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.

Every country has vulnerable populations that require special attention from policymakers in their response to a pandemic. This is because those populations may have specific characteristics, culture and behaviours that can accelerate the spread of the virus, and they usually have less access to healthcare, particularly in times of crisis. In order to carry out a comprehensive national intervention plan, policy makers should be sensitive to the needs and lifestyles of these groups, while taking into account structural and cultural gaps.In the context of Israel, the two most prominent and well-defined minority groups are the ultra-Orthodox Jewish community and parts of the Arab population. The government was slow to recognize the unique position of these two groups, public pressure eventually led to a response that was tailored to the ultra-Orthodox community and during the month of Ramadan a similar response has been implemented among the Arab community.

As of March 31, 2021, Israel had administered 116 doses of vaccine for COVID-19 per 100 population (of any age) – far more than any other OECD country. It was also ahead of other OECD countries in terms of the share of the population that had received at least one vaccination (61%) and the share that had been fully vaccinated (55%). Among Israelis aged 16 and over, the comparable figures were 81 and 74%, respectively. In light of this, the objectives of this article are: To describe and analyze the vaccination uptake through the end of March 2021 To identify behavioral and other barriers that likely affected desire or ability to be vaccinated To describe the efforts undertaken to overcome those barriers Israel’s vaccination campaign was launched on December 20, and within 2.5 weeks, 20% of Israelis had received their first dose. Afterwards, the pace slowed. It took an additional 4 weeks to increase from 20 to 40% and yet another 6 weeks to increase from 40 to 60%. Initially, uptake was low among young adults, and two religious/cultural minority groups - ultra-Orthodox Jews and Israeli Arabs, but their uptake increased markedly over time.In the first quarter of 2021, Israel had to enhance access to the vaccine, address a moderate amount of vaccine hesitancy in its general population, and also address more intense pockets of vaccine hesitancy among young adults and religious/cultural minority groups. A continued high rate of infection during the months of February and March, despite broad vaccination coverage at the time, created confusion about vaccine effectiveness, which in turn contributed to vaccine hesitancy. Among Israeli Arabs, some residents of smaller villages encountered difficulties in reaching vaccination sites, and that also slowed the rate of vaccination.The challenges were addressed via a mix of messaging, incentives, extensions to the initial vaccine delivery system, and other measures. Many of the measures addressed the general population, while others were targeted at subgroups with below-average vaccination rates. Once the early adopters had been vaccinated, it took hard, creative work to increase population coverage from 40 to 60% and beyond.Significantly, some of the capacities and strategies that helped Israel address vaccine hesitancy and geographic access barriers are different from those that enabled it to procure, distribute and administer the vaccines. Some of these strategies are likely to be relevant to other countries as they progress from the challenges of securing an adequate vaccine supply and streamlining distribution to the challenge of encouraging vaccine uptake.