Israel’s rapid rollout of vaccinations for COVID-19 [original]

INTEGRATIVE ARTICLE Open Access

Israel’s rapid rollout of vaccinations for

COVID-19

Bruce Rosen

1,2*

, Ruth Waitzberg

1,3

and Avi Israeli

4,5

Abstract

As of the end of 2020, the State of Israel, with a population of 9.3 million, had administered more COVID-19 vaccine

doses than all countries aside from China, the US, and the UK. Moreover, Israel had administered almost 11.0 doses

per 100 population, while the next highest rates were 3.5 (in Bahrain) and 1.4 (in the United Kingdom). All other

countries had administered less than 1 dose per 100 population.

While Israel’s rollout of COVID-19 vaccinations was not problem-free, its initial phase had clearly been rapid and

effective. A large number of factors contributed to this early success, and they can be divided into three major

groups.

The first group of factors consists of long-standing characteristics of Israel which are extrinsic to health care. They

include: Israel’s small size (in terms of both area and population), a relatively young population, relatively warm

weather in December 2020, a centralized national system of government, and well-developed infrastructure for

implementing prompt responses to large-scale national emergencies.

The second group of factors are also long-standing, but they are health-system specific. They include: the

organizational, IT and logistical capacities of Israel’s community-based health care providers, the availability of a

cadre of well-trained, salaried, community-based nurses who are directly employed by those providers, a tradition

of effective cooperation between government, health plans, hospitals, and emergency care providers –particularly

during national emergencies; and support tools and decisionmaking frameworks to support vaccination campaigns.

The third group consists of factors that are more recent and are specific to the COVID-19 vaccination effort. They

include: the mobilization of special government funding for vaccine purchase and distribution, timely contracting

for a large amount of vaccines relative to Israel’s population, the use of simple, clear and easily implementable

criteria for determining who had priority for receiving vaccines in the early phases of the distribution process, a

creative technical response that addressed the demanding cold storage requirements of the Pfizer-BioNTech

COVID-19 vaccine, and well-tailored outreach efforts to encourage Israelis to sign up for vaccinations and then

show up to get vaccinated.

While many of these facilitating factors are not unique to Israel, part of what made the Israeli rollout successful was

its combination of facilitating factors (as opposed to each factor being unique separately) and the synergies it

created among them. Moreover, some high-income countries (including the US, the UK, and Canada) are lacking

several of these facilitating factors, apparently contributing to the slower pace of the rollout in those countries.

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* Correspondence: [email protected]

Myers-JDC-Brookdale Institute, Jerusalem, Israel

Hebrew University Paul Baerwald School of Social Work and Social Welfare,

Jerusalem, Israel

Full list of author information is available at the end of the article

Rosen et al. Israel Journal of Health Policy Research (2021) 10:6

https://doi.org/10.1186/s13584-021-00440-6

Introduction

Worldwide, the year 2020 was dominated by the health

and economic harm caused by the COVID-19 pandemic.

That year ended with a glimmer of hope, as regulators

began to approve COVID-19 vaccines and governments

around the world began to administer them.

Table 1presents data, by country, from the Our World

in Data website [1] regarding the total number of doses

administered and the number of doses administered per

100 population, as of the end of 2020. The table high-

lights two striking things about the State of Israel, whose

end-of-year population was 9.3 million [2]. First, only

three other countries (the US, China, and the UK) had

administered more doses than Israel’s approximately

950,000. Second, Israel had administered almost 11.0

doses per 100 population, while the next highest rates

were 3.5 (in Bahrain) and 1.4 (in the United Kingdom).

All other countries had administered less than 1 dose

per 100 population. As of the end of 2020, Israel’s roll-

out of COVID-19 vaccinations had clearly been rapid

and effective.

As with any major accomplishment, a large number of

factors contributed to Israel’s successful early rollout.

This article begins with a brief overview of the Israeli

rollout, and then discusses 12 factors that contributed to

its early success, with the analysis focusing on the period

until the end of 2020. The concluding remarks note lim-

itations of the analysis and identify several avenues for

further research.

Overview of the Israeli rollout

Israel launched its COVID-19 vaccination campaign on

December 20th, but preparations for it began months

earlier. Over the course of 2020, Israel signed vaccine

purchase contracts with several pharmaceutical compan-

ies at the forefront of COVID-19 vaccine development.

By the time the US FDA had issued an emergency use

authorization for the Pfizer-BioNTech COVID-19 vac-

cine

on December 11, Israel already had contracts in

place with Pfizer to purchase and receive a substantial

(but undisclosed) number of doses of that vaccine by the

end of December. Within days, and largely on the basis

of the FDA authorization process, Israel’s Ministry of

Health (MOH) followed with an authorization of its

own.

Israel’s MOH also determined (on December 16) that

the initial target groups for vaccination would be people

aged 60 and over, nursing home residents, other people

at high risk due to serious medical conditions, and

front-line health care workers [3]. The responsibility for

vaccinating each of these groups was also clearly defined

at that time:

The primary responsibility for vaccinating the

general population over age 60 and at-risk persons

due to pre-existing medical conditions was assigned

to Israel’s four competing non-profit health plans

Responsibility for vaccinating nursing home

residents was assigned primarily to Israel’s national

medical emergency services organization - Magen

David Adom (MDA).

Responsibility for vaccinating front-line health

workers was assigned to the hospitals and health

plans with whom they work

As indicated in Fig. 1, the number of people vacci-

nated per day began at approximately 8000 on Decem-

ber 20, quickly rose to over 70,000 by December 24,

decreased over the following weekend, and then rose to

over 150,000 by December 29.

All of the vaccines ad-

ministered in Israel during 2020 were those manufac-

tured by Pfizer, and the vast majority of vaccines were

administered by nurses.

Table 1 COVID-19 Vaccine Doses Administered as of the End of

2020

Listing the 10 countries reporting the most doses administered

Total Doses per Reporting

Country Doses 100 pop’n date

China 4,500,000 0.31 31-Dec

United States 2,794,588 0.84 30-Dec

United Kingdom 963,208 1.42 27-Dec

Israel 949,112 10.97 31-Dec

Germany 165,575 0.20 31-Dec

Canada 99,946 0.26 31-Dec

Bahrain 58,643 3.45 31-Dec

Russia 52,000 0.04 22-Dec

Poland 47,600 0.13 31-Dec

Mexico 24,998 0.02 30-Dec

Source: Our World in Data. https://ourworldindata.org/covid-vaccinations

Note: For each country, the table presents data for the latest date in

December for which data were available in the database

The formal name of the vaccine is: Pfizer-BioNTech COVID-19 vac-

cine, BNT162b2 (brand name “Comirnaty”)

Personal communication, Boaz Lev, January 2021.

At this stage, the vaccine has been authorized for use by people aged

16 and over. There is no prohibition against vaccinating a pregnant

woman or a woman planning a pregnancy. A person with an acute

illness, including a fever of 38 degrees Celsius or above, will not be

vaccinated until they have recovered from that illness. According to

current guidelines, the following are not authorized to receive the

vaccine: people under age 16, people with a history of severe allergic

reaction (who should contact the warehouse nurse to find out if they

can be vaccinated), and people who were confirmed as having been ill

with COVID-19.

Israel did not face the issue, present in some other countries, of large

numbers of healthcare workers being on vacation during the week

between Christmas and New Year’s Day.

Rosen et al. Israel Journal of Health Policy Research (2021) 10:6 Page 2 of 14

At the same time, not all was well with the COVID-19

situation in Israel in December 2020, Israel –like many

other countries –was experiencing a major increase in

COVID-19 infections [4], including substantial morbid-

ity among health care professionals. Thus, the vaccin-

ation campaign was launched at a very challenging time

for Israeli health care.

In addition, the vaccination campaign experienced

labor pains of its own. During the first few days of

the rollout, it was quite difficult to schedule an ap-

pointment via the health plans’call centers or digital

tools. In some vaccination sites, not enough people in

the target population showed up, and at the end of

each day vaccines about to pass their expiration time

had to be either thrown away or given to people not

meeting criteria for first-round vaccinations. Even

earlier in the day, some hospitals, health plans and

other vaccine providers were somewhat lax about lim-

iting vaccines to people meeting the official criteria,

thereby increasing the total number of people vacci-

nated, but reducing the supply of vaccines available

to the elderly and other at-risk groups. At some vac-

cination sites, family of health professionals and

members of influential unions or occupations, were

vaccinated even though they did not meet the criteria.

And, while vaccination sites were set up throughout

the country, including in the peripheral regions and

in smaller villages and towns, the rate of vaccine up-

take was markedly lower than average in Arab

localities.

Moreover, as of December 2020 there were many

uncertainties looking forward. There was lack of clar-

ity about when the next vaccine shipments would ar-

rive and how large they would be [5], leading to talk

about a possible temporary suspension of first vacci-

nations (though Israel has been careful to set aside a

second dose for all Israelis and foreign workers

who

received a first dose). It was also not clear what pro-

portion of Israelis would ultimately sign-up for vacci-

nations, either due to general anti-Vax sentiments or

to vaccine hesitancy specific to the new COVID-19

vaccines. In addition, it was not clear how the need

to allocate nurses to the vaccination effort was affect-

ing the delivery of other health services. And, as was

the case worldwide, there continued to be uncertain-

ties about how long the vaccine-conferred immunity

would last, how effective it would be against new var-

iants of the virus, and the extent to which it prevents

transmission.

Still, there is no denying that, as of the end of 2020, Is-

rael’s vaccination campaign had achieved a great deal –

both in absolute terms and relative to other countries.

Accordingly, despite its imperfections, and despite the

uncertainties regarding how things would evolve in

2021, it is important to identify and analyze the factors

that contributed to the success of Israel’s vaccine rollout

in its initial phase.

Selected factors contributing to Israel’s success

The specific factors contributing to Israel’s successful

early rollout include, but are not limited to, the

following:

1. Israel’s small size, in terms of both area and

population, its relatively young population, and its

relatively warm weather in December 2020

2. Israel’s centralized national system of government

(as opposed to a federal system of government)

Fig. 1 Daily doses administered in Israel, by date (In thousands; December 20–31). Source: Our World in

Data. https://ourworldindata.org/covid-vaccinations

Foreign workers carrying for frail elderly living at home or in nursing

homes were included among the health care workers who were

vaccinated in the first phase of the rollout.

Rosen et al. Israel Journal of Health Policy Research (2021) 10:6 Page 3 of 14

3. Israel’s experience in, and infrastructure for,

planning and implementing prompt responses to

large-scale national emergencies

4. The organizational, IT and logistic capacities of

Israel’s community-based healthcare providers (the

four health plans), which are all large and national

in scope

5. The availability of a cadre of well-trained, salaried,

community-based nurses who are employed directly

by the health plans

6. The tradition of effective cooperation between

government, health plans, hospitals, and emergency

care providers –particularly during national

emergencies –and the frameworks for facilitating

that cooperation

7. The existence of well-functioning frameworks for

making decisions about vaccinations and support

tools for assisting in the implementation of vaccin-

ation campaigns

8. The rapid mobilization of special government

funding for vaccine purchase and distribution

9. Timely contracting for a large amount of vaccines

relative to Israel’s population

10. The use of simple, clear and easily implementable

criteria for determining who had priority for

receiving vaccines in the early phases of the

distribution process

11. A creative technical response that addressed the

demanding cold storage requirements of the Pfizer-

BioNTech COVID-19 vaccine

12. Well-tailored outreach efforts to encourage the

population to sign up for vaccinations

These specific factors can be divided into three major

groups of factors, as follows:

A. Long-standing characteristics of Israel which are

extrinsic to health care (items 1–3)

B. Long-standing characteristics of the Israeli health

care system (items 4–7)

C. Specific actions taken as part of the COVID-19 vac-

cination effort (items 8–12)

We now provide additional information on each of

the specific factors listed above, providing context

and detail about the Israeli rollout not previously

published in a comprehensive fashion. We also briefly

cite examples of high-income countries in which

those factors were not present, as vetted by country-

specific experts who reviewed a draft of this article.

We do so to demonstrate that many of these factors

are neither trivial nor universal. We purposely do not

present a comprehensive analysis of what have been

the main influences on the speed of the rollout in

any other country. Such comprehensive analyses are

best carried out by experts writing about their own

countries.

A. Long-standing characteristics of Israel which are

extrinsic to health

1. Israel’s small size, in terms of both area and

population, its relatively young population, and its

relatively mild weather in December 2020

Israel has a population of 9.3 million. As a result,

the number of doses required

was a small fraction of

the overall global supply, giving Israel agility and

maneuverability in its purchasing. Meanwhile, Israel’s

small size (about the same as New Jersey)

and highly

urbanized population, minimized the transport and

storage challenges associated with the Pfizer-

BioNTech COVID-19 vaccine (henceforth referred to

as “the Pfizer vaccine”, for short). Inter alia, a single

state-of-the-art medical warehouse sufficed to store

the nation’s entire Pfizer vaccine reserve in the

requisite ultra-low-temperature freezers.

In addition,

high population density increased the number of

people who can easily access any particular

community-based vaccination site –an important ad-

vantage with regard to the Pfizer vaccine.

Moreover, Israel’s population is relatively young (ap-

proximately 12% aged 65 or over) [6], reducing the

amount of vaccine needed to rapidly vaccinate the bulk

of the 60+ population.

Israel’s vaccination program covers all persons covered by Israel’s

National Health Insurance Law as well as additional groups, such as

soldiers (who are entitled to health care via the IDF) and prisoners

(who are entitled to health care via the Prisons Law). Undocumented

migrant workers are not covered.The Palestinian Authority is

responsible for the health and health care of Palestinian residents of

Gaza and the West Bank. This includes responsibility for providing

vaccinations against COVID-19. Thus, in general, they are not in-

cluded as part of Israel’s vaccination program. In contrast, Palestinian

workers legally residing in Israel by virtue of a residence permit

granted to them as part of a family reunification procedure, as they are

covered by the NHI.

We recognize that several European countries have areas similar to

that of Israel. The intention here is to distinguish this characteristics of

Israel’s area primarily from those of the US, China, Canada and other

large-area countries.

To some extent, these freezers were on hand prior to the pandemic.

Others were purchased during 2020 in preparation for the expected

need to store large quantities of the Pfizer vaccine.

Rosen et al. Israel Journal of Health Policy Research (2021) 10:6 Page 4 of 14

And, with Israel being a small country geographic-

ally, the vast majority of aging and infirm Israelis ap-

parently have a younger adult family member living

in close geographic proximity,

who can accompany

them to a vaccination site, while providing moral sup-

port and transportation assistance. The relatively mild

December in Israel in 2020 also made it easier for

older people to get to vaccination sites.

These facilitating factors - Israel’s small size, a

mild winter, and a relatively youthful population -

did not exist in some high-income countries [8]. For

example, the US has a population of over 300 mil-

lion, greatly increasing the amount of vaccine needed

by that country. Canada faced the challenges of a

large geographic area and parts of the country in

which the population density is low [9]; these cre-

ated a need for more storage facilities, greater in-

vestment in transportation, and a need for many

more vaccination sites.

And several European

countries have populations in which 20% or more

are over age 65

[10], meaning that vaccination

coverage of the elderly would require a greater vac-

cine supply in terms of doses per population. Thus,

many countries faced opening conditions –in terms

of geography, population size, and age distribution -

that were substantially more challenging than those

faced by Israel.

2. Israel has a centralized national system of

government

(as opposed to a federal system of

government)

Israel does not have states or regions which have

independent decision-making authority on public

health issues. While it does have active, and largely

independent, local authorities and municipal govern-

ments, they play only a limited role in health care.

As such, coordination of a public health response

across different levels of government was not needed

and this may have allowed the Israeli government

more flexibility in designing its rollout. It also

provided clarity in that the national government had

the primary responsibility for the vaccination

campaign, in terms of planning, financing, and

implementation.

In contrast, several high-income countries have fed-

eral systems, with significant implications for how

public health efforts are organized. For example in

the US, public health is administered and regulated

primarily at the state level. On the other hand, it was

the federal government that was responsible for pro-

moting vaccine development, approving vaccines as

safe and effective, procuring vaccines from pharma-

ceutical companies, and distributing them among, and

to, states. This has led to some ambiguity regarding

who is responsible and accountable for the success of

the vaccination effort [11–14].

3. Israel has extensive experience in, and

infrastructure for, planning and implementing

prompt inter-sectoral responses to large-scale na-

tional emergencies.

Partly as a result of its challenging geo-political

position, Israel has for many years invested substan-

tially in preparing for large-scale emergencies,

whether they be related to security, natural disasters,

or health, based on an “all hazards”approach [15].

Inter-sectoral decision making bodies and implemen-

tation teams have been established, protocols have

been developed, staff have been trained, and drills

have been carried out. The scenarios for recent large-

scale drills (pre-COVID-19) have included those in

which large scale vaccination efforts had to be imple-

mented. In Israel, the large community based health

care providers –the health plans –are an integral

part of national emergency preparedness drills. In

addition, due to its security situation, Israel has

amassed substantial real-world experience in respond-

ing to large-scale emergencies.

In the post-911 world, Israel is not the only country

investing time, energy, and money in preparations for

large-scale emergencies. But it is probably the case that

few European and North American countries have as

much experience as Israel does in responding to real-

world emergencies and many of them apparently do not

maintain surge capacity (relative to their size), to the ex-

tent that Israel does. Widespread public understanding

that large-scale emergencies are not rare events may en-

hance the seriousness with which the public,

According to the 2009 Social Survey carried out by Israel Central

Bureau of Statistics, 79% of the elderly in Israel met at least once a

week with a family member who does not live with them in the same

household [7]. The comparable figure in the 2019 Social Survey was

77%.

Confirmed by Greg Marchildon, personal communication, January

2021.

These include 23% in Italy, 22% in Germany, and 20% in France

Sometimes referred to as a unitary system of government

Nonetheless, some of these local authorities made an important

contribution to the vaccination campaign by making large municipal

facilities available as vaccination sites.

Of course, even with a single level of government involved, there

were issues to be resolved about the distribution of responsibility

between various agencies of the national government, such as the

Ministry of Health, the IDF, the Knesset, the Prime Minister, and the

Cabinet. In the case of the vaccine campaign, these issues seem to

have been resolved effectively. This has not been the case regarding

other aspects of the pandemic response.

Rosen et al. Israel Journal of Health Policy Research (2021) 10:6 Page 5 of 14

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