Publication of the State Comptroller's Annual Report – July 2024

• Read the State Comptroller's Annual Report – July 2024

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​​The State Comptroller and Ombudsman, Matanyahu Englman:

 The Prime Minister's Office should be one of the most protected from the information security aspect. The audit raises suspicion that former employees, including senior staff members, used their accounts at the Prime Minister's Office after termination of their employment. Another serious finding is the fact that the Prime Minister's Office's ability to identify unauthorized acts in the systems on the examined network, identify attacks and recover from them thoroughly and promptly has diminished. These are serious malfunctions that must be rectified as soon as possible.

 This is also the case in all matters pertaining to the Conversion Authority at the Prime Minister's Office: The team succeeded in issuing a false conversion certificate, enabling impersonation as a Jew, receive citizenship by virtue of the Law of Return, and make a mockery of every person and the state institutions, who regard this certificate as proof of proper conversion, while bypassing the work process and the means of control inbuilt in the system.

 

On the investigation of the fires:

"The reduced scope of the investigations into the fires has an adverse effect on deterrence and prevents effective enforcement against terrorists and other criminals. Thus, it was found that in 2022 an investigation was conducted in only 9% of the fires handled by the National Fire and Rescue Authority. Likewise, 228 investigation files were opened in the Israel Police from 2019 to 2022 on suspicion of arson against a nationalistic background, and indictments were only filed in 33% of them".

 "Alongside the published report, and following the Comptroller's tours in the north, we have recently approached the Minister of National Security and the Fire and Rescue Commissioner while indicating that the danger of fires has significantly increased in light of the missiles fired by Hezbollah in the north of the country. The Minister of National Security and the fire extinguishing array must provide appropriate solutions for the fire danger. Protecting Israeli citizens against fires in general, and those arising from missile fire in particular, is the government's supreme obligation".

 

On the number of doctors:

"There is a great shortage of doctors in Israel. Thus, the lack of psychiatrists is expressed even more strongly following the Swords of Iron War. The Yatziv Reform will harm the geographic periphery, and particularly the confrontation areas. The inadequate increase in the number of Israeli students, while in Israel they study foreign programs and occupy clinical fields – is a defect and it should be rectified".

 

The investigation of fires in the Fire and Rescue Authority​

 In 2022, an investigation was conducted in only 9% of the fires handled by the National Fire and Rescue Authority. 75% of the police files opened at the Israel Police on suspicion of arson were closed without an indictment being filed. 228 investigation files were opened in three years on suspicion of arson against a nationalistic background – indictments were only filed in 33% of them.

 

The State Comptroller found that the National Fire and Rescue Authority (the Authority) is operating without any written policy documents approved by the Authority's headquarters for determining its operation perception in the field of fire investigation. The existing policy in the field of fire investigation is not based upon a documented analysis of the risks and their optimum management. The risk levels of the fire incidents, set out in the Operations Department procedures relating to the fires outlines, do not necessarily correspond to the classification of the incidents set out in the regulations, focusing on other parameters (suspicion of arson; fire with casualties; and fire in a structure that was handled by the Authority).

 

The Authority did not investigate a multi-year average of approximately 89% of the fires handled by the Authority from 2019 to 2022 (approximately 188,000 fire incidents) and that were reported to the investigations array by the Authority's Control Center; this without the authorized parties in the Authority examining whether the aforesaid fire incidents require an investigation to be opened pursuant to the regulations. In 2022, the entire array conducted 4,016 investigations. Nevertheless, no documents were found documenting the decision-making process not to open an investigation regarding 40,573 fire incidents whose details were made known to the investigations array in 2022 (90.6% of all the fires handled by the Authority in such year).

 

The Commissioner or District Commander are not authorized to decide overwhelmingly not to conduct an investigation on all the fires that occurred in vehicles. This notwithstanding, in the Coastal and Judea and Samaria Districts it was decided that there is no obligation to open an investigation on fire incidents in vehicles, and in particular during a drive. In practice, in 2022 736 fires in vehicles in the Judea and Samaria and Coastal Districts were handled, out of which only 25 fires were investigated. It therefore transpires that the parties authorized by the regulations did not examine to begin with whether an investigation was required in approximately 96% of the incidents reported to the investigations array in these districts in 2022.

 

In 2022, the Authority established a Collection and Investigations Division which was designed to conduct ongoing activities in the fields of collection and research of information from various sources of fire incidents and to manage the fires investigations array at the Authority; however, until February 2024, approximately 62% (8 out of 13) of the professional positions in the job standard for the Collection and Investigations Division at the Commission had not been filled, and therefore after the four years since the decision to establish it, the new units added to the investigations array as part of the Division are only partially operational.

 

In 2023, the positions of commanders and investigators in the investigations array were under-manned: Out of seven positions of department heads in the districts, one position was not filled; out of seven positions of investigations division heads, two positions were not filled; and also 18% of the investigator positions in the job standard at the regional fire extinguishing stations were not filled.

 

The audit found that the Authority had not regulated in its procedures any provisions for the prevention of conflicts of interest of fire fighters performing the additional role of investigator. In this state of affairs, a fire fighter employed in the additional role of investigator is liable to be required to collect testimonies from his colleagues on their participation in the extinguishing of a fire that broke out during a joint shift, in a way that may place him in a situation where a conflict of interest is likely.

 

Apart from a basic investigators course, the Authority does not hold any advanced courses designed to raise the level and quality of investigations and train apprentices to be new fires investigators. Consequently, the investigators are unable to develop their professional skills and improve the investigation proceedings and outcomes.

 

According to the Authority's procedure, a fire investigation must be opened shortly after the incident; however, 28% of the investigations (4,428 out of 15,868) that were conducted from 2020 to 2022 were opened with a delay of two days and more, and 5% of the investigations (825) were opened with a delay of one week and more since the fire was extinguished.

 

The Police and Authority interfaces: 74% of the investigation files (6,728) that were opened on suspicion of arson from 2019 to 2022 were closed on the ground of "unknown offender", and 21% of the files (1,869) were closed due to lack of evidence.

 

According to the directives of the Authority's Investigations Division, a fire investigation should last up to one month from the date the investigation file was opened. However, from 2020 to 2022 at least 50% (8,011) of the investigation files were handled for an average time span of more than 11 months, out of which 1,537 investigation files remained open for more than 20 months, the majority of which without a documented ground and while failing to provide effective service to the citizens who were harmed as a result of the fire.

 

The Comptroller found that the investigations array is not equipped with the modern technological tools usually used in fire extinguishing services in other places in the world for streamlining the investigation process and economy of resources. Likewise, there is a shortage of investigation and personal protection equipment, such as gloves, helmets, work shoes, flashlights, designated cameras and advanced technological means, which is liable to endanger the health and safety of the fire investigators, delay the conduct of the investigation and encumber it.

 

A malfunction in domestic electrical appliances is the leading cause of fires (31% – 1,310 out of 4,178); and heading the list of the inflammable appliances – various components in air conditioners (59%) that are installed in almost every building in Israel. However, focused information regarding the malfunctions in appliances as aforesaid, is not published to the public on the Authority's website, including how to prevent fires starting in domestic electrical appliances.

 

Comptroller Englman determined that the Authority must perform the following acts: Formulate an effective operational perception of the investigations array; formulate an organizational structure that matches needs; determine a risk-based policy; draft an organized methodology; provide a protective envelope for investigators for optimum conduct of the investigations; train specialized personnel and preserve their competence over time; and regulate work interfaces with peer bodies.

Regulation of clinical training of doctors between the healthcare system and academia – follow-up audit

The Ministry of Health does not have any strategic planning mechanism that would allow it to formulate a long-term plan for increasing the number of doctors in Israel. The shortage is noticeable in a variety of fields, including geriatrics, anesthesia, intensive care and psychiatry – where the need for psychiatrists is especially prominent in view of the Swords of Iron War. The Comptroller also found substantive defects in the regulation of the clinical training of doctors and the effective allocation of the clinical fields in the hospitals and the community. 

In 2020, the number of doctors in Israel was 3.3 doctors for every 1,000 people, slightly less than the OECD average of 3.7 doctors for every 1,000 people.

The State Comptroller found that the shortage in doctors in certain professions creates severe competition for each doctor; the temptation of strong medical centers to recruit doctors at the expense of weak and peripheral centers; lengthening of queues and closing services in the periphery; and a surge in the prices of private medicine. Thus, it is already happening, for example, in the field of mental health, but in view of the existing and expected shortage of doctors in Israel, the situation is due to become aggravated in additional medical fields.

Since the previous audit report of the Office State Comptroller in 2018, the Ministry of Health has raised on its agenda the increase in the number of doctors in Israel, it is acting in various ways to achieve the objective and has even striven to rectify some of the defects that were raised in the previous report.

Nevertheless, the follow-up audit raised substantive defects in the regulation of the clinical training of doctors, and in particular the formulation of a strategic planning mechanism for medical personnel and the formulation of a long-term plan for increasing the number of doctors in Israel, the planning of the required number of specialists in each field of medical specialization and estimating the expected shortage in each field in the coming years. 

The Ministry of Health has a model for predicting the expected number of doctors for every 1,000 people, and it has formulated a detailed plan for increasing the number of medical students in Israel, but contrary to advanced countries in the world, such as the United States, England, Canada, France, Australia and Belgium, the Ministry of Health has no professional mechanism for the strategic planning of medical personnel that would allow it to formulate a multi-year plan appropriate for the population's needs. Neither has the Ministry made a precise situation assessment, and in particular has not mapped the data regarding the specialists in each field and the shortage thereof, and has not estimated the future need for doctors according to fields of specialization and geographic dispersion. It further transpired that the Ministry of Health does not have complete data regarding thousands of doctors living abroad (the Ministry of Health has estimated that in 2022 about 3,700 doctors were living abroad), how long they have been staying there, the doctors who have moved abroad and are returning to Israel and their expected date of return, and the Ministry has no organized array or plan for their return. 

According to data from the Civil Service Commission and the Ministry of Health, there is a shortage of doctors in the following professions: Geriatrics, pediatric neurology, anesthesia, intensive care, general surgery, pediatric surgery, internal medicine, oncology, urgent medicine (intensive care), pathology, radiology, rehab, neurology, forensic medicine and psychiatry. Thus, for example, in 2022 the Committee for Review of the Field of Neurology in the Hospitals and Community recommended increasing the number of neurologists by about 300 specialists in order to meet the population's needs at that time. In the field of psychiatry, in 2019 the shortage was estimated to be about 280 doctors (in hospitals and the community). The need for psychiatrists and their shortage in the public service is especially prominent in light of the Swords of Iron War, which has implications on the mental health and mental resilience of the entire public in Israel. According to the Ministry of Health's calculation for predicting the number of doctors in the coming years (the calculation did not include an increase in the number of medical students), in 2035 the shortage of doctors will even increase so that the number of doctors will be 3.02 doctors for every 1,000 people, smaller than the numbers in 2020 – 3.3 doctors for every 1,000 people.

In 2022, 1,025 licences to practise medicine were awarded in Israel to foreign graduates; 634 (approximately 62%) of them were awarded to Israelis who had studied medicine in universities where it had been decided, within the framework of the Yatziv Reform, that students who had commenced medical studies there after 2019 would not be able to take the medical licensing exam in Israel and in any event would not be able to practise medicine in Israel. The Yatziv Reform is supposed to ensure that only students who are graduates of foreign universities, that have been recognized by the Medical Professions Licensure Division as complying with the professional standards determined by experts in Israel, can take the licensing exam in Israel. Nevertheless, it should be noted that doctors who have studied abroad in disqualified universities have been integrated mainly in the periphery: According to Ministry of Health data concerning doctors who received a licence in 2022, their rate is 51% of the doctors in the Negev and 63% of the doctors in the Galilee, and in total their rate constitutes 34% of all the doctors who received a licence in Israel in this year. Hence, the Yatziv Reform will adversely affect mainly the number of doctors in the peripheral regions (in the north and south).

Additional defects were found in the follow-up report:

• An effective national allocation of the clinical fields in the hospitals and the community: The audit found that according to OECD data, in 2020 the State of Israel had trained only 24 students for every 1,000 hospital beds, less than the OECD average which was 38 students for every 1,000 hospital beds, and even 80 students in Denmark. It transpired that even though the Ministry of Health and the Council for Higher Education are responsible for the medical syllabus, they have not determined the fields of responsibility of each of them concerning the planning, management and operation of the clinical fields integrated into the syllabus. Neither have they determined a fixed base agreement for regulating the cooperation between the Faculty of Medicine and the hospitals for the operation of the clinical fields. The Ministry of Health and the Council for Higher Education have not jointly regulated the operation of the clinical training of the Israeli students from abroad who are undergoing training in clinical fields in Israel, and in practice they do not know what is the scope of this training and they do not have any information about the students studying within its framework.
• Regulation of the internship year: From 2017 to 2023 the number of interns increased from 1,547 to 1,793 (approximately 16%). On the other hand, the hospital beds standard in those years increased from 15,798 to 16,408 beds – an increase of only approximately 4%. Hence, after a period of about five years from the date of publication of the previous report, the trend of over-growth in the number of interns in relation to the increase in the number of beds remains the same. It also transpired that the Ministry had not determined the desirable ratio between the number of interns and the number of beds.
• Promoting the quality of medical studies by using innovative teaching methods: Since the previous report, the six medical schools have begun to combine innovative teaching methods, in accordance with the recommendations of a Council for Higher Education committee. Nevertheless, the syllabi of some have not been updated so as to integrate, even before the clinical studies stage, learning methods based on advanced technology, multi-element simulations and exposure to innovative clinical diagnostic tools. It also transpired that the Council for Higher Education has not completed the internal processes required for improving the quality of the teaching and medical education in Israel, and not even the processes with the medical schools.
• Comptroller Englman recommends that Ministry of Health and the Council for Higher Education formulate long-term strategic planning for medical personnel, determine clear goals and formulate a work plan to achieve them, while removing the existing barriers to operating the clinical fields in the community and budgeting them accordingly. It is recommended that the Minister of Health and the Minister of Education, in his role as Chairman of the Council for Higher Education, monitor the rectification of the defects that were raised in this report, in order to ensure an increase in the number of doctors and the regulation of their training.

English language studies in the educational system

The National Program for the Advancement of English Teaching was unofficially halted two years prematurely, without all its goals being achieved. The level of English of students from the well-established localities is considerably higher than that of students from weak localities – and the level of English of Jewish students is better than that of non-Jewish students. 70% of the graduates of 5 units in English are unsuccessful in obtaining an exemption from supplementary studies in English at higher education institutions. The shortage of English teachers remains high * Approximately 26% of English teachers did not comply with the qualification requirements for teaching the subject.

In September 2017, the Ministry of Education began to operate a multi-year program – "The National Program for the Advancement of English Teaching" – that was designed to reinforce the students' spoken English, increase the number of examinees in the enhanced track of the matriculation examinations, and improve the quality of English teaching. The State Comptroller found that the program was intended to continue for five years, but it was drastically reduced in scope during 2020, and in fact it was unofficially halted. No budgetary plan had been prepared for the annual and multi-year implementation of the program. 

The audit found that as of 2022, there were considerable disparities between students from different population groups in their English proficiency after they had completed their studies in the educational system. The English proficiency of students from the higher socio-economic strata, concentrated in the local authorities classified in the higher socio-economic clusters, as reflected in the matriculation examinations in English, was noticeably higher than the English proficiency of students from the lower socio-economic strata, concentrated in the local authorities classified in the lower socio-economic clusters: The number of examinees in the matriculation examinations at the very highest level – 5 units – was 66% among students from socio-economic clusters 7-10, as opposed to 26% among students from socio-economic clusters 1-3; similarly, the number of excellent students among the examinees in 5 units from clusters 7-10 was 74%, while in clusters 1-3 (and also 4-6) it was 64%.

Despite the results indicating the positive effect of the Ladders Program for increasing the number of students studying for matriculation in the enhanced track, and despite the intention to expand it from the 2020-2021 school year and thereafter, the Ministry of Education actually decided to drastically reduce the scope of the program – in the 2020-2021 school year, the number of hours allotted to the Ladders Program was reduced at a rate of approximately 75% for the 5 units track, and approximately 88% for the 3 and 4 units track, and in the 2021-2022 school year there was another cut in the program's budget, and it was operated in only 200 schools as opposed to 533 in the 2019-2020 school year (out of about 1,100 high schools – a drop from approximately 48% in the operation of the program in high schools in the 2019-2020 school year to approximately 18% in them in the 2021-2022 school year).

According to data from 2022, the level of English proficiency of students from the Jewish sector, as reflected in the matriculation examinations, was noticeably higher than the English proficiency of students from the non-Jewish sector: The number of examinees in the matriculation examinations in 5 units was 54% among students from the Jewish sector, as opposed to 27% among students from the non-Jewish sector, and the number of excellent students among the examinees in 5 units from the Jewish sector was 71%, as opposed to 59% in the non-Jewish sector.

The weakness of the ultra-Orthodox students in English studies is prominent in the Jewish sector: More than half (55%) do not take the matriculation examinations in English at all, and only a few take the matriculation examinations at the enhanced levels (11% were examined in 5 units and 12% were examined in 4 units). In the non-Jewish sector, the weakness of the students in the Bedouin sector in English studies is prominent – nearly one quarter (23%) do not take the matriculation examinations in English, and about one third (33%) take the matriculation examination at the level of 3 units; among the examinees at the level of 5 units, the number of excellent students is drastically lower than that in the other non-Jewish sectors (30% excellent students in the Bedouin sector, as opposed to 66% in the Arab sector and 49% in the Druze sector).

According to data from the English entrance exams of the candidates for studies at higher education institutions in 2022, the English proficiency level of the graduates of the educational system is low. The majority of the examinees did not reach the level of "exemption" from supplementary English studies in these institutions: Only approximately 30% of the examinees holding a matriculation certificate in English at the highest level – 5 units – and 4% of the examinees holding a matriculation certificate in English at the level of 4 units reached the exemption level.

There was a deterioration in the results of the graduates of English at the level of 5 units in the number of examinees who did not reach the level of exemption in the entrance examination (an increase from 64% in 2015 to 70% in 2022). The low rates of the examinees in the entrance examinations in English who reached the level of exemption from supplementary English studies raise concern of "inflation" in the matriculation grades in English; this concern, even though it was raised in studies conducted by NITE and the Central Bureau for Statistics in 2013 and 2021, was not examined by the Ministry of Education before or after the operation of the national program for English.

The Ministry of Education set a goal for the recruitment of 1,000 English teachers every year during the 2017-2020 school years, and it has met it and even recruited a larger number of new teachers. This notwithstanding, the problem of the quantitative shortage of teachers has not been solved, and every year towards the opening of the school year there is a shortage of hundreds of English teachers in the educational system. This shortage indicates that the entire future increase in the demand for English teachers was not taken into account when determining the aforesaid goal, and this raises doubts regarding the factual infrastructure upon which the Ministry determined this goal. Before the beginning of the 2022-2023 academic year there was a shortage of 711 English teachers, including 375 teachers (over than half) in the Tel Aviv and Central Districts. The qualitative shortage of English teachers also remained high, and according to the data in June 2023 approximately 26% of the English teachers (approximately 3,300 teachers) did not meet the qualification requirements for teaching the subject. 

Comptroller Englman recommends that the Minister of Education – in collaboration with the professional bodies at the Ministry of Education's headquarters, and led by the English Coordinating Supervisor – formulate a continuation plan for the national program, based on comprehensive lesson learning. Goals should be set for the reduction of the disparities in the achievements of the different student populations, the necessary resources for its implementation allocated, and its execution monitored.

The Ministry of Welfare's treatment of adults with disabilities

37% of the graduates of the special education system who are eligible to receive service are not receiving any service from the Ministry of Welfare. Only 5% of the special education graduates are participating in the adult life preparation programs. Only 4% of the persons with disabilities live in the community – and only 40% of them are employed in independent employment. In the dorms, there are no opportunities for intimacy between partners.

 

About one million people in Israel report that they are living with disabilities. Among them, in 2022, about 44,000 were eligible to receive services from the Ministry of Welfare, and around 57% of them (approximately 25,500) actually did receive services. Persons with disabilities are first and foremost human beings; accordingly this reinforces the Ministry of Welfare's obligation to provide them with services that respect them as human beings and allow them to live in society as equals, with liberty and independence. The entry into force of the Welfare Services for Persons with Disabilities Law at the beginning of 2024, and the budgetary addition accompanying it – about NIS two billion for five years (with effect from 2024) – are a golden opportunity for the Ministry of Welfare to implement this obligation.

 

Even though the vision outlined by the Welfare Services Law and the Ministry of Welfare's policy may be realized immediately among recent recipients of the Ministry's services, the State Comptroller found that many adults with disabilities are in a hopeless situation, and a considerable number (37%) of young adults with disabilities are not receiving any service from it. Likewise, despite the importance attached by the Ministry of Welfare to independent life in the community, the audit found that the majority of persons with disabilities are not living in the community (96%) and are not employed in independent employment (60%).

 

The average rate in protected frameworks (day center and rehabilitative work center) totals approximately NIS 3,800, and the average wage there totals NIS 0-3 per hour; while the average rate in the independent frameworks (work groups and individual integration in the free market) totals approximately NIS 1,900, and the average wage there totals NIS 17 per hour. In 2022, the Ministry of Welfare employed only about 10,000 persons with disabilities in the various employment frameworks out of around 37,000 persons eligible to receive services from the Ministry. The audit found that about one quarter (24% constituting around 600 persons) of the persons living in hostels and apartments did not have any employment at all during the day throughout the whole of 2022, and apparently they were idle.

 

The audit found that only 5% of the graduates of the special education system are participating in adult life preparation programs. Less than 1% of the persons with disabilities who have been placed in out-of-home housing move to more community-based housing frameworks.

 

Furthermore, even though the housing frameworks operated by the Ministry of Welfare are the homes of persons with disabilities for years, the main principles of life in the community and person-orientated services do not exist there; neither do they exist in the employment frameworks, in particular in the protected frameworks.

 

As part of the audit, the Office of the State Comptroller circulated several questionnaires – including a questionnaire circulated for the first time in Israel to persons with disabilities who live in the Ministry of Welfare's housing frameworks.

 

100% of them reported in the questionnaire that no intimacy between partners is possible in the residence. 41% of the persons living in the Ministry of Welfare's apartments reported in the questionnaire that on weekends and holidays they are moved to another apartment or room.

 

Comptroller Englman recommends that the Ministry of Welfare should develop housing services that allow the persons living in them a genuine life in the community with honor and the freedom to choose their lifestyle, and employment services that provide meaning and self-fulfillment, and enable, as much as possible, independent employment. The change required from the Ministry of Welfare is extensive and challenging. It is recommended that the Ministry of Welfare remove the barriers and improve the services it provides, first of all among persons with disabilities who are joining the circle of persons eligible to receive its services for the first time, including graduates of the special education system; and strive to provide persons with disabilities a continuum of services during the different life stages.

 

Acquisition of social services via outsourcing by the Ministry of Welfare and Social Affairs

The Ministry of Welfare does not conduct any monitoring of operators' financial conduct. The private companies operating frameworks for the Ministry of Welfare earn 2.5 times more than what is prescribed in the Ministry's rate. There is a surplus rate of more than 200% being held by non-profit organizations operating frameworks. The Ministry of Welfare pays more than NIS half a billion to operators for job positions that are unfilled.

 

The supply of welfare services in Israel is regulated by the Mandatory Tenders Law and the regulations thereunder, which are aimed at ensuring that sufficient bids are submitted to allow the best bid to be selected from them and ensure fair and equal competition.

 

In 2022, the Ministry of Welfare spent about 36% of its budget on the acquisition of out-of-home social services via outsourcing (approximately NIS 3.5 billion). The state of affairs regarding the social procurement market characteristics via outsourcing by the Ministry of Welfare shows signs of superfluity (profit margins and surplus) among the operators of the out-of-home frameworks. The audit findings indicate that the tender mechanism is not actually creating a situation of tangible competition, since in approximately 60% of the tenders every bid that passes the threshold conditions is successful in the tender; and this leads to a lack of dynamism in the out-of-home social services market, which is almost completely controlled by veteran operators. Thus, the Ministry of Welfare pays 89% (NIS 3.1 billion) of the payments for these services to operators who have experience of 17 years and even more in the provision of the services to the Ministry. This situation arises from the threshold conditions in the tenders that serve as an entrance barrier for new bidders, for example, of administrative requirements that new bidders find difficult to comply with and also from criteria that do not necessarily reflect the quality of the service actually provided, and so they grant an advantage to the veteran operators.

 

The audit findings show that the structure of the rate paid to the operators of the out-of-home frameworks by the Ministry of Welfare is not adapted to the structure of their actual expenses, and that the Ministry is not setting off the funds it has paid to the suppliers for services that in practice they did not supply; this involves a sum of more than NIS half a billion. Likewise, the Ministry of Welfare finds it difficult to conduct effective supervision over the quality of the services it provides. It was further found that the annual median number of inspectors' visits in out-of-home frameworks totaled just 2 or 3 visits, instead of 13-18 visits a year, as recommended by the Government Committee to Improve the Quality of Outsourced Social Services in 2016.

 

It transpires from all the aforesaid that the tenders system operated by the Ministry of Welfare for the management and procurement of welfare services via outsourcing is not optimal, and does not yield the desired result of a market structure where there is competition between operators leading to an improvement in the service actually provided to the recipients.

 

Comptroller Englman recommends that the Ministry of Welfare notify the inspectors about the bids that were successful in the tenders; reduce the inconsistencies in the existing rate mechanism; and set off the rate for failure to fully man the manpower standard. The Comptroller further recommends that the Ministry conduct an occupation analysis for the position of inspector and examine whether it is necessary to update the nature of the position similarly to other models worldwide. In a long-term strategic view of the Ministry of Welfare's social outsourcing procurement market, it is recommended that the Israel Competition Authority, in conjunction with the Ministry of Finance, the Prime Minister's Office and the Ministry of Welfare, formulate an inter-ministerial team to thoroughly examine the provision of welfare services by outsourcing market and the optimal mechanism for levering the latent advantages of competition, while examining the other accepted models for the provision of welfare services worldwide.

 

Cellular communication infrastructure

Israel is ranked in the 64th place among 145 countries in the median index of download speed in cellular browsing – this testifies as to Israel's low rank in relation to the rest of the world. The Ministry of Communications did not exercise its authority to impose financial sanctions on cellular infrastructure companies in all matters pertaining to cellular coverage. The cellular companies reported to the Ministry of Communications that they are complying with their obligation to provide cellular coverage for all the localities in Israel, but the State Comptroller conducted an examination and found that there are significant difficulties in cellular reception quality in dozens of localities: Only 3% of the local authorities examined reported that they have good reception. The Ministry of Communications does not have sufficient information to know whether and to what extent the companies are complying with their obligations to provide cellular service with the required coverage and quality under the licenses granted to them. Defects in the protection of the public against radiation from cellular transmission facilities.

 

According to data from the Ministry of Communications, data consumption in Israel via cellular networks from 2013 to 2022 increased 28 times, at an exponential rate of 40% per annum, and data consumption is expected to rise even more in the coming years until 2030, up to 43 times, with the development of new applications on the cellular infrastructure.

 

The State Comptroller found that as of August 2023, Israel is ranked in the 64th place among 145 countries in the median browsing speed index. This testifies as to Israel's low rank in relation to the rest of the world. The audit found heavyweight difficulties in the quality of cellular reception in dozens of localities in Israel and defects in the activity of the government ministries entrusted with ensuring safe and effective cellular service for the public.

 

A considerable part of the audit findings concern the manner in which the Ministry of Communications fulfilled its role as the industry's regulator. Thus, for example, it was found that the Ministry of Communications did not fully exercise its authority to obtain information from cellular companies about the cellular service they provide to the public, and relied on the companies' estimates, which do not reflect the service in practice. Likewise, the Ministry of Communications did not formulate a supervisory methodology for examining the extent of the cellular infrastructure companies' compliance with their obligations, and in fact it does not have sufficient information to know whether and to what extent the companies are complying with their obligations to provide cellular service with the required coverage and quality under the licenses granted to them.

 

The Comptroller also found that the Ministry of Communications did not exercise its authority to impose financial sanctions on cellular infrastructure companies in all matters pertaining to cellular coverage.

 

Additionally, in a survey conducted by the Office of the State Comptroller and a questionnaire circulated among local authorities, considerable discrepancies were found between the data held by the Ministry of Communications and the reports of the local authorities and interviewees on the actual quality of cellular reception. Thus, for example, in the 18 localities included in the survey, 11%-78% of the interviewees reported moderate or poor reception. In contrast, according to the Ministry of Communications' data, the cellular coverage in these localities ranges from 99.92% to 100%, namely – full or almost full coverage. The audit findings raise concerns that cellular infrastructure companies are not complying with the coverage and reception requirement mandated by the licenses.

   

Underlying the situation depicted in the audit, concerning significant difficulties in cellular reception in the localities examined, is a shortage of transmission facilities. The Ministry of Communications has not examined the scope of transmission facilities required, and therefore it has no data regarding how many facilities are missing. An examination of the deployment and operation rate of 5G transmission facilities indicates, apparently, that the number of 5G facilities deployed in Israel until July 2023 did not meet the requirements of the Ministry of Communications' licenses, and it also appears that Israel's coverage rate with this technology is lower than the rates in most European Union countries in the previous year. This is at a time when as of July 2023 1,943 transmission facilities were operating with 5G technology in Israel.

 

Furthermore, considerable disparities were found in the deployment of 5G communication infrastructures between large local authorities and peripheral authorities, and the shortage of 5G transmission facilities is most severe in peripheral Arab localities. The Ministry of Communications promoted legislative amendments to improve the planning and licensing processes of cellular infrastructure in Israel, but it did not complete the actions required to improve these processes.

 

The report also indicates defects in protecting the public from radiation from cellular transmission facilities. The supervision measures operated by the Ministry of Environmental Protection for examining actual radiation from the transmission facilities are mostly dependent upon data from measurements that the Ministry receives from the cellular infrastructure companies. Furthermore, no regulations have been enacted for determining the maximum exposure levels as mandated by the law. Instead, the Ministry of Environmental Protection has determined rules for the permitted exposure level, without consulting with the Ministry of Health, since the Ministry of Health does not deal with the matter of the health effects of non-ionizing radiation.

 

The Ministry of Health, which is entrusted with public health, has not formulated any professional information regarding the effects of non-ionizing radiation on public health, and still has no source of information in the matter in view of the termination of activity of the information center established by the government. Even though the Ministry of Health is of the opinion that there is insufficient knowledge about the effects of radiation from 5G technology transmission facilities on public health, and therefore there is difficulty in estimating the health effects of radiation exposure, the Ministry of Health did not participate in the formulation of the decisions made regarding health risks in the deployment of cellular communication infrastructures.

 

Government transparency, from the aspect of presenting the public with the data held by the government ministries, is likely to allow residents to make informed decisions concerning their use of a cellphone. Countries make data transparent to the public in relation to cellular coverage in a variety of ways, such as the publication of information to the public about cellular coverage forecasts or about the results of measurements they made, using maps. In this field defects were found in the publication of information and data to the public, both regarding the scope of the cellular coverage and the quality of the cellular service, and regarding the results of the measurements of radiation from the cellular transmission facilities. Defects were also found in the formulation of a public information format regarding the implications of radiation from cellular transmission facilities on public health – information that is essential to provide reliable data to the public on the topic and reduce its objections to expand the cellular infrastructure, as required for providing quality cellular service.

 

Comptroller Englman recommends that the government ministries, led by the Ministry of Communications, the Ministry of Health and the Ministry of Environmental Protection, along with their ministers, rectify all the defects set out in detail in the report. Rectification of the defects is likely to achieve an improvement in the level of cellular service provided to the public in Israel, while ensuring proper safeguarding of public health.

Protection of computerized information at the Prime Minister's Office

 The Comptroller found defects in various aspects of the overall management concerning the protection of information at the Prime Minister's Office. It was found that the level of protection of the classified networks at the Prime Minister's Office are lower than required. The audit raises concern that former employees, including senior staff, used their accounts after the termination of their employment. Among other things, the account of a former minister and the account of a senior official in the Prime Minister's Office, who had left their office a long time ago, were used. Against the background of the manner in which the monitoring array was operated, there has been a reduction in the Prime Minister's Office's ability to identify unauthorized activity in the systems in the network examined, identify attacks and recover from them thoroughly and speedily.

 

From March to August 2023, the Office of the State Comptroller conducted an audit on the protection of the computerized information located mainly in the computerized networks at the Prime Minister's Office (the PM's Office), where the networks are classified. The audit examined, among other things, the following topics: The overall management of the protection of the information at the PM's Office, including the budgetary aspects involved in the management; the user identification array and management of the authorizations; monitoring the systems in a particular network examined; that the versions of the operating systems and software are up to date; and security of the security classified information. The audit was conducted mainly at the PM's Office and at the National Security Council. Supplementary examinations were conducted at the Government Cyber Defense Unit (Yahav), at the ISA and at the Civil Service Commission.

 

The sub-committee of the Knesset State Control Committee resolved not to place on the Knesset table and not to publish data from this chapter in order to safeguard state security, pursuant to Section 17 of the State Comptroller Law, 5718-1958 [Consolidated Version]. The confidentiality of these data does not prevent an understanding of the nature of the audit.

 

The audit raised defects in various aspects of the overall management concerning the protection of the information at the PM's Office, including concerning the work proceedings of the cyber security steering committees operating at the Office and the budgetary management of the Office's information technologies: From 2018 to 2022, the Unclassified Information Steering Committee had not convened at the required frequency; the position of the committee chairman was not filled in 2020; from 2020 to 2022 the Director General of the PM's Office did not head the committee, as required by the government decision. The Unclassified Information Steering Committee and the Classified Information Steering Committee had not fulfilled their role as required in all matters pertaining to the examination process and approval of the annual work plans from 2019 to 2022.

 

It was further found that the PM's Office's policy regarding the cyber security of unclassified information had been approved in November 2018 and had not been updated and validated for four and a half years, as required by the regulatory bodies' directives, despite the fact that during these years there had been considerable organizational changes – the Information Security Division had been established at the Security and Emergency Department, and the PM's Office had assumed responsibility for the management of the information systems and information security in other government ministries. The PM's Office had also conducted a risks survey that was not in accordance with the requirements of the directives.

 

The computerized systems at the PM's Office contain a treasure trove of much information, including sensitive information and top-secret information. The protection required for the classified information is at the highest level. From January to May 2023 alone there were about 49 million attempts to attack the remote connection service at the PM's Office.

 

The State Comptroller found that the level of protection of the networks at the PM's Office is lower than required. An insufficient level of protection is liable to lead to substantial damage to the State of Israel from the political, defense, economic and public image aspects.

 

Defects were found in the management of the PM's Office access authorizations to its computerized systems, including concerning the periodical changing of access passwords to the networks, contrary to what is required by the Office's procedures.

 

Apart from the access authorizations to the network, the employee is also given authorizations defined for the work groups he belongs to. In a particular network examined, authorization groups that are no longer relevant were detected, such as a group dedicated to the staff of a former minister without portfolio who had ended his term of office more than a decade ago, as well as dozens of "double" groups with an identical name, where in each of them other users are members. The PM's Office has no concentrated information regarding the content and purpose of each authorization group.

 

The audit findings raised a suspicion that former employees were using their accounts after the termination of their employment, or that other parties, inside or outside the Office, were using the accounts of employees whose employment had terminated, while being exposed to information located in the PM's Office's networks that they were not supposed to be exposed to and are able to perform acts that they are not supposed to perform. Among other things, use was made of the account of a former minister and the account of a senior staff member at the PM's Office, who had ceased to hold office a long time ago. These suspicions entail a thorough exhaustive examination of each of the cases that arose, in order to verify or rule out each of the suspicions.

 

The Comptroller also found that the PM's Office had not operated the monitoring array in one of the networks as required, and consequently its ability to identify attacks on the systems and recover from them thoroughly and promptly, has diminished; the Office did not take care to install the necessary updates to various systems, including the operating systems in its servers, and consequently the information systems remained exposed to various malware, including malware frequently used by cyber attackers worldwide.

 

The responsibility for the rectification of the defects raised in the audit concerning the management of the PM's Office's information technologies and security of the computerized information therein is imposed upon the Director General of the PM's Office, who also heads the Cyber Security Steering Committee.

 

Comptroller Englman recommends that the PM's Office rectify the defects raised in the audit. The ISA and the Yahav Unit at the National Digital Agency, which are entrusted with guiding the PM's Office in all matters pertaining to information security, must ascertain that the PM's Office acts as required to rectify the defects.

 

Information security of the Conversion Authority at the Prime Minister's Office – resilience test results ​

 Breaches and defects in the information security of the Conversion Authority: The audit team succeeded in issuing, via the system, a fake conversion certificate, allowing its holder to impersonate a Jew and use it to fool every person and state institutions, who regard this certificate as confirmation of halachic (proper) conversion.

 

The Conversion Authority operating at the Prime Minister's Office (the PM's Office) is responsible for all the proceedings connected to the field of national conversion in the State of Israel. The Authority is responsible for the special conversion courts, the training processes for the converts before conversion, accompanying the converts and supporting them during the process and the actual performance of the conversion proceedings until the issuance of the conversion certificate, which is a civil-legal confirmation of the religion conversion and is recognized in Israel for all intents and purposes.

 

The State Comptroller examined the resilience of the computerized system used by the Conversion Authority. The information and documents collected in this system are sensitive, and any damage to confidentiality, wholeness or availability of the information in the system is liable to cause economic and public image damage to the State of Israel and to the converts. In August 2023, the Office of the State Comptroller conducted an application penetration test for the Maor system used by the Conversion Authority that operates at the PM's Office. The audit was conducted at the PM's Office, and in particular in the Conversion Authority operating within it.

 

The sub-committee of the Knesset State Control Committee resolved not to place on the Knesset table and not to publish data from this chapter in order to safeguard state security, pursuant to Section 17 of the State Comptroller Law, 5718-1958 [Consolidated Version]. The confidentiality of these data does not prevent an understanding of the nature of the audit.

 

The audit team succeeded in issuing, via the system, a fake conversion certificate, allowing its holder to impersonate a Jew and use it to fool every person and state institutions, who regard this certificate as confirmation of halachic (proper) conversion, while bypassing the work process and the system's inbuilt control measures.

 

The audit raised five high-risk defects, including the possibility of an anonymous attacker flooding the system with data, via the automatic sending of file opening forms. Five medium-risk defects were also raised, plus ten low-risk defects. It should be noted that most of the defects raised in the examination concern an "internal threat", namely a potential threat from users having access authorization to the Maor system. This is different from an "external threat" from parties who do not have access authorization to this system.

 

Comptroller Englman recommends that the PM's Office rectify the defects raised in the audit. It is appropriate for the National Digital Agency and its E-Government Unit to examine whether the defects set out in detail in this report are also relevant to other computerized government services issuing official certificates to the public.

 

The purchase and sale of public housing units – follow-up audit

6,000 apartments were removed from public housing within 5 years. While the Ministry of Construction and Housing sold 3,500 apartments, it purchased only 460 in their place. The "Reduced Price" and "Target Price" programs did not include public apartments at all. 4,300 eligible people were waiting for public housing in 2023, as opposed to 3,700 in 2019.

 

The State Comptroller found that in May 2023 the number of eligible people waiting for public housing was about 4,300, as opposed to 3,700 in 2019 (an increase of approximately 16%). The average national waiting time for receiving a public apartment lengthened from about 31 months in 2019 to about 35 months in May 2023 – an increase of approximately 13%.

 

In each of the years 2014-2022, the number of apartments sold by the Ministry of Construction and Housing under the Public Housing Law was greater than the number of apartments it purchased: In the accumulative, it sold approximately 12,900 apartments worth NIS 3.55 billion, as opposed to the purchase of approximately 3,100 apartments worth NIS 3.93 billion. From 2016 to 2019, the inclusive cost of the purchase of apartments was higher than the inclusive proceeds from the sale of apartments (approximately 2,300 apartments that were purchased for NIS 2.93 billion, as opposed to approximately 5,700 apartments that were sold for NIS 1.53 billion), while during the three years from 2020 to 2022, the inclusive proceeds from the sale of apartments were higher than the inclusive cost of the purchase of apartments (460 apartments that were purchased for NIS 676 million, as opposed to approximately 3,500 apartments that were sold for NIS 1.13 billion). Consequently, the sum intended for the purchase of apartments in the public housing fund increased from approximately NIS 453 million in 2020 to approximately NIS 1.254 billion at the beginning of 2023 – an almost threefold increase. It should be noted that in September 2023 about NIS one billion from the balance of the payment were designated for the purchase of the apartments where agreements had already been signed for their purchase, so that in practice the fund had an available balance of approximately NIS 250 million for the purchase of apartments. Likewise, the validity of the law expired in February 2023, and in December 2023 the legislative process for the extension of its validity that had commenced in the Knesset and supported by the government had not yet been completed.

 

It was further found that there had been a drop in the number of public apartments out of all the apartments in the country: In 2022, the number of public apartments out of all the apartments in Israel was approximately 1.7% – lower than their number in 2018 (2%), after the number of public apartments from 2018 to 2022 decreased from approximately 54,000 to approximately 48,000 (approximately 10%) following the sale of apartments to eligible people and in light of the increase in the number of all the apartments in the country from approximately 2.65 million to approximately 2.85 million (approximately 8%).

 

The state's handling of the defects from the previous audit:

• The previous audit found that the inter-ministerial team formed by the government had not presented recommendations to the government concerning the multi-year action plan to increase the stock of public housing. The follow-up audit found that the defect had been slightly rectified. In February 2022 a public committee was formed to examine the eligibility for public housing criteria; at the end of 2023, the committee dealt with the formulation of its conclusions and recommendations, but these have not yet been submitted.
• The previous audit found that as a matter of policy, the Ministry of Construction and Housing did not purchase apartments in localities where there is presently no public housing, including cities whose socio-economic index is low, the majority of which are cities where minorities or the ultra-Orthodox make up the population. The follow-up audit found that the defect had been slightly rectified – the Ministry of Construction and Housing indeed changed its policy and decided, at the first stage, upon the purchase of apartments in localities where there was no public housing – ten apartments in three minority localities – Umm al-Fahm (Arab), Rahat (Bedouin) and Shefar'am (Arab-Druze) and 11 apartments in an ultra-Orthodox locality (Modi'in Illit), but the actions of the Ministry of Construction and Housing and Amidar in the purchase of the apartments in these localities was partial, and potential channels that could have yielded the purchase of apartments in the minority localities was not exhausted. In practice, until the end of 2023 no apartments were purchased in such minority localities, and six apartments were purchased in Modi'in Illit.
• The previous audit found that until August 2019 the Israel Land Authority (ILA) had published tenders for only some of the projects, including the construction of 203 public apartments as part of various "Buyer's Price" projects in six localities. The follow-up audit found that the defect had not been rectified. Until the end of 2020, the ILA had marketed lands within the framework of the "Discount Apartment" tenders, which included only 232 public apartments (including the 203 apartments that had been included in the data of the previous audit), and from 2021 to 2023 the ILA had not marketed any lands containing public apartments, among other reasons due to a change in the Israel Land Council's policy in the matter. It turns out that in practice the state hardly used its main tool for handling the housing crisis for the benefit of the people eligible for public housing, within the framework of which from 2020 to 2022 it signed deals for the construction of approximately 33,000 housing units in the Target Price and Reduced Price tracks, while granting discounts in the price of the lands, that totaled approximately NIS 8.6 billion at the very least, according to data from the Accountant General Department.
• The previous audit found that in approximately 2,100 public apartments there was no consistency between their size and the size of the family living in them – apartments of four rooms and more where only a single tenant or two tenants were living; the follow-up audit found that the defect had not been rectified. Apart from the definition of "surplus housing" as a situation where tenants possess more than one apartment, the Ministry of Construction and Housing did not relate to the definition of "surplus area housing" as a situation where a household eligible for public housing comprises one or two persons living in an apartment of four rooms and more, as noted in the previous report. Furthermore, the Ministry of Construction and Housing has not yet examined possible mechanisms for incentivizing the tenants to change apartments and the number of tenants who would be willing to change their apartment for a smaller apartment.

Comptroller Englman held that the Minister of Construction and Housing must rectify the defects that have not yet been rectified and implement the recommendations set out in detail in this report with the aim of improving the responses for the people eligible for public housing, so as to shorten the waiting list as well as the waiting time for receiving a public apartment. The Comptroller further recommended that subsequent to the government decisions regarding the extension of validity of the Public Housing Law and in accordance with the progress of the legislative process, the Ministry of Construction and Housing and the Ministry of Finance should formulate agreements in the matter, and within this framework examine the eligibility conditions criteria for the purchase of the apartments, such as an examination of the tenant's financial situation, as well as the scope of the benefit.

Clalit Health Services – financial audit

At the end of 2022 there were approximately 4.8 million members in Clalit Health Services (approximately 51% of the residents of Israel). The Comptroller found that in comparison to the years 2019-2021, there was a deterioration in Clalit's financial situation: 2022 ended with a deficit of NIS 589 million – and the war is liable to increase its expenses by about NIS half a billion. Clalit has not complied with the provisions of the stabilization agreement in the matter of stopping the award of privileges and benefits to new employees.

 

Clalit Health Services (the HMO or Clalit) is the largest of the four HMOs, and in December 2022 it supplied health services to approximately 51% of the residents of Israel (approximately 4.8 million members). Clalit is active in two sectors: The community sector, where it operates around 1,400 clinics supplying health services via nine districts dispersed all over the country; and the hospitals sector, where it is the owner and operator of 14 hospitals that are also dispersed all over the country.

 

From 2019 to 2021, Clalit demonstrated an upward trend in surplus (deficit) in net assets but the Comptroller found that there was a deterioration in its financial situation in 2022, which led to a drop in the surplus of net assets from NIS 710 million in 2021 to NIS 190 million; Clalit ended 2022 with a deficit of NIS 589 million.

 

An explanation for the changes in the trend is based upon the fact that from 2020 to 2021 the COVID-19 pandemic broke out, and with it a change in the dilution of services supplied by the HMO. Simultaneously, the HMO received an additional budget from the state in order to assist it in coping with the COVID-19 pandemic via the addition of manpower for the hospitals and support in the sum of approximately NIS 900 million for each of the two years 2020 and 2021. After the receipt of the additional budget, the HMO ended these years with a surplus of NIS 354 million and NIS 495 million respectively. On the other hand, the HMO ended 2022 with a deficit of NIS 589 million, among other things since the state had not continued to indemnify the HMO for the costs of coping with the COVID-19 pandemic and the increase in salary expenses due to the new agreements signed. The deficit in Clalit's working capital is liable to intensify the cash flow crisis and make its ongoing functioning more difficult. The war that broke out on October 7th, 2023, is liable to aggravate the HMO's financial situation because its expenses are expected to increase by about NIS half a billion, according to the HMO's estimate at the end of October 2023 – the date on which the HMO still had not received indemnity for them.

 

The rate of the deficit in Clalit's hospitals from 2019 to 2022 was approximately 20% of the operating turnover, while in the government hospitals the rate of the deficit was approximately 5%-9% from 2019 to 2021 and surplus at a rate of 11% in 2022. Clalit's hospital infrastructures are not utilized in full (for example, some of the operating rooms are not used after 15:00), and the waiting times to receive some of the medical services remain long.

 

The Ministries of Health and Finance, as well as Clalit, did not regulate the activity of all the HMO's subsidiaries by way of possession permits, as required pursuant to the Health Insurance Law, which restricts the Ministries' supervision and control methods over the activity of the companies that have a surplus balance of around NIS one billion and delays the transfer of profits from them to Clalit. Clalit, which owns very valuable real estate, has a large number of clinics for which the effectiveness index determined by the HMO (the number of doctors' and therapists' hours in relation to the opening hours and the number of rooms in the clinic) is lower than the determined threshold. The HMO did not complete a pilot conducted in Jerusalem that yielded a potential for flipping of eight assets for a nationwide examination of all the assets it owns in order to locate additional assets that may be flipped. Clalit did not comply with the provisions of the stabilization agreement in the matter of stopping the award of privileges and benefits to new employees, and it estimates that the total benefits to its employees and pensioners total approximately NIS 70 million in each of the years 2019-2022. There is no appropriate representation for the Arab society, the ultra-Orthodox society and women on the Board of Directors and the General Council.

 

Comptroller Englman recommends that Clalit strive to reach a balance in all the spheres of its activity, and in particular by way of expanding the activity in the hospitals sector while utilizing the size advantage enjoyed by the HMO. It is recommended that the Ministry of Health reinforce the budgetary certainty of the HMOs and examine, in conjunction with the HMOs and the Ministry of Finance, the mechanisms by which the health basket budget is updated, so that these will achieve their objectives, and thus halt the increasing trend in the HMOs' deficits.

 

Stroke – treatment and rehabilitation ​

In 2020, about 18,400 new stroke events were reported in Israel, but it is estimated that there are 100,000 stroke cases each year – about 5.5 times higher than the reported cases. 46.5% of the stroke victims in 2021 did not arrive at the hospitals by ambulance but independently – and this is liable to delay their treatment. About 50% of the stroke victims in 2020 were not hospitalized in the neurological department or the neurosurgical department and in particular not in stroke units. The Ministry of Health has no mechanism for efficient and central management of the cerebral angiography array.

 

Stroke is the second leading cause of death worldwide. Strokes can affect various areas of the brain, causing a wide range of motor, cognitive, speech, emotional, and behavioral disorders, and may lead to disability and even death. In 2020, about 18,400 new stroke events were reported in Israel, but it is estimated that there are 100,000 stroke cases each year – about five and a half times higher than the reported cases. The direct and indirect costs of the consequences of stroke in Israel are estimated at NIS 2.3 billion each year as of 2018. Timing is a critical factor in providing treatment to stroke victims, and treatment within the recommended time window leads to a significant reduction in disability and mortality rates caused by stroke and affects the patient's recovery. But the State Comptroller found that 46.5% of the stroke victims in Israel in 2021 (approximately 8,300) did not arrive at the hospitals by ambulance but independently – and this is liable to delay their arrival, cause health damages and have an adverse effect on their chances of recovery.

 

The Comptroller found additional defects concerning the optimum treatment for stroke patients, including:

• About 50% of stroke victims in Israel in 2020 (about 9,000) were not treated in the neurological department or the neurosurgical department and in particular not in stroke units; the European Union's target for 2030 is that 90% of the patients be admitted to the stroke units. Admitting patients to non-dedicated departments for stroke treatment is less suitable for stroke patients, due, among other reasons, to stroke treatment not being in the field of specialization of the staff, and in particular the doctors and nursing staff.
• The Ministry of Health has no mechanism for efficient and central management of the cerebral angiography array, resulting in patients in need of cerebral angiography potentially not receiving it or wasting valuable time arriving at a hospital without an available doctor, risking deterioration in their condition.
• Stroke patients do not receive the full range of rehabilitation services required during general hospitalization, and the services they receive in rehabilitation frameworks are not always available and accessible as needed, especially in districts where the ratio of rehabilitation beds to stroke patients is lower than in others. Furthermore, the Ministry does not make any assessment of the effectiveness of the entire rehabilitation array for stroke patients.

 

The number of stroke events is expected to increase significantly during the coming decades due to demographic changes in the population size and composition, and in particular due to predicted increase in the age groups of those aged 65 and over – from approximately 18,400 events in 2020 to 30,000 in 2030, 1.7 times higher. This is in comparison to the expected increase in the population aged 18 and over, which is 1.2 times higher. The estimate indicates that one in every four people worldwide will experience a stroke of some degree of severity during his lifetime.

 

Comptroller Englman recommends that the Ministry of Health reinforce the awareness of identifying a stroke event and the need to arrive at the hospital promptly, so that the patients receive the best and most suitable treatment within the appropriate timeframe and in a treatment-bed dedicated for stroke patients. Likewise, the Ministry must improve the dispersal of the doctors specializing in the field and increase their availability to provide optimal coverage in all parts of the country, as well as providing useful rehabilitation that can restore stroke patients to independent functioning, while improving their quality of life and that of their families.

 

Agricultural production boards – functional and financial aspects

 The price of fruits and vegetables increased by approximately 25% in a decade, contrary to an increase of 10% in the general prices index. The original state budget for 2023-2024, which was approved in May 2023, allocated more than NIS half a billion for direct budgetary support for the plant industry – but the method of its distribution was not agreed upon. The government did not appoint any representatives to the plenary board of the Fruits and Vegetables Products Board.

 

This report deals with the production boards in the plant industry (the Plants Production & Marketing Board, the Israeli Honey Production and Marketing Board, the Israel Ground Nuts Production & Marketing Board, the Israel Wine Grapes Board and the Fruits and Vegetables Products Board) and not with the Israeli Dairy Board and the Egg and Poultry Board, whose functioning was examined in another report. The State Comptroller found that in all the production boards examined, excluding the Israel Ground Nuts Production & Marketing Board, the amount of expenses on management and general elements from the revenues is higher than that prescribed in the Ministry of Finance procedure for supports that relates to this expenditure: In the Plants Production & Marketing Board these expenses deviated by 57% (approximately NIS 5.8 million) from what is prescribed in the procedure; in the Israel Wine Grapes Board – by 71.6% (approximately NIS 310,000); in the Israeli Honey Production and Marketing Board – by 27.9% (approximately NIS 153,000); and in the Fruits and Vegetables Products Board – by 247% (approximately NIS 252,000).

 

The Israeli Honey Production and Marketing Board has a profits balance that at the beginning of 2022 totaled approximately NIS 5.3 million, a sum that is greater by approximately NIS 800,000 than the Board's annual budget for such year (approximately NIS 4.5 million). The Board invests large amounts of its cash and cash equivalent balances in securities (up to 70%): Approximately NIS 3.2 million from 2020 to 2022.

 

Even though the objective of the union of several production boards into the Plants Production & Marketing Board in 2003 was to streamline the system and reduce administrative expenses, the Plants Production & Marketing Board operates four different collection teams that operate separately from each other. Furthermore, the collection of the levies is carried out in accordance with the procedure prescribed about 15 years ago, which by the date of the audit had not been updated (nor was the olive industry included in the collection process). The split in the collection mechanisms causes financial damage originating in the duplicity of the salary expenses of the employees in charge of collection in each industry and the prolongation of proceedings against the debtors, which could have been avoided if one collection team had been formed for the whole board. In the past decade, the prices of fruits and vegetables have increased, but its activity in the representation of the plants industries vis-à-vis the executive authority and the supply of information about prices have indirect effects on the price to the consumer. The board's roles are anchored in law – including its liability and obligations vis-à-vis the growers – are likely to be contrary to its liability vis-à-vis the general public. Thus, it was found that in a survey conducted by the board for the growers it consistently publishes produce rates at higher prices than those published by the Ministry of Agriculture, and this is liable to lead to an increase in the price passed on to the consumer. Furthermore, the board persuaded the decision-makers to act in a way that would benefit the farmers, while placing greater weight on its role concerning price assurance for the grower over its role concerning the assurance of a regular supply of plants at proper prices for the whole population. The average inclusive price of the vegetables examined as part of the audit in the Class A quality group in the Plants Production & Marketing Board survey was approximately 32% higher than the price in the Ministry of Agriculture survey. Thus, for example, the prices of eggplants and zucchinis are higher in the Plants Production & Marketing Board survey by approximately 70% and 60% respectively. This is likely to contribute to the price increase passed on to the consumer. The sum of the levies that have not yet been paid to the Plants Production & Marketing Board for the years 2020 to 2022 was approximately NIS 8.5 million.

 

The consumer prices of fresh fruits and vegetables rose by approximately 24% and 25% respectively during a time span of ten years, from November 2013 to October 2023. This is in contrast to the price increase of approximately 10% in the food prices index (excluding fruits and vegetables) and the general Consumer Price Index. It was found that the levies collected from the growers by the Plants Production & Marketing Board had a negligible effect on the price increase in fruits and vegetables during the past decade, but its activity in the representation of the plants industries vis-à-vis the executive authority and the supply of information about prices have indirect effects on the price to the consumer. The board's roles which are anchored in law – including its liability and obligations vis-à-vis the growers – are likely to contradict its liability vis-à-vis the general public. Thus, it was found that in a survey conducted by the board for the growers it consistently publishes produce rates at higher prices than those published by the Ministry of Agriculture, and this is liable to lead to an increase in the price passed on to the consumer. Furthermore, the board persuaded the decision-makers to act in a way that would benefit the farmers, while placing greater weight on its role concerning price assurance for the grower over its role concerning the assurance of a regular supply of plants at proper prices for the whole population. The average inclusive price of the vegetables examined as part of the audit in the Class A quality group in the Plants Production & Marketing Board survey was approximately 32% higher than the price in the Ministry of Agriculture survey. Thus, for example, the prices of eggplants and zucchinis are higher in the Plants Production & Marketing Board survey by approximately 70% and 60% respectively. This is likely to contribute to the price increase passed on to the consumer.

 

It transpires from OECD data that in 2020 the ratio of imported goods of local Israeli produce was only about 17.1%, and it is the fifth lowest ratio among the 34 OECD countries that were examined in that year. According to the OECD estimates, in 2021 the rate of indirect budgetary support was 90.7% of the total budgetary support of farmers in Israel. This rate is considerably greater than the rate of indirect budgetary support in the OECD countries, where it is only 23.1%. The OECD recommended a reduction in the indirect budgetary support simultaneously with the grant of direct budgetary support to farmers.

 

In 2021, the government began to reduce the indirect budgetary support. However, the difference in the reduction rates of the fruit and vegetable import rate between the government decision in August 2021 and the board's proposal in November 2021 was an average of 68%, when regarding 16 species out of the 28 species mentioned in the board's proposal, the board aimed at revoking any reduction in the protective rates. Hence, by virtue of its role as assuring a fair price for growers, the Plants Production & Marketing Board managed to persuade the decision-makers to reduce the reform in the indirect budgetary support for agriculture that was designed to raise the import price. The Plants Production & Marketing Board did so without balancing this against the effects of this course of action on the consumer price, notwithstanding that by virtue of its role it is also committed to ensure a proper price for the population.

 

From 2022 to 2023 a process of reduction in the indirect budgetary support began, and the first two steps of quota reductions were made. However, during 2023 the Ministry of Agriculture and the Ministry of Finance decided to freeze the continuation of the outline determined for the reduction in the indirect budgetary support. This was after they had not come to any agreements as to the method of distributing the direct budgetary support between the farmers. As a result, as of December 2023 the direct budgetary support in the sum of approximately NIS 518 million for direct budgetary support in the plant industry (approximately NIS 270 million for 2023 and approximately NIS 248 million for 2024) was not utilized.

 

Under-manning of the organs managing the boards was found in all the boards examined: Only 12 out of the 24 possible representations mandated by law, from the Ministry of Agriculture, the Ministry of Economy and the Ministry of Finance, attended the boards' plenaries, even though this is mandated by the law establishing the boards or in their articles of association; 5 out of 12 government representatives are missing in the board of directors of all the boards, excluding the Israel Ground Nuts Production & Marketing Board. Neither was a chairman appointed on behalf of the Ministry of Economy in the Fruits and Vegetables Products Board, as required.

 

As of the date of the audit, gatekeepers in the agricultural production boards (legal advisor, auditor and internal auditor) held their office – as external service providers – for an average term of about 13 years, without rotation. Contrary to the provisions prescribed in the government companies rules and in the Civil Service Commission directives for government ministries, no provision was prescribed restricting the duration of the office of the gatekeepers in the production boards and their term of office may even continue for decades (the term of office of one gatekeeper lasted 19 years).

 

The Comptroller found that the Accountant General had not published on the Ministry of Finance's website the financial statements of the Fruits and Vegetables Products Board for 2022, contrary to the Budget Foundations Law.

 

Legislation regulating the activity of the production boards was enacted in the middle of the 20th century, and in various aspects it is based upon an out-of-date perception. The unsuitability of the regulations to the reality of life in the present age in Israel sometimes turns them into a dead letter. Thus, for example, pursuant to the Fruits and Vegetables Products Board Regulations, the producers of citrus fruit products must purchase citrus fruits for the industry only through the Fruits and Vegetables Products Board, and pursuant to the Plants Production & Marketing Board Law, the export of fruits and vegetables without an export permit from the Plants Production & Marketing Board is forbidden. This is despite this legislation not being implemented in practice.

 

The failure to apply the Honey Order and the Bees Regulations in Judea and Samaria is liable to lead to hives density in Judea and Samaria and in the areas adjoining Judea and Samaria; and also, to a decline in the bees' resilience and harm their ability to cope with the spread of diseases and pests. Consequently, a decline in the honey harvest is liable to occur and the bees' pollination ability harmed.

 

Comptroller Englman recommends that the Ministry of Agriculture and the Ministry of Finance continue to promote an outline for the transition from indirect budgetary support to direct budgetary support for farmers, including in the fruits and vegetables branches. There is a noticeable trend in the western world of a transition from mainly voluntary agricultural production boards or statutory boards whose membership is conditional upon the consent of a majority of the growers in each branch. In light of the examination of the activity of the various production boards in Israel in this report, it appears that this is the correct direction to apply here as well.

 

The protection of traffic axes in the Judea and Samaria area

This audit was conducted before the outbreak of the Swords of Iron War, but the report's findings and recommendations are all the more so relevant at this time. Despite the reinforcement of the forces in the Judea and Samaria areas, the IDF has not succeeded in all the defense tasks it had set itself. It is not clear whether the General Staff and the Security Cabinet are aware of the fact that a considerable number of the roadblocks in Judea and Samaria are open. The Judea and Samaria (Shai) District of the Israel Police does not provide a prompt and effective response for citizens: Only 24% of the residents of Judea and Samaria who have experienced a security event on the axes and who replied to the questionnaire of the Office of the State Comptroller – reported the incident to the 100 hotline, while 75% reported it to the Authority's emergency hotline. Foot dragging in paving bypass roads: The Hawara road was only completed after 32 years. The cellular coverage in Judea and Samaria is erratic.

 

The Israeli population in Judea and Samaria, comprising about 503,000 residents, has been suffering for years from terror attacks on the traffic axes. Since the beginning of 2022 there has been an increase in the number of hostile terrorist activities on the Judea and Samaria axes, where 19 citizens were murdered, among them 13 during the first half of 2023.

 

Central Command data show that the number of popular terror attacks (events that do not include shooting) in Judea and Samaria during 2022 totaled around 3,780 events (an average of 315 events per month), and 646 (17%) of them were events of laying explosives and throwing Molotov cocktails. Some were committed on the main axes used by many Israeli residents. The Central Command data further showed that in 2022 the number of shooting incidents in Judea and Samaria increased fourfold in contrast to 2021 (167 incidents in contrast to 41 respectively).

 

From December 2022 to September 2023 the Office of the State Comptroller examined the topic of protection of the traffic axes in Judea and Samaria and the response for the residents during a security incident on the axes, including the operational activities of the bodies who are jointly responsible for security on the axes, the activities for paving bypass roads, the civilian communications response via the cellular companies and the intelligence response on site via a "smart space".

 

During the audit, the Office of the State Comptroller shared the audit process with the public by holding meetings with security officers (Kabatim) and military security coordinators (Ravshatzim) from the local authorities in Judea and Samaria. The sharing with the public also included the circulation of a questionnaire among all the residents of Judea and Samaria, to which 5,236 residents responded.

 

This audit was conducted before the outbreak of the Swords of Iron War, but the report's findings and recommendations are all the more so enhanced and relevant at this time, and in particular from a forward looking viewpoint.

 

The Comptroller found that despite the reinforcement of the forces in the Judea and Samaria areas, the IDF has not succeeded in all the defense tasks it had set itself, and that the reinforcements of additional forces, for the most part after the occurrence of terror attacks, was not sufficient to create the necessary security consistently and systematically.

 

Approximately 14%-57% of the defense tasks in the three territorial brigades examined (Samaria, Benjamin and Etzion) were not performed according to plan, including the installation of lookouts, foot and vehicle patrols, the placing of ambushes, the placing of a temporary roadblock on the axes and guarding the hitchhiking stations.

 

Most of the terrorists who carried out shooting attacks from 2019 to 2023 came from the cities of Jenin (145 terrorists), Nablus (104 terrorists) and Ramallah (72 terrorists). In 2023 there was an increase in the number of terrorist attacks originating in the city of Jenin, in contrast to a reduction in their number in the other cities. There are no permanent roadblocks on the exits from these cities. The audit found that the IDF's policy concerning the level of effectiveness of the permanent roadblocks as a means of defense, is coordinated between the division, the command and the General Staff (via the Operations Division). According to the Head of the Operations Division in the IDF, this policy includes the provision of an operational response via the placing of random roadblocks and the removal of existing roadblocks, and it is regularly examined in situation assessments. Nevertheless, it is unclear whether the fact that a considerable number of the roadblocks in Judea and Samaria are open is known at the level of the General Staff and the Council of Ministers for National Defense Matters (the Security Cabinet).

 

The audit found that the "Smart Space" project had not yet been fully utilized. The audit further found that the Israel Police via the Shai District does not provide a prompt and effective response for the citizens, and the local emergency hotlines provide the missing response and enjoy greater trust from the public. Thus, in at least 75% of the events documented in the Shai District Police's calls log, the reaction times of the district's police officers was not measured, or they make a record that is not credible. Just 24% of the respondents to the questionnaire of the Office of the State Comptroller who had experienced a security incident on the axes, reported it to the Police's 100 hotline – while 75% reported it to the emergency hotline. 64% of the residents of Judea and Samaria who responded to the questionnaire testified as to low satisfaction with the arrival times of the Israel Police to security incidents on the axes.

 

The audit raised a severe picture testifying as to the prolongation of the proceedings until the paving of sections of bypass roads for the axes passing through Palestinian localities and where hundreds of security incidents have occurred: The paving of the Hawara bypass road at a length of 7 kilometers, the paving of the Al-Arroub bypass road at a length of 7.5 kilometers, and the completion of the paving of the Beit Aryeh road, whose length is approximately 11 kilometers.

 

Thus, the works for paving the Hawara bypass road whose length is 7 kilometers, which commenced in 1992, were only completed after about 32 years – in 2024, and at a cost of NIS 387 million. It is possible that paving the road earlier would have had an effect on the number of terrorist attacks that occurred on this axis in recent years and their outcomes.

 

The audit further found that the cellular coverage in the Judea and Samaria axes is erratic, including on sections of the axis that frequently suffer terrorist attacks, and that various plans that were formulated over the years did not come to fruition nor is there any effective enforcement on the part of the regulatory bodies over the cellular companies to complete the coverage.

 

Comptroller Englman recommends:

• To the Prime Minister and the Security Cabinet: To make a decision concerning the defense perception in Judea and Samaria, including the policy concerning the placing of permanent roadblocks in Judea and Samaria.
• To the IDF: To examine the order of forces in the command sector to comply with the defense tasks and the policy for the placing of permanent roadblocks in Judea and Samaria.
• To the National Headquarters of the Israel Police: To ascertain that the Shai District is complying with the arrival times required for calls from the public.
• To the Ministry of Transport: To learn lessons in collaboration with Netivei Israel in order to complete the paving of bypass roads in the future in a shorter time span.
• To the Ministry of Communications: To act immediately and effectively to complete the communications coverage in the Judea and Samaria axes in general and in the red axes in particular, in conformance with the licenses granted for the operation of the cellular networks in Judea and Samaria.