Based on the report's recommendations, MHS has decided to designate promotion of equality as its strategic objective, a filter through which every policy decision will be reviewed. In addition it was decided to: 1. develop an organizational methodology to produce an index to assess reductions in disparities over time; 2. adjust MHS services to member's ethnic and cultural needs; 3. strengthen perceptions of community orientation based in primary care; 4. target resources to "social peripheries", beginning in 2010; 5. improve service accessibility and availability in geographically peripheral areas; 6. reduce economic barriers to healthcare. This article details the disparities as analyzed in the report in addition to the specific policy decisions made in their wake.

The quality gap is defined as the gap between the observed and the expected, evidence-based, quality indicators. Experts agree that significant reduction of the quality gap requires transformation of the current system of health care provision. Maccabi Healthcare Services has formulated a "change package" in order to redesign its community-based healthcare services. This is based on a proactive approach in primary care, which manages all aspects of health for a defined community of members. This is built on multidisciplinary team-work, led by a physician and a nurse; planned visits for the management of patients with chronic diseases; one-stop-shopping for efficient health promotion; and encouraging patient-centeredness, which ensures that patient values will guide all clinical decisions and patients will be provided with support to enable self-management. The following conditions and infrastructure were required to allow for the redesign: 1) Redesign became a focus of the organizational strategy; 2) Building a comparative performance measurement for presentation at all managerial levels; 3) Agreement on the incentives to primary care clinics, which voluntarily joined the process of change; training of "quality leaders" who will use common terms and methodology to improve the quality of care. Starting in 2005 as a "pilot project", the change process has gradually evolved to include about 50 primary care clinics towards the end of the year 2007.

The recent concern regarding the quality of healthcare services is partly due to the empowerment of health consumers, cost containment measures that may compromise quality, increased complexity of the medical practice and the accelerated growth of data on the magnitude and extent of quality problems. The framework of the delivery of health services, including quality parameters, differs fundamentally in the community as opposed to the hospital setting. In the community, the episode of care lacks geographic and temporal boundaries, and is divided among different facilities and caregivers. Hence, the healthcare systems lack control over the management of care. In the solo practice, the physician lacks the opportunity to discuss and share medical decisions with his/her peers and physician's reimbursement does not encourage him/her to invest time and effort in the provision of quality care. Furthermore, in the community setting, the patient is expected to take responsibility for compliance to the therapeutic regimen, a condition that may frequently interfere with regular life routines. Therefore, quality promotion should embody the "quality triangle" encompassing patients, caregivers, the healthcare system and appropriate interfaces. Ideally, the voice of the health consumer should be an integral consideration in the design of health policy, care should be patient-centered and physician reimbursement should reflect the quality of care provided. In addition, the design of the healthcare system information technology in supporting decision-making and training "quality leaders" to facilitate quality improvement programs. Consequently, it is pivotal to nurture agreement among policy-makers, patients and caregivers as to the essence of the dilemma: "What is quality in community care?" Meanwhile, we may suggest a primordial definition to community-based health care quality management: An ongoing multidisciplinary effort to identify and respond to the needs of patients, by providing systemic infrastructure that will support the caregivers and help in achieving better outcomes in the six basic dimensions of quality care-safe, timely, effective, efficient, equitable and patient-centered. In conclusion, in light of the medical activities conducted in the community, and the prevalent and ever-growing shortage of resources, there is a need to integrate efforts to develop and implement both unique tools and strategies to manage quality in community-based health services.

Background: Despite its critical importance, the issue of confidentiality in the provision of adolescent health care has not been specifically clarified by Israeli law., Objective: To review the conflict between the needs of adolescents, attitudes of the medical community and daily medical practice, and to promote legislation that would allow health care providers to treat adolescents without parental consent under certain circumstances., The Current Conflict: A major key to the productive encounter between the adolescent and the health professional is the confidence that sensitive information, communicated between them, will not be divulged to anyone, including parents. The Israeli law does not allow minors to give independent consent to care, except under certain circumstances. Also, Israeli physicians frequently do not provide confidential care, even when the issue is explicitly covered by the law such as in the case of termination of pregnancy., Steps Towards Change: The Ministry of Health adopted an analogy stating that "in the case of an activity in which minors of his/her age are accustomed to engaging, a legal act performed by a minor cannot be cancelled". On this basis, medical associations and other bodies involved in adolescent health recommended that care related to issues requiring privacy should be provided to minors without parental consent or knowledge whenever it is common among a certain age group to seek the specific type of care. However, a clear and updated legislation is still required in order to enhance professional legitimization and awareness.

Problem: Teenage pregnancies are frequently unplanned, the young pregnant woman being often unmarried. These pregnancies occasionally end in induced abortion. Teenage pregnancy, especially when unintended, is correlated with negative effects for the child and the mother. Despite the need to reduce the magnitude of this phenomenon, there is no reliable database on teenage pregnancy. Such a database could help define populations at risk, and could help in designing prevention programs. Birth rates, fetal deaths, and induced abortion are reported, but there is no uniformity or merging of the data., Objectives: The aims of the paper are to present a methodology for the estimation of pregnancy rates and to use it for the analysis of characteristics and trends in adolescent pregnancies in Israel., Methods: The pregnancy rate was calculated as the sum of three outcomes: live birth, induced abortion, and fetal loss, at all stages of pregnancy., Results: Based on these computations, the teenage pregnancy rate in Israel was estimated as 32 per 1,000 adolescent girls. This rate was three times higher among Moslems as compared to Jews. From 1988 through 1998, the rate decreased by 12%. The pregnancy rate in Israel is similar to the rate of most Western-European countries, and is three times lower than the US rate., Conclusion: There is a need to improve the means for collecting the data on which the computations are based, to build an algorithm specifically adapted to Israel, and to publish detailed pregnancy rates on a regular basis.