Israeli Healthcare Payroll

Israeli Healthcare Payroll

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Problem

Israeli public-healthcare workers are not paid like private-sector employees. A nurse, a physiotherapist, or a hospital doctor is paid under a public-sector collective agreement: the base is a combined-salary cell from a wage-grade (dirug) table of rank by seniority, and on top sit healthcare-specific allowances (tosafot) and, for shift and on-call staff, pay lines that follow their own rules. A generic gross-to-net calculator gets this wrong: it does not know which of several dirugim the worker belongs to, it treats the base as a freely negotiated number instead of a table cell that already includes seniority, and it has no idea that a doctor's on-call is paid in workday equivalents that are not even part of base salary. This skill encodes the Israel-specific structure so an agent can read a healthcare payslip, estimate a gross from the right track, and route the deduction step correctly.

Instructions

Work in four steps. Steps 1 to 3 build the GROSS; step 4 turns gross into net.

Before any of them, know the layer sitting above every dirug: the public-sector framework agreement (heskem misgeret) signed 17.7.2023 covering 2020 to 2027. It moves EVERY wage-grade table, so a base read without it is stale by construction.

It pays a flat shekel supplement (tosefet shiklit) of 400 NIS from 1.7.2023, raised to 500 NIS from 1.10.2024. The raise to 500 does NOT reach everyone, and nurses are on the excluded list: nurses (including public-health nurses), social workers, medical imaging technicians, medical technologists, and administrative-and-maintenance staff all stay at 400 NIS. Do not put 500 NIS on a nurse's slip. It also pays cumulative percentage raises: 2% from December 2024, 3.5% from April 2025, 5% from April 2026, 6% from April 2027.

Order of operations (read this once and apply it consistently). The tranches are folded INTO the published wage table: a table issued as "in force from 1.4.2026" already contains the 5%. Read a DATED cell, check the date, and do NOT apply a tranche on top of a cell that already postdates it. Apply a tranche yourself only when deliberately rolling a cell forward from an earlier in-force date to a later one, and say so when you do. Never apply a tranche to a cell of unknown date.

The framework also shortened the working week from 42 hours to 40 in two steps, 182 monthly hours to 177.667 and then 173.333. That matters beyond leave: the hourly rate (erech shaa) is monthly salary divided by the monthly hours norm, so a shorter week RAISES erech shaa and every line derived from it. The tranche dates differ by employer and government hospitals are on their own schedule: first tranche 1.12.2023 (at the latest 1.1.2024), second 1.7.2024 (or 1.6.2024 if the first was deferred). Every other employer under the agreement, local government included, ran 1.10.2023 (deferrable to 1.11.2023) and 1.9.2024. Use the hours norm actually in force for the month being read.

Do not assume a tosefet yoker (cost-of-living allowance) line is live: it is activated only by a separate extension order and is not paid routinely.

Full tables, the complete exclusion list, and the per-employer tranche schedule are in references/framework-agreement.md.

Step 1: Identify the wage grade (dirug) and the employer

The dirug decides which table and which tosafot apply, so pin it first. Public healthcare pay is set by collective agreements between the Histadrut and the profession unions and the Wage Commissioner (haMemune al haSachar) at the Finance Ministry, organized into occupational wage grades.

Allied health is not one grade: occupational therapy, physiotherapy and the para-medical grade are three separate dirugim. They are published as TWO table sets, occupational therapy sharing one with the para-medical grade and physiotherapy having its own, so never carry a physiotherapy number to either of the other two. Pharmacists and some hospital scientists sit in the academic dirug, which is why two "healthcare" workers on the same ward can be on different tables.

The employer of record is a separate question from the dirug. The same nurse grade is paid by the Ministry of Health, Clalit, Hadassah, or a municipal hospital. The employer issues the payslip and can run a different pension arrangement and different employer-specific supplements even though the dirug table is the same. Ask who employs the worker before reading a slip.

Step 2: Read the base combined salary (education, rank, seniority)

The base line (sachar meshulav) is read from a table that is THREE-dimensional, not two. Skipping the first dimension is the most common way to read the wrong number:

1. Pick the table by education level. The nurses' dirug is not one table but five: practical (maasi), registered (musmach), BA, MA, and doctorate.
2. Find the rank (daraga). Nurse ranks run 10 to 21.
3. Find the seniority row (vetek). Rows run 0 to 40.

The cell at that (education, rank, seniority) point IS the combined salary and ALREADY includes seniority. Do NOT add a seniority percentage on top, or you double-count. The per-year increment is itself banded and flattens with age: 3.10% a year for years 1 to 9, 2.10% for 10 to 19, 1.90% for 20 to 32, 1.10% for 33 to 35, and 0.85% from 36 on. A veteran whose base has stopped moving is on the flat end of that curve, not looking at a payroll error.

Education does not open a separate scale; it shifts the worker along the same ladder by about one rank per level. At seniority 0 the same cell is reached by a doctorate at 15, an MA at 16, a BA at 17, a registered nurse at 18, a practical nurse at 19.

The combined-salary cell is an index, not a take-home base. This is the most misread thing on an Israeli healthcare slip. The cell for a registered nurse at rank 13 with no seniority is 3,037.67 NIS in the last openly published grid (effective 01/12/2008), while that nurse's actual pay is several times that. The cell is what every percentage supplement, the hourly rate and the pension base are computed FROM, so answering "what does a rank-13 nurse earn" with the cell alone is wrong: give it as the base index, then add Step 3. Do NOT add a framework tranche here; a currently dated table already contains it.

references/nurses-salary-tables.md carries all five nurse grids in full (ranks 10 to 21, seniority 0 to 40) so the ladder can be read directly. Those cells are effective 01/12/2008 and are reproduced for STRUCTURE ONLY.

Do NOT bridge the 2008 cells forward to a current base. The 2008 grid predates every nurses' agreement and every public-sector raise between 2009 and 2023, and the framework tranches cover only the tail of that period. Multiplying a 2008 cell by 2%, 3.5% or 5% produces a confidently wrong number, not an estimate. Use the file for STRUCTURE only, never as the arithmetic base.

Where the current cell actually comes from. No current-dated grid is published openly, so there is no URL to send the user to. In order of reliability: the worker's own payslip, where it appears as a named line (sachar meshulav) and which is usually the right answer to "what is my base"; the employer's HR or payroll department, which holds the current table; then the profession union or the Wage Commissioner on request. Feed that cell into scripts/healthcare_gross.py. If none is available, say the current cell cannot be established rather than estimating it from the 2008 grid.

Step 3: Add the healthcare tosafot (and, for doctors, on-call)

On top of the combined-salary cell sit healthcare-specific additions. Some are a percentage of the base; some are named fixed-shekel lines; shift and on-call pay follow their own rules and are supplied as explicit amounts.

Nurses. A nurse's base is driven by more than the combined-salary cell:

• Gmul hishtalmut is one of the largest levers on a veteran nurse's pay: a permanent, pensionable percentage of the combined salary, credited in units of recognized study hours approved by the nursing studies committee. Read the current per-unit rate and unit cap from the committee rather than freezing a number. Omitting it understates a course-holding nurse badly.
• Tosefet achayot 2024: 250 NIS per full-time position from 1.10.2024, raised to 500 NIS from 1.4.2025. It counts as salary for all purposes (hourly rate, overtime, on-call, severance, pension, keren hishtalmut), is pro-rated for part-time, and is excluded from special and reinforcement shift calculations.
• Tosefet nihul (management), from 1.12.2023: 7.2%, but ONLY for nurses at ranks 14 to 21, so do not apply it across the board. Its base is the hourly-rate base as it stood on 31.12.2022, not the combined salary alone. Pensionable.
• Tosefet achrayut mishmarot, from 1.12.2023: 80 NIS per shift. NOT salary for any other purpose, so keep it out of the pensionable lines.
• A rotating-shift supplement, an academic-degree supplement (tosefet toar), and legacy fold-in shekel supplements also appear. Read each current rate. The full per-dirug table is in references/healthcare-tosafot.md.

Allied health. From 1.4.2025 the allied-health agreement pays tosefet hachsharot (a training supplement) as a percentage of the combined salary, banded by professional seniority. It is computed on the combined salary ONLY, with no other contractual supplements in the base. Render all three bands, not just one:

The band boundaries are exclusive at the top: a worker with exactly 7 years is in the 9.00% band, not the 3.50% one. Seniority here is PROFESSIONAL seniority only, counted from the date the licence was issued; army or national service does not count toward it.

Tosefet hachsharot REPLACES gmul hishtalmut for these grades rather than adding to it, and a worker never receives both. The rule is the higher of the two: a worker whose existing gmul hishtalmut is larger keeps the gmul and gets no tosefet hachsharot; once rising seniority makes tosefet hachsharot the larger of the two, the worker moves to it and stops receiving the gmul. The keren hishtalmut (study fund) itself is a separate payroll line and still applies, so do not read any of this as "no study fund". Tosefet hachsharot is salary for all purposes, including the hourly rate, on-call, severance, pension, and keren hishtalmut.

Allied-health staff in government hospitals are also entitled to a position-scope grant (mena'ak heikef misra) under the same 22.4.2025 agreement, per implementation instructions issued 18.9.2025 and paid in the April 2026 salary. It is conditional, on an undertaking to work at a qualifying position fraction and on completing a number of months at it, so it will not appear on every slip and is easy to miss.

Allied-health workers also have a capped monthly incentive (tamritz); the ceiling rose from 4,125 NIS to 5,400 NIS per full-time position per month for output from 1.4.2025. A retention and recruitment grant of 10,000 NIS per full-time position goes to eligible workers who completed 12 continuous months, but only in eight named psychiatric hospitals and child-development units at seven named medical centres, paid in the January salary. The grant is explicitly NOT salary: no severance, no hourly rate, no pension or keren hishtalmut deposits. The incentive and the grant are variable or conditional lines, not part of the fixed base.

Doctors. First pin the career stage, because the base track differs by it: a resident (mitmach) sits on a different track from a specialist (mumche), who differs again from a senior physician, and residents split by the board exams into darga alef (45-hour week) and darga bet (42). Do not model "a doctor" as one base cell.

Doctors have their own agreement (30.9.2024, replacing the 2011 one) raising the combined-salary table cumulatively: 4.88% from 1.1.2025, 6.5% from 1.7.2025, 7.5% from 1.1.2026. It has been amended repeatedly, so name the amendment you rely on. A separate tosefet mesima leumit runs 1.1.2025 to 31.12.2029 on a base of 3,000 NIS staged to 4,500 then 6,000, with pension computed as if 6,000 throughout; it is salary for severance and carries keren hishtalmut but is NOT in the mashkoret koveat. The base is multiplied by a per-specialty coefficient, so the headline figure is not what an individual doctor receives. Detail in references/healthcare-tosafot.md.

A doctor's slip is structurally different: much of the pay is duty and on-call, paid in workday equivalents that are NOT part of base salary. The two words are distinct and pay differently. Toranut is an on-site duty shift; kononut is on-call standby from home. A toranut pays roughly double a kononut for the same weekday, so never read a kononut value for an on-site duty. Both are valued off the doctor's day-value (erech yom), so the same shift pays a specialist more than a resident.

The day-equivalent values for each toranut and kononut band are tabulated in references/healthcare-tosafot.md. In outline, a weekday toranut pays four day-equivalents against a weekday kononut's two, which is why reading a kononut value for an on-site duty roughly halves the line.

Planned duty and on-call are not part of base salary, so they do not enter the pension and severance base the way the combined salary does. As a department-level sanity check, a rota runs about 20 to 30 on-call slots a month and about 60 in psychiatric hospitals; an individual doctor works a fraction of those. A doctor's slip also carries a presence supplement (tosefet shehiya); read the amount.

Three more doctor-specific lines sit outside the base:

• Shortage-specialty premium (miktzo'ot bemtzuka): about 12.5% of the doctor's salary, for specialties such as neonatology, anesthesia, cardiology, and the general, pediatric, and cardiac intensive-care units.
• Periphery: a one-time recruitment grant (ma'anak periferia) of 300,000 NIS, and 500,000 NIS for residents and shortage-specialty specialists, plus an ongoing periphery premium that ramped from 10% (from 1.8.2011) to 17.5% (2012) to 25% (from 1.8.2013) of salary for a resident or field specialist; read the current ongoing rate.
• Global additional hours (sha'ot nosafot globaliyot): a substantial senior-doctor line that is neither base nor on-call; read the current amount.

Use scripts/healthcare_gross.py to apply percentage tosafot to the combined-salary cell and add explicit shift or on-call shekel amounts you have computed. The script never re-adds seniority and never ships a NIS grade table.

Step 4: Gross to net

Healthcare net follows the standard statutory deductions. For the full mechanics (income-tax brackets, credit points, ceilings) defer to the israeli-payroll-calculator skill; do not restate income-tax brackets here. The pieces:

• Income tax (mas hachnasa): progressive brackets, less credit points.

• National insurance (bituach leumi) and health tax (mas briut), employee share: charged on a reduced step and a full step. Health tax is 3.23% up to the reduced-collection step of 7,703 NIS (2026) and 5.17% above it. For the exact National Insurance percentages and the full net mechanics, defer to israeli-payroll-calculator.

• Pension: check the pension TYPE. Veteran workers hired long ago may be on a budgetary pension (pensia taktzivit), where the employee deduction differs; newer workers are on a funded pension (pensia tzoveret) into a pension fund. Ask which one applies before estimating net.

• Keren hishtalmut (study fund) and union dues: essentially every public-sector healthcare slip carries a union deduction (demei chaver or demei tipul) to the Histadrut or the profession union. Do not omit it; read the current amount.

• Temporary wage reduction (hafchatat sachar zmanit): a war-cost participation deduction, agreed by collective agreement on 25.11.2024 and separately legislated in 2025. THREE tracks apply across the health dirugim, and which one applies depends on the dirug, not on the employer. Histadrut-represented healthcare dirugim are on the agreement track: 2.290% from December 2024 to December 2025, then 1.200% for 2026. Workers outside an approved collective agreement are on the law track: 0.000% to March 2025, 3.307% from April to December 2025, then 1.200%. The doctors' dirug is on a third track of its own under the agreement of 23.1.2025 (a freeze of the seniority supplement and of index linkage), NOT the 31.3.2025 wage agreement: 1.081% from 1.1.2025, raised to 1.781% for 1.7.2025 to 31.12.2025 by the monitoring committee of 30.6.2025, then back to 1.081% for 2026. Under the separate agreement of 14.5.2025, state-employed doctors' havraa was also cut, by 66.2% in 2025 and by 5% in 2026.

  All three end 31.12.2026 and no successor instrument has been published, so do not assume the 1.2% continues into 2027. A worker who changes dirug between 1.4.2025 and 31.12.2025 KEEPS the track they started on. The line shows as "tikun pensioni", is computed on salary excluding havraa, the clothing allowance, expense reimbursements and non-monthly payments (mena'ak yovel IS in the base), and reduces the keren hishtalmut base. It does NOT reduce a one-off end-of-employment payment to the worker or their survivors, bridging payments, the amount paid into a pension fund, or the mashkoret koveat: the agreement lists those expressly and requires them to be computed as if the reduction had never been made, so never subtract it before computing those four items. A 2025 or 2026 slip read without this line overstates net pay. Full tables in references/wage-reduction.md.

Pensionable base: not every line feeds the pension and severance base. As a rule the combined salary, gmul hishtalmut, and certain permanent tosafot are pensionable, while shift premiums, on-call, havraa, and the clothing allowance are not. The incentive (tamritz) is widely treated as non-pensionable but we could not source that either way, so check the agreement rather than asserting it. For budgetary-pension veterans the pensionable subset (the mashkoret koveat gimlaot) is defined even more narrowly. When estimating a pension or severance figure, separate the pensionable lines from the rest rather than using the gross.

Additions on the gross side (not deductions): havraa (recreation pay) and an annual clothing allowance (ktzuvat bigud). Both appear on their own schedule, not evenly each month, and neither is pensionable.

Public-healthcare workers are PUBLIC sector, so the public havraa day rate applies: 511.60 NIS a day from 1.6.2026, up from 471.40, per the Commissioner on Wages circular of 8.6.2026. Do NOT apply that rate raw to a doctors'-dirug slip. Under the collective agreement of 14.5.2025, state-employed doctors' havraa was cut by 66.2% in 2025 and is cut by 5% in 2026, so a doctor's havraa is the public rate less that year's reduction. The private-sector 451.50 NIS agreed on 22.6.2026 is a different figure for a different population, and using it understates every havraa day. The days are higher than the private table and the per-dirug day table sits in the Takshir rather than on a readable page, so read the days from the employer and never reuse a private days table.

The clothing allowance was updated 1.9455% over 2025 by the circular of 17.6.2026, paid in the July 2026 salary and pro-rated. The 2026 amounts are 1,812.00 NIS at level 3 (to administrative grade 16 or unified 7) and 2,527.00 NIS at level 4 (grade 17 or 8 and above), per Takshir 28.425.

Two more lines a practitioner will look for:

• Mena'ak yovel (long-service award): a recurring public-sector tenure entitlement that appears on veteran slips. Unlike havraa and the clothing allowance, it IS inside the base on which the temporary wage reduction is computed. Read the current entitlement rule and amount for the dirug.
• Retroactive pay (hefreshei sachar, "retro"): expect it. Almost every agreement cited here was signed after its own effective date, so the money arrived as a back-payment lump rather than in the month it was earned. This is one of the most common reasons a slip refuses to reconcile against a computed gross: the month contains arrears for earlier months. Check for a retro line before concluding a figure is wrong. The temporary wage reduction does NOT apply to arrears paid for periods preceding its window.

Examples

Example 1: Hospital nurse, night shifts

A certified nurse in the nurses' dirug at a government hospital, grade and seniority known, works rotating shifts including nights. Build gross: read the combined-salary cell for that (grade, seniority) straight from the union table, the cell already includes seniority so do NOT re-add it. Add the tosefet achayot 2024 (500 NIS per full-time from 1.4.2025), the current shift-responsibility supplement per entitled shift, and the actual shift premium for the nights worked. Statutory night and overtime hours follow standard labor law, so keep them separate from the collective-agreement shift supplement. Run: python3 scripts/healthcare_gross.py --base <cell> --add-prorated 500 --add <shift_pay> --position <fraction>, then apply Step 4 for net. Tosefet achayot 2024 goes through --add-prorated because it is pro-rated for part-time, while the shift pay goes through --add because it reflects shifts actually worked.

Example 2: Physiotherapist, mid-career

A physiotherapist in the physiotherapists' dirug, 10 years of professional seniority, full position. Physiotherapy is allied-health, so tosefet hachsharot is 9.00% (the 7 to 17 band), applied to the combined salary only. Check first whether the worker already holds a gmul hishtalmut larger than 9.00%: if so they keep the gmul and get no tosefet hachsharot, since a worker never receives both. Gross: read the current (education, rank, seniority) cell from the payslip or employer (it already includes seniority, and if it is a currently dated table it already includes the framework tranche), then apply 9.00% as a tosefet. If the worker earns the capped monthly incentive, add it up to the current 5,400 NIS ceiling. Run: python3 scripts/healthcare_gross.py --base <cell> --tosefet 9.0 --add <incentive> --position 1.0. Note the incentive is a variable line, not part of the fixed base.

Example 3: Hospital doctor, duty and on-call

A specialist doctor under the IMA agreement, base read from the doctors' dirug cell, who did several weekday on-site duties (toranut) and one weekday on-call standby (kononut) in the month. Duty and on-call are paid in workday equivalents times the day-value (erech yom): a weekday toranut is four day-equivalents (one plus three, section 42), and a weekday kononut is two day-equivalents (section 49), so a toranut pays about double for the same day. Do not read the kononut value for an on-site duty. Compute each shift as its day-equivalent count times the doctor's day-value, sum them, and pass the total as an explicit addition. These lines are NOT base salary, so they do not raise the pension and severance base. Run: python3 scripts/healthcare_gross.py --base <cell> --add <duty_total> --position 1.0.

Gotchas

• Treating healthcare pay as private-sector negotiation. The base is a collective-agreement combined-salary cell (grade by seniority), not a freely negotiated gross. Read the table; do not invent a base from hours times a rate.
• Using the wrong dirug. Occupational therapy, physiotherapy, and the para-medical grade are three separate tracks, and pharmacists sit in the academic dirug, not a health dirug. The base row and the tosafot differ by track. Pin the dirug before reading any number.
• Re-adding seniority that is already in the cell. The (grade, seniority) cell IS the combined salary; it already includes vetek. Adding a seniority percentage on top double-counts it.
• Confusing kononut with toranut. Toranut is an on-site duty shift; kononut is on-call standby. They are different pay lines with different rules.
• Putting on-call into the base. For doctors, planned on-call and duty are paid in workday equivalents and are NOT part of base salary, so they do not raise the pension and severance base. Do not fold them into the combined salary.
• Writing a banded rate flat. Tosefet hachsharot is 3.50%, 9.00%, or 9.50% depending on professional seniority, and the jump from the first band to the second is large. Picking one band for everyone misstates the slip badly. Read the worker's professional seniority (from licence date, excluding army and national service) and apply the right band, remembering the boundaries are exclusive at the top.
• Paying gmul hishtalmut and tosefet hachsharot together. For allied-health grades the two are mutually exclusive; the worker gets the higher one only. Adding both overstates the slip.
• Applying the nurses' management supplement to everyone. Tosefet nihul (7.2%) is paid only at ranks 14 to 21. A nurse at rank 13 or below does not get it.
• Quoting a combined-salary cell as "the salary". The cell is a base index that supplements are computed from, not take-home pay. A rank-13 registered nurse's cell is about 3,038 NIS in the last openly published grid (effective 01/12/2008), which is nowhere near what that nurse actually earns today.
• Omitting the temporary wage reduction. From December 2024 public-sector slips carry a negative line. A net estimate without it is too high.
• Freezing a shekel table. The combined-salary cells, the shift-responsibility amount, the clothing allowance, and the incentive ceiling all change with agreements and CPI. Read the current figure from the union or the Wage Commissioner; never hard-code a NIS cell.
• Omitting the nurses' gmul hishtalmut. For a course-holding nurse, the professional-development supplement is one of the largest lines on the slip and is pensionable. Leaving it out badly understates a veteran nurse's pay.
• Modeling a doctor as one base cell. A resident, a specialist, and a senior physician sit on different base tracks, and on-call and global hours sit on top. Pin the career stage before reading a doctor's slip.
• Treating every line as pensionable. Shift premiums, on-call, havraa, and the clothing allowance do not feed the pension and severance base. Do not estimate a pension or severance figure from the gross.
• Forgetting who signs the slip. The same dirug is paid by the Ministry of Health, Clalit, Hadassah, or a municipal hospital, which changes the pension arrangement, the employer-specific supplements, and who issues the payslip.

Reference Links

Bundled Resources

• references/dirug-map.md - the healthcare wage grades and who falls under each.
• references/nurses-salary-tables.md - all five nurse combined-salary grids (education level by rank 10-21 by seniority 0-40), the education-offset ladder, and the seniority-increment schedule. Cells are effective 01/12/2008 and are reproduced for structure, NOT as current pay.
• references/healthcare-tosafot.md - the named healthcare additions and how each is paid.
• references/framework-agreement.md - the 2020-2027 framework layer: shekel supplement, exclusion list, percentage tranches, and the per-employer working-week tranche schedule.
• references/wage-reduction.md - the three temporary-wage-reduction tracks.
• references/domain-checklist.md - the coverage contract for this skill.
• scripts/healthcare_gross.py - applies percentage tosafot and explicit shift or on-call amounts to a combined-salary cell you supply (--example for a worked run). It never ships a NIS grade table and never re-adds seniority.
• evidence.json - every figure with its source and verbatim snippet.

Troubleshooting

See references/troubleshooting.md.