Risk avoidance and missed opportunities in mental health reform: the case of Israel.

Passage of the National Health Insurance Law (NHI) [National Health Insurance Law (NHI) (1994). Israel Law Code, 1469, 156 (Hebrew).] provided a window of opportunity for mental health reform in Israel. The reform called for transfer, within a period of 3 years, of responsibility for psychiatric services formerly provided mostly by the Ministry of Health, to Israel's four major healthcare providers. Planners of mental health reform in Israel saw in the NHI Law an opportunity to bring about far-reaching structural changes in mental health policy and service provision, shifting the locus of care from psychiatric hospitals to the community. This paper reports results of a case study assessing factors that hindered or promoted the planned reform. The theoretical and conceptual framework of the study was derived from public policy theories and in particular on those related to public agenda and agenda setting processes. The study was also informed by organizational and interorganizational theories and exchange theory. Data was gathered from documents and interviews of key informants. Sources of data included official reports, proceedings of Knesset's Labor and Social Affairs (LSA) Committee, Ministry of Health documents, healthcare providers' reports, budget documents, newspaper analysis, and about 60 interviews with persons who played important roles in the process of the negotiations regarding the reform efforts. Analysis identified the major stakeholders and their concerns, distinguishing between the key stakeholders involved directly in the negotiations and secondary or additional stakeholders outside the main circle, some of whom were very involved and influential in the process. The study identified the major issues and the problems that emerged during the process of negotiations. Analysis of the failure of the attempt to implement the reform reveals a combination of obstacles emanating from the process of negotiation, on the one hand, and from the larger political, economic and social context, on the other. Findings show that conflict of interests and risk avoidance of the major stakeholders were major obstacles to reaching agreement on a formula for implementation. The major risks were related to the inability to predict future demand for ambulatory services, uncertainty regarding future costs, and disagreements regarding the reliability and validity of data. Contextual factors that undermined the chances for successful implementation of the reform included lack of a strong political commitment and a coalition supporting the reform, a financial crisis in the health system resulting from early stages of implementation of the National Health Insurance Law, and social turmoil created by the Rabin government's attempts to implement the Oslo agreements. This turmoil ultimately culminated in the assassination of the Prime Minister Yitzchak Rabin, creating a climate far from conducive to generating public interest in mental health reform and facilitating the planned change. As a result the mental health system remained virtually unchanged.