Specialist palliative care services are provided in a number of different health care settings most of which rely on complex sources of funding (Table 2). Patients with cancer are entitled to free medication. Patients with other illnesses are entitled to medication, including opioids, at a discounted rate depending on their health plan insurer; usually this is a flat rate per prescription.

Table 2: Funding sources for hospice and palliative care services in Israel

*Tel Hashomer Hospice inpatient unit has made a transition from combined charitable/HMO to sole HMO/MoH funding

Palliative care services which are entirely charitable and relying on donations are able to offer all patients free care and consultation. There is one private service available to any patients able and willing to pay fees. Health plan insurers are also referred to as health maintenance organisations (HMO).⁴⁵ Three services receive a combination of charitable funding and HMO funds. One service has made the transition from combined funding to HMO/MoH funding only. (HMO funds all include an annual per capita proportion of government Ministry of Health (MoH) funds). Some palliative care services operate within one of the institutions owned and run by Clalit Health Services; the oldest and largest of the four non governmental health plans providing insurance and services to 55% of the population. Where an HMO, such as Clalit Health Services (Kupat Holim Clalit) runs all or part of the service the patient can only receive free care for a certain number of services if they are signed up to that HMO insurance.

Charitable funding may include monies from national and international donors from institutional or private sources. Currently the largest and most generous national, institutional donor funding palliative care services is the Israeli Cancer Association. The Jewish Federation in the USA (specific donor branches include New York and Detroit) is a major international donor. Charitable funds support a range of activities in a service; funding a health professional post; providing financial support to run a service; funds for individual projects as part of establishing a service; new facilities within a service; research and development.

Although an institution within which the palliative care service is based also receives a percentage of Ministry of Health (MoH) funds, the palliative care service does not itself receive any direct government funds. The competitive nature of government versus HMO allocation can result in loss of funds for the service.⁴⁶  Some elements of community based services and half of all acute or rehabilitation hospitals are government funded, and patients can access free care if they have Israeli ID with paid up National Health Insurance (NHI) benefits. However, no government funded NHI cover directly funds any specialist palliative care service. Hence, access to any degree of specialist palliative support within government funded settings is entirely dependent on whether physicians or nurses in that unit or institution have received specialist training elsewhere.⁴⁷

Palliative care is not in (what is known as) the ‘basket of services’ of the four national HMOs - who consequently are under no obligation to fund end of life care.⁴⁸ HMO funding is subject to continual negotiation i.e. year on year (or in some cases month on month)⁴⁹ and accordingly the palliative care services funded through a HMO have been found to be financially precarious and subject to sudden loss of funds.⁵⁰ In fact, some (though not all) services funded either entirely or in part through charitable, non government organisations (NGOs) may have greater financial security if they are fortunate to have highly committed benefactors and regular donations.⁵¹