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.