Isr J Psychiatry - Vol. 55 - No 3 (2018) Uri Aviram and Sagit Azary-Viesel Mental Health Reform in Israel: Challenge and Opportunity Part I: Fundamentals of the Reform and the Mental Health Service System on the Eve of the Reform

Uri Aviram, PhD,1,2 and Sagit Azary-Viesel, PhD candidate3

1 School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Israel 2 School of Social and Community Sciences, Ruppin Academic Center, Israel 3 Public Policy Department, Tel Aviv University, Tel Aviv, Israel

Introduction Abstract At the start of July 2015, the mental health reform of Israel In July 2015, the mental health reform of Israel went into went into effect. The decision for the reform was taken effect. This reform, which transfers responsibility for hospital in June 2012 by means of a government order (1) after a and ambulatory mental health services to the health funds, series of former attempts had failed. Undoubtedly, this constitutes a major change in mental health services in Israel. reform, which transfers the insurance responsibility for It concludes a process of fifty years of Israel’s attempts to hospital and ambulatory mental health services to the achieve this change. This paper examines the opportunities health funds (2),1 constitutes a major change in mental and challenges associated with implementation of this health services in Israel. reform and comments on lessons other jurisdictions Although the principle and general direction of the interested in reforming their mental health service system reform seemed relatively clear to decision makers, at could learn from the Israeli experience. The study was of the the time the decision was made questions on many exploratory and “formative” assessment type – an evaluation issues remained unresolved. The decision was made to in the course of program implementation with the objective go ahead with the reform and contend with the unre- of improving its functioning and outcome. It relied on both solved issues in the course of the three years allocated quantitative data and interview-based qualitative data. for preparations towards its implementation or even The comprehensive interviews included discussions with after the reform went into effect. In light of the vari- various persons, represented various organizations and ous problems, such as limited knowledge in the field, interest groups, connected to the reform decision and its a significant level of disagreement regarding the target implementation. populations, as well as ideological, organizational and The manuscript is divided into two major parts and political aspects of the topic, the decision to implement published as two papers: The first describes the reform the reform without resolving all the issues in advance and analyzes the system prior to the reform and the second was appropriate. In fact, if this step had not been taken assesses the issues that should be dealt with following and the decision makers had waited until all matters implementation. were resolved, it is doubtful that the reform would have been undertaken at all.

1Health funds, Kupat Holim in Hebrew, are similar to HMOs in the United States. According to the National Health Insurance Law (2), residents must enroll in one of the four health funds responsible for delivery of health services based on a basket of services according to law and government’s orders.

Address for Correspondence: Uri Aviram, PhD, 114 Hameyasdim Street, Pardess Hannah-Karkur 3713446, Israel [email protected]

45 Mental Health Reform in Israel: Fundamentals

The aim of the present study was to examine the advantages and risks associated with the transfer of Background responsibility for mental health services to the health Fundamentals of the Mental Health funds and their integration into the general medical Insurance Reform service system. The paper analyzes the issues confronting The reform in mental health was meant to implement the those in charge of its implementation and the regula- provision set by the National Health Insurance Law (2) tors and recommends the appropriate modifications or which stipulated that the mental health services should ways of dealing with the issues and problems that may be transferred from the state’s responsibility to the health arise in the course of the reform’s implementation. In funds and be integrated into the general healthcare system. addition, the purpose of this case study was to highlight According to planning, after the reform, the situation in matters that other jurisdictions, attempting to reform the field of mental health services was to be parallel to their mental health services systems, may learn from the accepted arrangements in medical services under the the Israeli experience. National Health Insurance Law (except for a small number The study is of the exploratory (3) and “formative” of items). The fundamentals of the reform are detailed assessment type – an evaluation in the course of pro- in an order from May 10, 2012 (1) and in an agreement gram implementation with the objective of improving between the Ministries of Health and Finance and the its functioning and outcome (4, 5). It relies on both Clalit Health Services (6).2 These documents are based on quantitative data and interview-based qualitative data. previous decisions and agreements made since the first The comprehensive interviews (49 in total) included attempt to transfer responsibility for mental health services discussions with the various persons connected to the to the health funds in 1995 (7), but mainly on the proposal reform decision and its implementation – including enacted by the Knesset (Israeli parliament) in 2007 (8). senior health fund officials, officials in the Ministries of The reform concerns the insurance responsibility Health and Finance and in other government agencies, and financing arrangements for mental health services, suppliers of health services, professionals in psychiatric including patient co-payments. At heart, it seeks to apply hospitals and in the field, as well as associations of persons the principles of the National Health Insurance Law – coping with mental illness, families of people suffering justice, equality and mutual assistance – to the mental from mental illnesses, human rights organizations, and health services. It is supposed to realize and extend the public figures. principle of availability and accessibility of the National The manuscript is divided into two major parts pub- Health Insurance system to the mental health services, lished as two papers: This part (Part 1) focuses on a and lead to a fair and equitable deployment of these description of the fundamentals of the reform and analysis services in all parts of the country and among the various of the mental health services system prior to the reform. population sectors. Likewise, the reform was intended The second part, Part 2, focuses on an assessment of to bring order to the budgeting and financing of mental the major issues that remained to deal with after the health services similar to the accepted arrangements in implementation of the reform. This paper begins with a the general health services. brief description of the reform’s aims and fundamental The primary elements of the reform included the components. It then sets out a brief background leading transfer of insurance, services and treatment responsibil- to the reform and the state of the mental health ser- ity for inpatient and ambulatory mental health services vice system immediately preceding the decision on and from the state to the health funds, and the integration of implementation of the reform, with an emphasis on the these services in the overall array of health services. The major changes in mental health services in the last two order arranged the funding of the transfer of responsibil- decades since the enactment of the National Health ity to the health funds, stipulating that NIS 1.78 billion Insurance Law (2). The following paper reporting this (2014 data)3 be added to the health funds’ basic annual research deals with several unresolved issues and topics 2 that require thought and attention in the course of the Clalit Health Services is the Israel’s largest health fund (HMO) reform’s implementation. In the concluding section of insuring about 60 percent of the country’s population. The other health funds in Israel are Maccabi Health Services, Kupat Part 2, several recommendations arising from the analysis Holim Meuhedet and Leumit Health Fund. are presented and lessons from the Israeli experience 3On June 2012 ,6, the exchange rates were US 1$ = NIS 3.887 are highlighted. and 1.00€ = NIS 4.863.

46 Uri Aviram and Sagit Azary-Viesel budget for the inclusion of responsibility for mental of psychiatric diagnoses and defined the average duration health services in the framework of the basket of services of treatment as well as the terms of payment. From then to the public. This sum mainly represents the costs of on, anyone seeking mental health ambulatory treatment psychiatric hospitalizations, which amount to about or hospitalization would be required to present a financial NIS 1,078 million annually, and about NIS 706 million agreement voucher (Form 17) from the health fund. for clinical ambulatory services (1, 6). In effect, since a However, in contrast to the medical insurance arrange- considerable part of this money had already been in the ments for physical illnesses, in the case of mental illness budgets allocated to mental health (which until now were the order allowed referral to private psychotherapeutic included in the state budget), the reform was supposed services with higher patient co-payments than those for to add about NIS 300 million (in 2012 prices) to the a specialist consultation in the general health services. annual health budgets. These sums were to be added to As stated, the goals of the reform were to integrate the health funds’ basic budget and were to be updated the mental health services with the general medical ser- periodically, according to the criteria that apply to the vices, to improve the quality of treatment by expand- regular updating of the health funds’ budgets. As with ing the ambulatory services, to prevent unnecessary the arrangements in general medicine set by the National hospitalizations, to increase the number of alternatives Insurance Law, and as opposed to the situation when the to hospitalization, and to offer more options for people responsibility for mental health services lay with the state, with mental illness within the community. Policy makers once the reform had been implemented, service users hoped that the reform would help to remove the stigma were entitled to sue the health fund if they felt they had from people suffering from mental illness and emotional not received the services included in the health basket problems in general. in whole or in part, within a reasonable time and located The goal of the reform’s planners was to reach 4% of at a reasonable distance from their home. the adult population and 2% of the child population who The reform order left three years for preparations and would be entitled to and receive mental health services. for the system to get organized, stipulating, as mentioned The plan stipulated an average number of 9 contacts for previously, that the reform would enter into effect on 1 adults and 12 for children. The assumption was that in July 2015. Likewise, it was agreed that three years from the wake of the expansion of these services it would be the start of its implementation (i.e., 2018) there would be possible to prevent unnecessary hospitalizations, make the first periodic evaluation and the necessary modifica- the mental health services significantly more efficient, tions would be discussed. and, of course, improve the health and quality of life of Since the number of people diagnosed with mental people suffering from mental illness. illness insured by the Clalit Health Services was far greater The main effort in the intermediate period was invested (2/3 of the total) than the number of those with mental in expanding the ambulatory services – increasing the illnesses insured by the three other health funds (9, 10) number of mental health clinics and their distribution the government chose to come to an agreement with around the country (including in the geographic periph- Clalit Health Services and afterwards the other health ery), as well as preparing the organizational and adminis- funds were negotiated with and joined the agreement. trative infrastructure of the health funds for the reform’s These agreements were approved by the Knesset’s Finance implementation, as well as the introduction of Managed Committee (11) and were included in the Economic Care arrangements to the mental health services, similar Arrangements Law (12). to the arrangements in the general health services. The agreement between the Ministries of Health and Finance and the Clalit Health Services (6) and the order Mental Illness and Mental Disability: Extent of (1) detailed which mental health services would be under the Problem the health funds’ responsibility and which would remain The World Health Organization has ranked mental ill- in the hands of the government – community rehabilita- nesses on a par with coronary diseases and malignant tion services for people with psychiatric disabilities, hospi- diseases in terms of the global burden of disease. They talization of those suffering from double illness (physical are included among the ten main factors leading to dis- and mental), services for prison inmates who suffer from ability in the world (13). In addition to the disability and psychiatric disorders, and services for addiction and social handicap, people with mental illness suffer from drug rehabilitation. The reform related to a specific list stigmatization and social exclusion (14-17). The World

47 Mental Health Reform in Israel: Fundamentals

Health Organization estimated that at any given time, mental health treatment in the private sector (27). In about 10% of the population suffer from mental illness addition, as mentioned previously, the economic dam- and mental distress, and between a quarter and a third age caused to families caring for the people with mental of the population will require mental health services in illness in terms of workdays lost and other expenses, as the course of their lives (18). There is a broad consensus well as the emotional and economic price of higher rates that between 1 and 2% suffer from serious and persis- of illness among families caring for people with mental tent mental illnesses, and that every year 3 to 5% of the illness versus their counterparts in the general population population require mental health treatment (18-20). needs to be taken into account as well (23). There are In addition to those who suffer serious and persistent also considerations of the financial and organizational mental illness, much of the population suffer from mental burden on the general medical services resulting from problems that harm their functioning, impact on their treatment of those suffering from mental illness, as well livelihood and quality of life, affect their families, and as the harm to the economy as a result of lost workdays place a significant burden on the health services and and of the non-employment of people with mental illness. on society at large. In Israel, the largest group receiving On the basis of an estimate of the economic and social disability pension from the National Insurance Institute cost of mental illnesses that was conducted in the U.K. is the one with psychiatric disabilities. This group com- (28) and adjusted to the size of the population and the poses one third of all recipients of disability pensions, standard of living in Israel (29, 30), the annual cost of and the level of pensions paid is highest compared to mental illnesses to Israeli society amounts to U.S. $13 other disabilities (21). billion. Furthermore, following the results of the study Although the reform determines who the target by Kessler et al. (31) in the United States, the loss to population is, it is far from simple to define, locate and GDP due to the non-employment of people suffering measure the rates and distribution of mental illnesses in from mental illness in Israel is estimated at $2.5 billion the population. Issues related to defining what mental per annum (32). Although these estimates are imprecise, illness is, the psychiatric diagnosis and its reliability and they undoubtedly suffice to underscore the high economic validity, and the epidemiology of mental illnesses have price of mental illnesses to society, and the economic and already been discussed extensively in the literature (22), social benefit to be gained from appropriately dealing and it is not necessary to discuss them again. with them and with the rehabilitation of people with There is no doubt that this is a wide-ranging and psychiatric disabilities in the community. serious health and social problem. Furthermore, fam- As already mentioned, according to the international ily members of sufferers from mental illnesses are also estimates, 3 to 5% of the population suffer from various harmed both directly and indirectly; not only does it kinds of mental illnesses and mental disorder and require cause anguish and distress, but there is also an impact treatment every year, and these may be considered the on family members’ economic situation, quality of life target population of the mental health reform. Of them, and even their physical health (23, 24). according to different estimates, the number of those Mental illnesses are a substantial factor in the national suffering from serious and persistent mental illnesses in expenditure on health. The overall cost due to mental Israel is about 100,000-150,000 (19, 21, 33-35). According illnesses and their economic consequences has not been to National Insurance Institute data, in 2015, the number measured to date in Israel. Nonetheless, it is clear that this of those receiving a disability pension due to psychiatric expense far exceeds the governmental budget devoted to diagnoses was about 78,500. However, this figure is an mental health services which today (in 2014) amounts underestimate, as it includes only those who chose to to about NIS 2.7 billion annually (25). To this amount submit a claim to the Institute and who not only met the needs to be added, among others, the health funds’ bud- criterion of medical disability, but were also defined as gets devoted to mental health services; the disability persons whose earning capacity was reduced by at least pension granted by the National Insurance Institute to 50%. The group of people disabled by mental illness people with mental disabilities (21, 26); the pension given constitutes about a third of the recipients of disability to disabled persons by the Ministry of Defense due to pension and is the largest in this category (21, 26). It is also mental health problems; the funds allocated by the local the largest group that receives disability pension at 75% authorities; the housing support granted by the Ministry or over of the maximum pension. It should be empha- of Housing; and the not insignificant amounts paid for sized that this number refers to only a small portion,

48 Uri Aviram and Sagit Azary-Viesel albeit those in great need of the services, of the broader basis, and many of the existing services are not evidence- target population of the law. To this estimate of those based. Perhaps more than in any other medical field, in with mental illness who constitute the reform’s target the mental health field there is disagreement with regard population, should be added the close family members to the problems that the system needs to contend with, caring for the disabled and the ill, since the physical, the population entitled to service, as well as the range of mental and economic burden involved in caring for services that the system should provide (43-46). these family members is, as noted previously, immense. In addition to the global issues, the mental health According to the Central Bureau of Statistics’ estimates service system in Israel is faced with three major inter- of the size of the population and the average household related problems: limited development of community size in Israel, the estimated number of people with serious mental health services, the dominance of the psychiatric and persistent mental illness and the persons caring for hospitalization system and the medicalization of the them is about 350,000-400,000 – about the population mental health services (47). These problems reflect both of a medium-sized town in Israel (36). organizational and economic issues as well as social- cultural structural factors. The explanations for their Trends in the Mental Health Services Policy continued existence and influence on the system are The attempted reforms in the mental health services linked to the historical background of mental health ser- in Israel are connected to the new worldwide trends in vices in Israel (48-52), traditional beliefs and approaches the fields of treating and caring for people with mental regarding mental health problems and ways of dealing illness. Although it is a complicated subject, it can be with them, and a series of interests that have sprung up defined by means of four prominent changes: a drastic and become rooted over the years (43, 47, 53). reduction in hospitalization rates, the development of The insurance reform is supposed to complete two community services, a change in therapeutic approaches, partial reforms that took place in the last 20 years in and the general expansion of the welfare state (22, 37-39). the mental health services. The first was the structural The radical changes in the mental health arena arrived reform, that is, the reduction in the number of psychiatric somewhat late in Israel compared to other developed beds and a lowering of the hospitalization rates, the countries, but since these trends have been extensively number of hospitalization days in the course of a year, discussed elsewhere it is unnecessary to deal with this and hospitalization duration. This reform began in the matter any further (38-42). mid-1990s. The second was the rehabilitation reform, What led to the change in the mental health service which was legislated in 2000 (54). As shown elsewhere systems in the world? Essentially, it was a combination (32, 55), in the wake of the reforms the number and of circumstances, and not necessarily the outcome of rates of psychiatric beds dropped by 65% between 1996 careful, rational planning. The main factors were: the and 2015 (from 1.17 to 0.41 beds per thousand people). beginning of the use of psychoactive medications; the During the decade from 2006 to 2015 the rates of expansion of the welfare state and the transfer of financial inpatients dropped by 20%. However, when looking at and other supports to the disabled; the immense costs the rates of the long stay patients (one year and over) of the system of psychiatric hospitals and the burden it dropped by 36% (from 0.44 to 0.14 per 1,000 of the on state budgets; and the disappointing results of the population (10). We may assume that the development of psychiatric hospitalization system. That system failed to the psychiatric rehabilitation in the community program achieve the three main goals of any mental health system: has been responsible, at least in part, for this change. social control, humane treatment and low costs. The The decrease in the number of inpatient beds stems civil rights movement, discussed extensively elsewhere mainly from the closing of private (for profit) psychiatric (38-42), was also significant among the factors leading hospitals, where conditions and the standard of treatment to the change. drew continuous public criticism. Between 1996 and 2011, It is impossible to understand the reforms proposed in six of the eight private hospitals in the system closed. In Israel and the problems and difficulties in the attempts to 1996, the number of beds in private hospitals was 2,419, implement them without reference to the main problems and by the end of 2015, the number was only 178 – that plaguing the Israeli mental health service system like any is, most of the psychiatric beds in private hospitals (93%) other mental health service system. Quite a few of the were eliminated, quite a significant accomplishment (10, customary therapeutic approaches lack a solid empirical 56). In the same period of time, the number of psychiatric

49 Mental Health Reform in Israel: Fundamentals beds in government hospitals dropped by 25% – from the end of 2015. A similar increase occurred in the field 3,772 to 2,876 beds. of supported employment (9, 10, 64). In parallel, there was a drop in the rate of full hospi- These changes are also seen in the budgetary distribu- talizations: from 1.15 hospitalizations per thousand in tion for mental health services during the period under 1996 to 0.4 in 2015 (10). study. Whereas in 1999, on the eve of the enactment of Between the years 1995 and 2007 there was a dramatic the Rehabilitation Reform Law, the rehabilitation ser- reduction in the number of annual hospitalization days. vices accounted for only 2% of the government budget Whereas in 1995 the number of hospitalization days for mental health services, by 2014, they accounted for amounted to 2,255,591, in 2007, the number of yearly 27%. At the beginning of the period, hospitalization hospitalization days was 1,204,628, that is, a 47% drop in services accounted for 80% of this budget, but that share a 12-year period. Beginning in 2007, in parallel with the dropped to 54% in 2014. It may be assumed that, at least end of the drastic decline in the number of psychiatric in the initial years of the implementation of the reform, beds, the number of yearly hospitalization days stabilized there was a connection between it and the decline in the at about 1,200,000. However, the rates per 1,000 contin- number of psychiatric beds and hospitalization days (66). ued to drop. During the decade from 2006 to 2015 they Despite the drastic drop in the hospitalization rate declined by 20% (10). and in hospitalization days in the 15 years since the The duration of hospitalization also shortened appre- enactment of the Rehabilitation Reform Law, not a single ciably during the same period. In 1996, the average psy- government psychiatric hospital has closed and the overall chiatric hospital stay was 151 days, whereas in 2011, the budget for inpatient services (including costs for hos- number stood at 68 days – a drop of 55% (9, 56). It should pitalization in government hospitals and payments for be noted that until the year 2000, the average number of hospitalizations in Clalit psychiatric hospitals as well as annual hospitalization days per person was even higher, public non-government hospitals and private psychiatric ranging between 180 and 339 a year. Since 2001 (the hospitals) has grown (in fixed values) by about 20% first year of implementation of the Rehabilitation in the between 1999 and 2013 (66). Community of Persons with Mental Disabilities Law Despite the legislators’ intention to strengthen the [54], this number has consistently decreased every year ambulatory services, in the years after the enactment of [9,10, 36, 56-60], in a conversation with Ministry of the National Health Insurance Law the opposite process Health, Department for Information and Evaluation, occurred. Between 1995 and 2007, the budget for govern- March, 2014). ment mental health clinics declined by 40% (34), and The rehabilitation reform was the second big change the availability and accessibility of ambulatory mental that took place in the mental health services in the period health services continued to be far from satisfactory. The under study (34, 55, 61-63). The Rehabilitation Reform distribution of clinics in the country’s various regions Law (54) constituted a breakthrough. Following this law, and in certain sectors (e.g., the Arab Israeli sector) was a special allocation was granted for the rehabilitation of not uniform and was unequal (in a conversation with persons with mental disabilities in the community, and in 2014, that sum amounted to about NIS 700 million Figure 1. Hospitalization Days (in millions) During the (9, 25, 56, 64). In the years since the enactment of the Year and Number of persons in Rehabilition Programs During the Year Rehabilitation Law, a network of community services has been put in place in the framework of the mental 2.5 25,000 Hospitalization health services, including supported living arrangements, Rehabilition 2.0 20,000 supported employment, continuing education programs, clubs, and so forth – all of which was just a dream only a 1.5 15,000 few years ago (34, 36, 55, 62, 63). At the end of 2015, the 1.0 10,000 community rehabilitation system was providing services 0.5 5,000 to about 20,109 people with mental disabilities, versus 0 0 only 4,600 in 1999 (9, 10, 56, 64, 65). 1999 2001 2003 2005 2007 2009 2011 2013 2015 The number of people with mental illness in com- munity supported living arrangements has multiplied Source: Uri Aviram and Haim Bleikh, Taub Center Data: Ministry of Health, State Budget by six since the law went into effect, reaching 12,350 at

50 Uri Aviram and Sagit Azary-Viesel

I. Elroy, Myers-JDC-Brookdale Institute, June, 2015). clinics have been added by the health funds to the 56 Likewise, the funding of mental health services was far government clinics that existed prior to the decision, from adequate to meet the population’s needs and funding and the number of recipients and the number of new was not updated in the same way that the health funds’ recipients of ambulatory mental health services shot up general medical services were. Development budgets were by 140%, from about 50,000 to about 120,000 a year (in also directed mainly to the hospitalization system – 98.5% a conversation with Dr. G. Lubin, former head of Mental as opposed to only 1.5% for the community clinics (34). Health Services Division, May, 2015). This trend seems In addition to the Rehabilitation Reform Law, other to continue. By the end of 2016 there were 83 new clin- laws and judicial decisions have had an impact on the ics established by the Health Funds and the number of system, like the Treatment of the Mentally Ill Law (67); ambulatory care recipients in 2016 was 147,386 persons, the Equality of Rights for Disabled Persons Law (68); 25% over the number in 2015 (in an e-mail from D. the Basic Law – Human Dignity and Liberty (69); and Bodovsky, Head of Ambulatory Services, Mental Health various judicial rulings in matters pertaining to people Services, March, 2017). suffering from mental illnesses. Prior to the implementation of the reform, the relative However, these changes are far from what is required to share of the mental health services out of the total public meet needs. While 90% of persons suffering from serious expenditure on health services was also lower than in mental illness are in the community at any given time other developed countries. While some Western countries (19), only 35% of the mental health services budget is allocate 10% of the total health package, in Israel the share directed to community services, including ambulatory allocated to mental health services was approximately and rehabilitation services (9, 25, 56). This differs from 5% (27, 72). This situation forced many of those with the situation in the general health services, where half mental disabilities and their families to pay privately of the system’s expenditures are invested in community for mental health services, or even to forego the services services (70, 71). Likewise, even though the structural altogether (25, 62, 63). At a recently held conference on reform and the decline in the number of psychiatric the topic, it was reported that the private expenditure on beds in the mental health services (including those in mental health services is appreciably higher than in the the government hospitals) led to a relative drop in the general health services. Whereas in the general health share of the budget devoted to hospitals, in numerical services the ratio between public and private funding terms the budgets of the government hospitals were stands at 60% to 40%, in the mental health services the augmented in the years 1999-2014 and rose by 26%, situation is reversed: private funding accounts for 67% from NIS 798 million in 1999 to NIS 1,009 million in and public funding for 33% (in a conversation with I. 2014 (in 2014 prices). Saragusti, director, “Bizchut” Mental Health Project, In light of the planned insurance reform, it would have May, 2015). The decline in the clinics’ budgets during seemed more appropriate to strengthen the ambulatory the years preceding the reform, as well as the high rate services. In contrast, there was a drop of about one-third of private funding in the mental health services, should in the budgeting of government ambulatory services be reflected in the findings of the studies that have exam- (clinics) between 1999 and 2011 from NIS 202 million ined the availability and accessibility of mental health in 1999 to NIS 134 million in 2011 (in 2014 prices). services. These studies, which were conducted by the The relative share of the budget for clinics out of the Myers-JDC-Brookdale Institute, found that only a third government budget for mental health has also declined. of the interviewees who had felt mental distress in the Whereas in 1999 it constituted 14% of the mental health previous year sought treatment, that the rate of applicants services budget, in 2014, it accounted for only 8% – and from the lower socioeconomic clusters (usually including this after a special budgetary infusion of over NIS 300 the localities in the periphery) was lower than the rate million in the wake of the reform order of 2012 (66). in the upper ones, and that the rate of treatment-seeking Indeed, only after the reform order was issued in 2012 among Arab Israelis who felt mental distress was lower did the budgets allocated to ambulatory rise, reaching than among Jews (in a conversation with I. Elroy, Myers- NIS 222 million in 2014 – a 75% increase since 2011. JDC-Brookdale Institute, June, 2015). These data, which As was reported at the conference of the Israel National attest to the availability and accessibility of the mental Institute for Health Policy Research on 13 May, 2015, health services for the entire population, to the unequal following the decision on the reform, 61 community distribution among the various sectors of the population

51 Mental Health Reform in Israel: Fundamentals and to the high level of private financing of these services, It bears mentioning that in the framework of efforts to are undoubtedly troubling. promote the reform, NGOs of people with mental disabili- The data prove how far the mental health service sys- ties and their family members, human rights organizations tem still is from the planned goal, which is to deliver the (“Bizchut”) and public figures (former Knesset member majority of the services in the community. What are the Tamar Gozansky and former Minister of Health Nissim reasons for this? Why has the reform not been imple- Dahan) were active and lobbied to advance the issue. For mented until now? What are the challenges facing those example, in 2005, a petition was submitted to the Supreme implementing the reform? To answer these questions it Court to require the government to execute a reform, and is necessary to determine who the major interested par- in the wake of an interim order issued at that proceeding ties were, what the main issues were when they tried to (80), the government proposed a bill and submitted it to implement the reform, and what the interested parties’ the Knesset in 2007. In order to convince those within positions were with regard to the reform. Then it may the Ministry of Health who still hesitated to support the be possible to deduce what the existing threats are to its reform, they were shown the financial loss incurred by current successful implementation. Before conducting the mental health system as a result of its budgets not that analysis, the five major attempts made over the past being updated by the same criteria that the health fund 40 years – usually upon the Ministry of Health’s initia- budgets are periodically updated. Indeed, the long delay tive – to implement a substantial change in the mental in completing the reform cost the mental health services health services in Israel will be briefly surveyed. considerable sums. As a general estimate, from 1998, the last year in which the reform had been intended to enter Previous Reform Attempts in the Mental into effect according to the National Health Insurance Law Health System (2), until 2009 – the year in which the Deputy Minister If the current attempt to make a substantial change in of Health4 decided to support the reform and take action the mental health services in Israel succeeds, it will mark in the matter (81) – the mental health system lost about the end of an effort that began over four decades ago. As NIS 800 million (in 2009 prices). According to another early as the beginning of the 1970s, the state sought to estimate, from 1995 (the first year in which [based on the institute a fundamental reform in the mental health service national health insurance reform of 1995], an attempt was system, the purpose of which was to transfer the locus of made to execute the insurance reform) to 2014, the mental care from a system based mainly on psychiatric hospitals health system lost NIS 1.9 billion (in 2014 prices). This to a community-focused system (73-75). The attempts at considerable amount of money could have augmented the a community reform in the mental health field in Israel mental health budgets and improved the level of services.5 matched the general trends in the mental health systems of the Western world in the second half of the twentieth Acknowledgements century (22, 38). Since the major previous attempts of Israel This study was supported by the Taub Center for Social Policy Studies in Israel, Jerusalem. It lead to an earlier version of this at reforming the mental health services have already been manuscript published in 2015 by Taub Center, as Policy Paper reported in the literature (7, 8, 11, 34, 36, 76-79) and in fact 2015:02. For detailed acknowledgments, please see following Part II of this manuscript. are beyond the focus of this paper we will not deal with the previous failed attempts of Israel to reform the system. The latest attempt, which is now in progress, began References 1. Government Secretariat. Transferring Full Insurance Responsibility in when decision makers in the Ministry of Health came the Area of Mental Health from the State to the Health Funds. Jerusalem, to the conclusion that the 18th Knesset would not finish Israel: Government Secretariat, 2012, May 10. Government Decision the legislative procedure of the Mental Health Reform No.: 4611 (Hebrew). 2. National Health Insurance Law 1994, Israel (Hebrew). Law (8) before the end of its term or its dissolution. In 3. Wholey JS. Exploratory evaluation. In: Newcomer KE, Hatry HP, Wholey light of that, they decided on a change of course and saw JS, editors. Handbook of Practical Program Evaluation, Third Edition. to it that a decision on reform was taken by means of San Francisco: Jossey-Bass, 2010: pp. 81-99. a governmental order. The government decision from 4 2012 stipulated that the reform would enter into effect Due to political reasons, the Deputy of the Minister of Health, three years from when the order was issued, that is, on MK Yaakov Litzman, acted as the Minister of Health. 5The loss is calculated according to the cumulative differential 1 July, 2015 and, indeed, it went into effect on time. It is amount between the cost of the health basket according to the to be hoped that this attempt will succeed. cost factors of the health funds and its cost in nominal terms.

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