Land of Israel: Health Services
At the beginning of the 19th century, the Land of Israel (Ereẓ Israel) was ridden with disease. Wide areas were infested with malaria; enteric fever, dysentery, and trachoma took a heavy toll; and infant mortality was very high. There was an improvement under the British Mandatory administration (1922–48), but, due to budgetary restrictions, its earlier efforts were concentrated almost exclusively on malaria control. Its elementary preventive and curative health services, moreover, were mainly intended for the Arab population, and the Jews had to build up their own. Their efforts were spearheaded by two voluntary organizations: *Hadassah, the Women's Zionist Organization of America, and *Kuppat Ḥolim, the medical insurance fund of the *Histadrut.
In 1913 Hadassah had sent two American-trained nurses to do pioneer work in the Old City of Jerusalem; they were followed in 1918 by the American Zionist Medical Unit. From these modest beginnings grew a countrywide network of diagnostic, preventive, and public health services and teaching and research institutions. In 1918–19 modern hospitals were opened in Tiberias, Safed, Jaffa, Haifa, and Jerusalem. The first Jewish nursing school was opened in Jerusalem by Hadassah in 1918. A network of mother-and-child care stations was established in many parts of the country, while school hygiene and lunch programs were initiated in Jerusalem. Most of these were handed over, at different stages, to the municipalities or to the Jewish authorities and, later, to the government of Israel. This also applied to the hospitals, except the one in Jerusalem, which in 1939, in partnership with the Hebrew University, became the country's first university hospital.
Whereas Hadassah began its services in a town, the initial aim of Kuppat Ḥolim ha-Kelalit (General Health Fund) was to bring medical care to the villages. However, its curative services – clinics and hospitals – soon spread to the towns as well, playing a vital role in the development of Jewish medical care. It set up an organizational system aiming to ensure that medical services were available to all its members according to need, no matter where they lived, with premiums based on income.
By the time the State of Israel was proclaimed in 1948, health standards among both Jews and Arabs had risen enormously. Malaria and tb had been wiped out; all children were inoculated against smallpox and typhoid; and infant mortality was low, even by international standards. The Mandatory government's Department of Health was succeeded by a ministry, but existing health services had to be taken over as they stood and gradually adapted to the changing needs. Owing to the conditions prevailing at the time, more radical planning for the future had to be postponed.
On the whole, there was a serious deterioration in the health of the population after 1948. Among the hundreds of thousands of immigrants were many whose health standards were low, and a high proportion suffered from contagious diseases, some of which, like trachoma, had been eliminated in Ereẓ Israel. For example, thousands of Yemenite Jews were stricken by tuberculosis within months of their arrival, and tens of thousands more, who hailed from other Eastern countries, lacked the most elementary knowledge of hygiene. Problems were enormous, and immediate solutions had to be found. The new Ministry of Health had to start from scratch, recruiting medical personnel previously employed by various Jewish public institutions and voluntary organizations. The ministry was faced with the dual task of detecting and treating all cases of infectious diseases among the newcomers while protecting the health of the existing population. Since there had been neither time nor opportunity to examine the immigrants in their countries of origin, this had to be done thoroughly on their arrival. Arrangements for such examinations were set up in the transit camps. Serious cases were immediately hospitalized, putting considerable pressure on the country's limited hospital resources, while milder cases were treated on the spot. Health services, such as mother-and-child care stations and general clinics, were set up in the immigrant camps and ma'barot by Kuppat Ḥolim ha-Kelalit and the Ministry of Health. Women's voluntary organizations, like *wizo (the Women's International Zionist Organization), opened crèches and kindergartens in them.
The slowdown in immigration between 1952 and 1954 gave the Ministry of Health breathing space and enabled it to organize on a more permanent basis. By the time large-scale immigration was resumed in 1954, the reception of the newcomers had undergone a radical change. Health examinations took place before their departure for Israel, and healthy arrivals were taken immediately to permanent accommodation. A small number of would-be settlers had their entry deferred if their health fell far below the required standard.
Health of the Population
The state of health of the Israeli population compares favorably with Western standards. Life expectancy at birth in 2000 was 76.6 for males and 80.4 for females. Life expectancy for Israeli males is among the highest in oecd countries while for women it is in the low middle range. In the last two decades of the 20th century life expectancy increased by 4.8 years for males and 5.0 years for females. The crude birth rate in 1995–2000 was 21.7 per 1,000. The crude death rate was 6.1 per 1000. The infant mortality rate was 5.4, per 1,000 live births in 2000.
The leading causes of death at the beginning of the 21st century were heart diseases, malignant neoplasms, cerebrovascular diseases, diabetes, and accidents. Among women, breast cancer was the leading cancer ailment, accounting for approximately 30% of all cancer morbidity and 20% of cancer mortality. Among men the leading cancers were prostate cancer (in Jewish men) and lung cancer (in Arab men). The cancer with the highest mortality was lung cancer for both Jewish and Arab men (National Cancer Registry, www.health.gov.il).
The Ministry of Health
In addition to being the supreme authority in all medical matters, the Ministry of Health operates as the licensing body for the medical, dental, pharmaceutical, nursing, and paramedical professions and is responsible for carrying out all health legislation passed by the Knesset. It is the policy of the ministry to step in where no services are furnished by nongovernmental institutions to assure the provision of adequate medical care throughout the country. It is, in addition, Israel's principal public health agency. It has two main divisions: curative services and preventive and promotive public health services. The former is responsible for the licensing and supervising of nongovernmental medical institutions and operates all government hospitals (general, mental, tuberculosis, and other long-term illnesses). The division for public health services coordinates the six district and 14 subdistrict health offices. It maintains its own public and preventive services and supervises those of nongovernmental institutions, operates mother-and-child care centers and school health services, and is responsible for industrial hygiene, water purity, milk and food supplies, and prevention of air pollution by industry, motor vehicle exhausts, and radiation.
Israel's population is covered by a compulsory health insurance law, which is operated by the four non-profit health insurance funds (kuppot ḥolim). The insured are entitled to free treatment in clinics, at home, or at the physician's residence, free hospitalization, dental and optical care at reduced rates, medicines, facilities for convalescence, and so forth. The law established a range of services equal for all. In addition, people can purchase supplementary services via the health insurance funds or private insurance companies.
[Malka Hillel Shulewitz /
Shifra Shvarts (2nd ed.)]
The following were the principal health insurance funds in 2000:
kuppat Ḥolim ha-kelalit
Kuppat Ḥolim ha-Kelalit, the first health insurance institution in Israel, was founded in 1911 by a small group of agricultural workers and taken over in 1921 by the Histadrut (Federation of Labor). It is the largest countrywide fund of its kind, with its own medical institutions and a staff of 30,000 (in 2000), including 5,000 doctors and 10,000 nurses. Over 50% of the population is insured with Kuppat Ḥolim, which covers inhabitants of town and country, manual laborers and professional people, salaried and self-employed, Israel-born, veterans, and new immigrants.
Its countrywide organization (1,200 primary care clinics in 2000) enables it to extend its services to the most outlying areas. It provides medical care in its own clinics and has its own laboratories, pharmacies, and convalescent homes. Hospitalization, the largest item, is provided in its own hospitals, situated in rural and development districts, as well as in urban areas, or at its expense in other hospitals. These have outpatient clinics for consultation and the follow-up of discharged patients, as well as nurses' training schools, and some of them have centers for postgraduate medical training and research.
Until 1994 a Histadrut member was automatically a member of Kuppat Ḥolim and his insurance premiums were included in his membership dues, which were fixed according to income. Members of certain other workers' organizations, such as *Ha-Po'el ha-Mizrachi and *Po'alei Agudat Israel, were also insured with Kuppat Ḥolim. Between 1948 and 1994, its membership, including dependents, increased tenfold: from 328,000 to 3,600,000.
Kuppat Ḥolim grants medical care to insured breadwinners and their families (covering industrial injuries and chronic illness), as well as convalescence and sick pay. It provides the services of general practitioners, specialists, and nurses in clinics and at the patient's home, hospitalization in its own and other hospitals, X-ray treatment, physiotherapy and medical rehabilitation, and laboratory tests; medicaments and medical appliances come from its own pharmacies. Preventive medical services include mother-and-child care, industrial medicine, and health education. Eyeglasses and dental treatment are provided at moderate charge. Kuppat Ḥolim ha-Kelalit provided medical services for new immigrants from the day of their arrival, with no qualifying period. During the period of mass immigration, newcomers ignorant of the elementary rules of health and hygiene were instructed in its clinics and mother-and-child centers. In January 1995 the affiliation of Kuppat Ḥolim ha-Kelalit to the Federation of Labor ended with the enactment of Israel's health insurance law, and Kuppat Ḥolim became an independent organization.
[Izhak Kanev /
Shifra Shvarts (2nd ed.)]
kuppat Ḥolim le-ovedim le'ummiyyim
Kuppat Ḥolim le-Ovedim Le'ummiyyim (Sick Fund for National Workers) was founded in 1933. Its services in 2000 encompassed about 10% of the Israeli population. Although it is linked to the National Labor Federation (*Histadrut ha-Ovedim ha-Le'ummit), members of the sick fund are not obliged to belong to the federation. Its main feature is the free choice of a doctor by the patient, in addition to the maintenance of dispensaries and arrangements for hospitalization for the insured in government and other hospitals.
kuppat Ḥolim me'uḤedet (amamit)
Kuppat Ḥolim Me'uḥedet (Amamit) ("Popular Sick Fund") was founded in 1931 on the initiative of Hadassah, mainly for farmers in villages not affiliated to the labor movement. It serves about 11% of the Israeli population (2000). In the larger centers members are free to choose their doctor; in smaller places the fund employs doctors for the insured. It has arrangements for the hospitalization of its members in government and other public hospitals. In 1974, Kuppat Ḥolim Amamit merged with Kuppat Ḥolim Merkazit to become Kuppat Ḥolim Me'uḥedet.
kuppat Ḥolim maccabi
Kuppat Ḥolim Maccabi (Maccabi Sick Fund), the second largest health fund in Israel (2000). Maccabi was founded in 1941 and serves about 24% of the population. Most of its members live in urban areas, smaller towns, and rural localities. They are free to choose their doctors; hospitalization is arranged with government and other hospitals.
the national health insurance law
In January 1995, the implementation of the National Health Law revolutionized Israel's health system. All Israelis can now affiliate with the health insurance funds of their choice with premiums charged in proportion to income. The premiums are collected and then distributed by the National Insurance Institute among the Israeli health insurance organizations according to the number of insurees and according to the special needs of particular population groups. The law established a range of services equal for all. People can supplement these services via the health insurance funds or private insurance companies
mother-and-child health services
The objective of these services is to provide for prenatal, natal, and postnatal care for every mother and full preparation for the birth of every child; protection and promotion of health for every child from birth to adolescence; and the detection and rehabilitation of handicapped children. Health protection includes routine immunization. Every child is vaccinated against smallpox, and a triple vaccination against diphtheria (mortality from which has virtually vanished), tetanus, and whooping cough is automatically given to over 80% of children from age three months upward, as is immunization against measles. Following a serious polio epidemic that started in 1950, the Salk vaccine was administered to all children between six months and four years from 1956 and the Sabin vaccine has been in use since 1961. As a result, cases of the disease in Israel are very rare, though the public health problem of rehabilitating patients from previous years remains.
One of the characteristics of Israel's mother-and-child care services has been their flexibility, in response to the demands of a constantly developing society. The scope of the services also aims at promoting the healthy growth and development of the family as a unit, and, since the family is bound up with the neighborhood in which it lives, the centers have undertaken to serve the surrounding community. In addition to coordination between preventive and curative services, several family health centers assume full responsibility for promotive, preventive, and curative services for all members of the family. In two Arab villages (Ṭayyiba and Ṭīra) they also provide lying-in facilities. In 2000 a network of 800 mother-and-child care centers dotted the country (in contrast to 120 in 1948). Of these, 520 were run by the Ministry of Health and by Kuppat Ḥolim ha-Kelalit, the remainder being the responsibility of the Jerusalem and Tel Aviv municipalities. Three were still retained by the Hadassah Medical Organization in Jerusalem (including a family and community health center) as part of its teaching framework.
school health services
Health services for children of school age, originally started by Hadassah in the early 1920s, are provided by the Ministry of Health for 66% of the pupils who benefit, and local authorities for 20%, while Kuppat Ḥolim looks after the remainder. The work is done by school health teams, consisting of a physician and a public health nurse, special attention being given to the requirements of handicapped children. The control of infectious diseases through immunization is continued in this older age group, with the addition of the bcg vaccination in the seventh grade. There is also considerable activity in the field of health education.
Though Kuppat Ḥolim is responsible for 50% of the population, it provides only 30% of the country's acute hospital beds, which are available primarily for its own members, and it pays for the treatment of members in other hospitals. Government, Hadassah, municipal, private, and mission hospitals accept all fee-paying patients and take turns in admitting emergency cases immediately (on days set by the Ministry of Health), financial adjustments being made afterward. In 2000 there were 48 general hospitals in the country with over 14,000 beds (2.2 beds per 1,000 population). There were also over 272 chronic disease hospitals providing 18,200 beds (2.9 beds per 1,000 population), and 21 psychiatric hospitals with approximately 5,500 beds (0.9 beds per 1,000 population).
A reduction in the average period spent in the hospital has led to better utilization of beds. This has been due to the combination of up-to-date medical skills, the establishment of more special departments, and the development of laboratory facilities. Nevertheless, the availability of beds still falls far short of the country's requirements, particularly in relation to chronic patients. In order to remedy the situation, a master plan for the construction of hospitals was worked out by the Hospital Planning Unit of the Ministry of Health.
All Jewish births and 95% of non-Jewish births take place in hospitals. Jewish women in Israel have always preferred hospital to home confinements, but Arab women, as well as many of the new immigrants, were not accustomed to this. To lower child mortality, which was higher among women who chose to deliver their babies at home, and to induce mothers to avail themselves of the advantages of delivery under safe conditions, the National Insurance Law of 1953 stipulated that the maternity grant is payable only to mothers confined in the hospital or who arrived at the hospital within 24 hours after the delivery.
There were 26,000 licensed doctors in Israel at the end of 2000: one for every 370 persons (and the supply of specialists in Israel does not lag behind that of other progressive countries). This is the highest ratio in the world, but many of the doctors are in the higher age groups. Over two-thirds of Israel's doctors graduated abroad. It was therefore necessary to equalize the various levels of training gained in different countries by additional training for the immigrant physicians. In partnership with Kuppat Ḥolim, the Hebrew University and Hadassah Medical School established in 1962 the Institute for Postgraduate Training, which specializes in short-term refresher courses. A second medical school was opened at Tel Aviv University in 1965, a third in Haifa in 1969, and the last in 1973 at Ben-Gurion University of the Negev in Beersheba.
Most doctors are salaried full-time staff in hospitals and other institutions; few are in private practice. All are members of the Israel Medical Association, which has adapted Hebrew terminology to the needs of contemporary medicine, set up libraries and information services, and, through its Scientific Council, laid down qualifications for specialization. Since 1980, following the initiative of Kuppat Ḥolim ha-Kelalit and the Ben-Gurion University Medical School, the Israel Medical Association started the family medicine track in medical specialization. In 2000, there were already over 800 family physician specialists working in primary care in Israel.
In 2000 there were about 30,000 nurses in Israel, 70% of them registered nurses and 30% practical nurses. From the mid-1990s, Israel suffered a shortage of nurses in the health care system. The practical nursing route was established in order to cope with the nurse shortage and to offer new immigrants with a nursing background a chance to work in the health system. Practical nurses can become registered nurses by passing the Israel Ministry of Health licensing tests. There are 40 nursing schools in Israel, almost in every general hospital. The diploma of registered nurse is awarded after a three-year course, according to standards set by the Nursing Department of the Ministry of Health. By the year 2000 almost all nursing schools in Israel upgraded their studies to a university level with a B.A. in nursing – a four-year program. In 1968 a University School of Nursing affiliated to the Faculty for Advanced Studies in Medicine of Tel Aviv University was inaugurated, leading to a B.A. degree. Schools of occupational therapy, physiotherapy, and X-ray and laboratory techniques function in different parts of the country. The Hebrew University's course for the M.A. in Public Health provides training in administration. There is a dental school at the Ein Kerem Medical Center and also at Tel Aviv University.
In 1994, following the recommendations of the Netanyahu Committee for the health care system, Ben-Gurion University opened a bachelor and postgraduate program for health administration, both managed jointly by the Ben-Gurion University School of Management and the Faculty of Health Sciences. In 1998 Ben-Gurion University opened the first school for emergency medicine to fill the need for paramedics in the civilian and military sectors. The need was felt due to the increase in terrorist attacks in Israel from the mid-1990s. In 2000 Ben-Gurion University opened the second school of public health in Israel, which has about 50 graduates every year. In 2003 Haifa University established a new Faculty for Health and Society.
hospital emergency services
Israel's security situation demands a well-planned emergency system that can be speedily put into operation. The effectiveness of this advanced planning was put to the test during the Six-Day War (1967) when the main hospitals – Soroka University Medical Center in Beersheba, Sheba (Tel ha-Shomer) Medical Center, Rabin Medical Campus (Beilinson), and Hadassah Ein Karem Medical Center – were ready to receive the wounded immediately after hostilities broke out. Beds, operating and laboratory facilities, and equipment were available underground, and casualty teams worked around the clock. The use of helicopters to facilitate the speedy transport of the wounded to the hospitals and the remarkably high standards of preparedness and treatment saved many lives. During the succeeding years of almost continuous border warfare, the hospitals continued to maintain this degree of preparedness.
[Malka Hillel Shulewitz /
Shifra Shvarts (2nd ed.)]
Medical research in Israel has a long-standing tradition dating back to before the establishment of the state. Its contribution is undoubtedly a significant factor in the high standards of medical care in the country. The areas in which Israel exhibits particular competence today include genetics, cancer research, immunology, autoimmune diseases, diabetes, neurology, cardiovascular conditions, gene therapy, bone marrow transplantation, and stem cell research.
The first steps towards establishing medical research institutions in Palestine were taken before World War i, with the creation in Jerusalem of the Nathan Straus Health Center and Dr. Beham's Pasteur Institute. The Institute of Microbiology (Parasitology), founded in 1924 at the Hebrew University, with its departments of biochemistry and bacteriology and hygiene, founded two years later, served as the basis for the first Medical Center on Mount Scopus. In 1927 I.J. Kligler opened the Malaria Research Station at Rosh Pinnah, which initiated research, control, and supervision of anti-malarial projects in all areas of Jewish settlement and in the adjacent Arab villages.
Research in general, including medical research, can be placed in three broad categories: basic, strategic, and developmental and evaluative. Each of these categories covers, in varying degrees, the full spectrum of health and medical research: namely biomedical, clinical, public health, health economics, health policy and health services, and each of these categories maintains its own balance between advancement of knowledge and application.
This category of research is initiated by the researcher (curiosity-driven) and generates new knowledge on questions of scientific significance.
This category can be initiated by researchers, the health system, or the health industry. It generates new knowledge to answer specific health needs and problems.
developmental and evaluative research (applied research, including clinical trials)
This category is mainly initiated by industry, but can also be sponsored by research institutions and government. It evaluates products (vaccines, drugs, diagnostics, prostheses, or equipment), interventions (public or personal health services), and instruments of policy that improve existing options.
Support of research in Israel comes from several sources: the Israeli government, European Community (ec), National Institutes of Health (nih), international and national nongovernment organizations (ngos), international and national private foundations, charitable organizations, and private donations. The Israeli government supports research via different ministries and international agreements. The most important source of government support of basic research comes from the Israel Science Foundation (isf), whose funds are budgeted by the Finance Ministry and channeled via the Budgeting and Planning Committee of the Council for Higher Education of the Ministry of Education. The Ministry of Science and Technology (most) supports both basic and strategic research and the Ministry of Commerce and Industry supports for the most part r&d by industry. Under bilateral agreements the Israeli government allocates matching research funds to the U.S.-Israel Binational Science Foundation (bsf) and the German-Israeli Foundation for Scientific Research and Development (gif). These granting agencies support competitive grants in the different areas of scientific research that also include medical research. Medical research is also supported by organizations such as the Israel Cancer Society (ica), the Israel Cancer Research Fund (icrf), the Juvenile Diabetes Foundation (jdf), etc.
Most medical research in Israel is performed at its four medical schools: the Hebrew University (hu), Tel Aviv University (tau), Ben-Gurion University (bgu), and the Technion, and their affiliated hospitals. Medical research and research in disease-linked life sciences are performed in the relevant faculties of the above universities and at Bar-Ilan University, which does not have a medical school, and the Weizmann Institute of Science. It is noteworthy that in two of the four medical schools more than 90% of the clinical researchers are from the respective hospitals. At bgu more than 90% of the clinical researchers are from the Soroka Medical Center and at hu more that 90% are affiliated with Hadassah University Hospital. For the most part, the number of investigators at a specific hospital is relative to the size of the hospital and the closeness of the affiliation with its medical school.
Several government ministries have chief scientists whose responsibility is to support and administer research and development grant programs in their respective fields.
The office of Chief Scientist established in the Ministry of Health in 1970 is a pivotal factor at the crossroads of research in biomedical science and the pursuit of disease-oriented clinical research and development. Its aims are (1) to promote, assist, and undertake basic, applied "disease-oriented" and clinical research in the health sciences; (2) to promote and support research in hospitals and universities; and (3) to encourage young physicians to do research.
Efforts are made to assist investigators working in peripheral hospitals situated far from the major centers of medical research in Israel and to assist young investigators taking their first steps in research.
[Bracha Rager and
Benny Leshem (2nd ed.)]
Services for the Arab Population
When the Ministry of Health was established, a special division was set up to serve the Arab and Druze communities. In 1952, however, with their progressive integration into the structure of the state, the division was abolished. The ministry set up clinics and mother-and-child health centers in Arab areas. An Arab officer is attached to the Regional Services Administration of the ministry to act as a liaison between the head office and the field units. Many Arabs and Druze have joined Kuppat Ḥolim, which has set up clinics in many villages. Integrated preventive and curative services are available at six health centers, in addition to general clinics and mother-and-child centers, covering more than 80% of Israel's Arabs. Case-finding activities are conducted among the Bedouin tribes in the Negev to combat tuberculosis, trachoma, and ringworm. The incidence of these once-prevalent diseases has decreased considerably, thanks largely to a mobile unit that regularly visits Arab villages and Bedouin encampments examining children and others. This service facilitates the early diagnosis and treatment of these diseases where they still exist. Eighty-four percent of Arab women now have their babies in hospitals, and the supervision of the mother-and-child centers is highly valued. Until 1994 about 87% of the Arab population were insured in the public health sector in Israel, mainly in Kuppat Ḥolim ha-Kelalit. Since 1995 all Arab citizens in Israel are entitled to equal health services under the Health Insurance Law. The extension of health coverage to the entire Arab population led to expansion of primary health services within the Arab villages in the north of Israel and also in the south in the Bedouin community. The major part of the Arab population chose to stay with Kuppat Ḥolim ha-Kelalit and only few moved to Macccabi and the smaller Me'uhedet and Le'ummit health insurance funds.
[Malka Hillel Shulewitz /
Shifra Shvarts (2nd ed.)]
in the administered territories
Immediately after the Six-Day War, a civil administration to deal with health services was attached to the military government in the areas administered under the cease-fire agreements. It faced two major problems: first, the low standard of health among large sections of the population in comparison with that prevailing in Israel, as well as higher infant and maternal mortality rates and inadequate inoculation rates, particularly against such serious diseases as polio; and second, the exodus of medical and paramedical personnel, which continued in 1967–68. This movement ceased in 1969, however, and a reverse trickle started. The situation was further relieved by the participation of Israel personnel, and joint efforts led to an overall improvement. In addition, Israel's health services were opened to residents of the administered territories when they required specialized treatment (including hospitalization) unavailable in their own places of residence. Following the signing of the Oslo Accords in 1994, responsibility for health care was gradually transferred to the *Palestinian Authority.
[Malka Hillel Shulewitz]
B. Rosen, R. Goldwag, S. Thomson, and E. Mossialos, in The European Observatory on Health Care Systems, 5:1 (2003); S. Shvarts, The Workers' Health Fund in Israel, Kuppat Ḥolim, 1911–1937 (2003); S. Shvarts, in Social History of Medicine, 11:1, 73–88; S. Brammli-Greenberg and R. Gross, The Private Health Insurance Market in Israel (2003).
"Land of Israel: Health Services." Encyclopaedia Judaica. . Encyclopedia.com. (August 15, 2018). http://www.encyclopedia.com/religion/encyclopedias-almanacs-transcripts-and-maps/land-israel-health-services
"Land of Israel: Health Services." Encyclopaedia Judaica. . Retrieved August 15, 2018 from Encyclopedia.com: http://www.encyclopedia.com/religion/encyclopedias-almanacs-transcripts-and-maps/land-israel-health-services