Mental health services in Israel at a crossroads: Promises and pitfalls of mental health services in the context of the new National Health Insurance

Pergamon

International Journal of Law and Psychiatry,Vol. lY, No. 314,pp. 327-372.1996 Copyright 0 1996 Elsevier Science Ltd Printed in the USA. All rights reserved 0160.2527196 $15.00 + .OO

PI1 SO160-2527(96)00012-X

Mental Health Services in Israel at a Crossroads: Promises and Pitfalls of Mental Health Services in the Context of the New National Health Insurance Uri Aviram*

On June 1, 1995, the reform of mental health services in Israel went into effect, and the implementation process began. It has been considered one of the major changes in the structure and delivery of services (Mark & Sham, 1995) brought about by the new legislation of the national health insurance (National Health Insurance Act, 1994). Whereas under the new legislation services for physical health care are based on what most of the population had already been getting in the past, the reform in mental health services is a dramatic departure from the past. It presents many promises and hopes. However, there are also many concerns and pitfalls in this new policy. As this article is being written, both the full implementation of the planned reform and its direction are uncertain. The objective of this article is to discuss Israel’s mental health policy and services in light of the recent mental health reform. The paper will describe and assess the system just before the new arrangements of the reform went into effect. It will attempt to provide a basis for comparisons for future evaluation of the changes that will take place in the system as a result of the reform. The paper will pay special attention to the group of mentally ill persons who must be a high priority for any mental health services, the most needy and disabled population, the severely and persistently mentally ill. Based upon interviews with mental health administrators, providers, and legislators, and reports and studies of the mental health policy and services in Israel, this article will first describe the essential elements of the mental health reform. It will be followed by an analysis of mental health services in Israel,

*Zena Harman Professor brew University of Jerusalem, This study was supported to acknowledge with thanks

of Social Work and Director, Paul Baerwald Mt. Scopus, Jerusalem, Israel.

School of Social Work,

in part by the Center for Social Policy Studies in Israel. The author research assistance provided by Anat Zeira and Hadas Rosenne. 327

The Hewould like

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ending with a discussion of current issues and continuing problems of mental health services in light of the reform, and emphasizing promises and pitfalls presented by the new policy.

The Mental Health Reform of 1995

The recent reform in mental health services is the most dramatic policy change since mental health services were established in Israel following its independence in 1948. It is related to the national health insurance legislation that went into effect in the beginning of 1995. According to this legislation, all Israeli citizens are insured and receive medical care from an insurer/provider organization, similar to the American Health Maintenance Organization (HMO) (in Hebrew, and henceforth: “Sick Fund”). Health insurance is mandatory. Israelis pay a health tax, based on their income, and are free to choose the Sick Fund from which to receive the medical services (National Health Insurance Act, 1994; Shemer & Vienonen, 1995). After some hesitations, the Israeli government decided in include mental health services in the framework of health services that people were entitled to under the new national health insurance scheme (Mark, Rabinowitz, & Feldman, 1996). Thus, the law offered mental health services, including inpatient care, ambulatory treatment as well as substance abuse treatment. It has been claimed that the basis for the reform was a state commission report about the health care system in Israel issued in 1990 (State of Israel, 1990: henceforth, Netanyahu Commission, 1990) and the State Comptroller Report of 1991 (State Comptroller, 1991). However, these reports reflect long-term criticism on the mental health service delivery system in Israel (e.g., Aviram, 1983,1991,1994; Elizur, 1994a; Ginath, 1992; Halevi, 1984; State Comptroller, 1980; Yishai, 1993). Broadly speaking, this reform has been driven by political and economic considerations, namely to transfer all direct health care provision from government agencies to nongovernment organizations so as to resolve the chronic financial crisis of the largest Sick Fund (General Sick Fund; in Hebrew: Kupat Holim Klalit), and to control the increase in the health care costs by introducing market considerations and managed-care systems into the health service arena. Mark and Shani (1995), representing the Israeli government view of the reform, describe five major features of the mental health reform: 1. Inclusion of inpatient and outpatient mental health services among the Iasic health services that must be provided by the Sick Funds under the new National Health Insurance Act. 2. Transforming all government and public mental health services to become independent economic units that must compete for Sick Fund contracts. 3. Regionalization of mental health services within regional health administrations. For each region, a Regional Psychiatrist would be appointed whose role would be to coordinate and supervise the provision of mental health services in the region. The Regional Psychiatrist would also have

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forensic responsibilities as a District Psychiatrist according to the Treatment of the Mental Patients Law of 1991. 4. Establishment of a special fund, controlled and operated by the government, to insure and finance the care of long-term psychiatric patients (in addition to patient membership in one of the four Sick Funds) for their general (physical) health care. 5. Reorganization of the government’s Mental Health Services Division in accord with the Ministry of Health changed roles within the health care system. Mental Health Services, which prior to the reform were operated and financed directly by the government’s Mental Health Services of the Ministry of Health, would divest itself of the direct operation of the mental health services, assuming a supervisory position and becoming a regulatory policy-making organization. As mentioned above in point 4, the government would maintain its direct service function to chronically mentally ill persons who had been hospitalized for more than a year just before the reform went into effect. This decision was a compromise driven by two major factors. The first was opposition from the Sick Funds concerned with the financial burden of long-term care for chronically mentally ill persons. The second reason was the government concerns for the level of care of the most disabled mentally ill population who might be affected by financial considerations of the Sick Funds attempting to reduce hospitalization costs. Another consideration for this compromise was the government employment policy that tried to avoid potential upheavals that could result from the Sick Funds transferring patients from government hospitals to less expensive arrangements. Thus, about half the funds allocated for mental health care would remain under government control in the special fund established (RUT in Hebrew, which is the acronym for welfare and hope). As one of the reasons for the reform was to control costs, a financial cap was placed by the Ministry of Finance on the total expenditures for mental health services, which was not to exceed the amount spent on mental health services (adjusted for cost-of-living increases) prior to the implementation of the reform. About half of the financial allocation was to be transferred to the Sick Funds, whereas the remaining money would be administered by the government through the RUT Fund. As one can see, the mental health reform was driven also by an attempt toward managed care. The reformers expected that the move toward marketbased services would contain costs, reduce reliance on inpatient care, increase community care programs, and, in general, improve services (Mark & Shani, 1995; Mark, Rabinowitz, & Feldman, 1995a). It must be stressed at this point that as this article is being written, at the end of 1995, there is a great deal of fluidity and uncertainty in the system regarding the implementation of this reform. Historical Overview of Mental Health Services

Assessment of any reform efforts of a service delivery system requires an understanding of the nature, structure, and dynamics of the present country’s mental health system. This cannot be done without taking into account the

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historical background of the development of this system. Like any other type of service delivery, the Israeli system reflects the political and social conditions of the country as well as the historical and cultural background of its people. The Country Israel, a small country located at the eastern end of the Mediterranean Sea, was founded in 1948 as a homeland for Jews from all parts of the world.’ Its size (21,946 square kilometers) is about the size of the state of New Jersey. Its current (1995) population is about 5.5 million people, 81% of whom are Jews and 19% are mostly Arabs. The Jews, many of whom immigrated to the country after its establishment, represent heterogeneous ethnic groups. The Jewish population is divided about equally between those who came from European countries and America (and their descendants) and those who came from Asia and Africa (and their offspring). The population is younger than that of Western European countries and the United States. Thirty percent are under age 15 and 9.5% are 65 and over. The majority of the population, about 90%, are city dwellers. Israel is a democratic republic with a parliament-cabinet form of government. By most economic and social indicators, Israel can be considered a developed or affluent country. The literacy rate is about 95%. It has a relatively high standard of living, with a per capita income level categorized as high, and similar to those in such countries as Spain, Singapore, and Ireland (per capita GDP for 1994 was about $13,500). The average annual growth of the country’s GDP since 1990 has been 6%. Israel has a mixed economy, largely based on services and manufacturing industries. Israel can also be characterized as a welfare state. It has quite an advanced system of social welfare insurance and services. The National Insurance Institute (NII) provides a broad range of benefits, including old age and survivors’ pensions, maternity benefits, family allowances, industrial injury benefits, unemployment compensation, and disability benefits. The government also offers relief grants and an array of welfare and health services. As mentioned, a national health insurance law was recently enacted and is being implemented as of 1995. However, even before this legislation was passed, 96% of the population was enrolled in one of several comprehensive health insurance plans, providing hospitalization and a wide range of other medical services. By most indicators used worldwide, Israel has a well-developed health care system. National expenditures on health in 1993 constituted 8.2% of Israel’s GDP. This proportion is higher than for countries such as Denmark, England, and Japan. Health conditions in Israel are generally good; life expectancy (79.1 years for women, and 75.3 years for men) is among the highest in the world, while infant mortality is among the lowest (7.5 deaths per 1,000 live births). The ratio of physicians to population is one of the highest in the world

‘Data for this section 1995c), Israel Government Bank of America (1990).

arc based on the following sources: Central Bureau of Statistics (1995a, 1995b, Year Book (1993). Ministry of Finance (1995), Encyclopedia Judaica (1972), and

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(1:290) and the number of specialists compare favorably with the most developed nations (Yishai, 1990). Israel has been defined as a “new society” (Elazar, 1986). Like other similar new societies such as the United States, Canada, Australia, and New Zealand, its major characteristic is that it was established by immigrants who came to new “frontier” environments where they could establish a social order with minimum obstacles of old tradition and ways of life for those who inhabited the land. The Jewish settlers established their new society alongside the several thousand Arabs who inhabited the country (Yishai, 1993). Immigration is one of the major characteristics of the country. About 50% of Israel’s population was born elsewhere. Furthermore, an overwhelming majority of those who were born in the country are only second-generation natives. About 80% of the population is either immigrants or first-generation native born. Immigration is not only a source of the strength of Israeli society but also produces many problems, economic as well as social. Mass immigration was not easy on the country. Israel’s population doubled in the first 4 years after its establishment. Recently, with the demise of the Soviet Union, about 650,000 Jews from the former Soviet republics immigrated to Israel over a S-year period. The magnitude of this immigration can be understood by the fact that this group added more than 10% to the population of Israel during that time, and between 1990 and 1994 about 60% of the population increase was due to immigration. In addition to immigration, two more factors shape the history and the nature of Israel. Both are related to the very existence of Jews and the state of Israel. The common memory of the Holocaust, and the fact that since its establishment Israel has been in a state of conflict with the Arab world, both have a major effect on the social, cultural, and political life of Israel. The constant threat to the existence of the country and its people, intensified through several wars, has taken a toll on the social and emotional outlook of the Israeli people and created an enormous economic burden. Even now, when a peace process with the Palestinians is under way, these two factors of security and Holocaust memory, along with a rift over national and religious principles, cause a great deal of stress among the Israeli population. Immigration, the Holocaust, and security concerns have created a great deal of hardship and sources of stress. These have been considered as having an effect on mental health problems of the Israeli citizenry (Miller, 1977; Yishai, 1993).

The Scope of the Problem

Data on the extent of mental health problems and needs are limited. Most of the studies were clinical or epidemiological research based on treated cases (Sanua, 1989). Epidemiological community surveys provide data of limited value for generalizations, because they are based on nonrepresentative samples of medical family practice (Aviram & Levav, 1975; Levav & Aviram, 1986; Gilboa, 1990). However, based on the fact that mental health services are well developed in Israel, as Dohrenwend and his colleagues suggested (Dohrenwend et al., 1992) it is most likely that the majority of the severely and

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persistently vices-both

mentally disordered persons would be identified mental health services and others.

by these ser-

Factors Affecting the Development of the Mental Health Service System Mental health needs, the policies that were developed, and services organized to meet these needs were affected by five major factors: 1. The pioneering ideology and the circumstances in the prestate period. 2. The mass immigration into Israel and the dramatic growth of the country’s population. 3. The nature of the different waves of immigrants and the heterogeneity of Israel’s population groups and their cultural background. 4. The strong medical model approach and orientation toward curative medicine of health care services. 5. Security problems and existential issues with which the country has been confronted. The pioneers who came since the beginning of this century to build a homeland for the Jewish people in Palestine had low tolerance for mental health problems, viewing them as emotional weakness. Immigration to prestate Israel was selective. Many of those who failed to cope with the difficulties of their new land returned to their countries of origin or went to other countries (Aviram & Shnit, 1981; Yishai, 1993). This explains why the Sick Fund (Kupat Holim Klalit, in Hebrew) of the General Federation of Labor (Histadrut, in Hebrew), which was responsible for the development of health care services in the prestate era, was at first reluctant to include mental health services in its health insurance scheme, and later was rather slow to develop them (Brill, 1974). This situation was dramatically changed during World War II and more so after the establishment of the Israeli state. The Holocaust for the Jews in Europe made Palestine, and later Israel, a place of refuge for Jews, who could not nor wished to return to their home countries. Furthermore, for those who might even have considered returning to their home countries due to difficulties of coping with the situation they were facing in their new country, the doors were tightly closed. Immediately after its independence in 1948, Holocaust survivors and Jewish refugees from Arab countries poured into Israel. In 3 years the population of the new country doubled. The state’s commitment to accept any Jewish person, including the mentally ill, who wanted to come to Israel, precluded any kind of selective immigration policy. Israel needed to find an urgent solution to the large numbers of mentally ill who were disabled, disturbed, and disrupting the social order of the newly established state. The compassion as well as the guilt the established Jewish community felt toward Holocaust survivors and the other new immigrants added another motive to find a solution. Providing an immediate shelter and care for mentally ill persons became an urgent policy matter. The process of developing a community care system seemed to be too slow. Perhaps the only possible and immediate response to the problem created by the large numbers of mentally ill who arrived with the mass immigration was the inpatient solution

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(Aviram, 1981). Deserted British Army camps as well as an old prison fatuity were found to provide a place for shelter and care for the mentally ill (Aviram , 1991; Miller, Broza, & Barzilai, 1968). The preference for institutional treatment was also influenced by the cultural gap between the established population and the newcomers. This made it difficult to develop community treatment based on individual and group understanding and support. In fact, owing to the tremendous demographic changes in the early days of statehood, in many instances “communities,” in the social sense of the word, were lacking (Aviram & Shnit, 1981; Miller, 1977). Another factor present in the prestatehood era that shaped the mental health service system for years to come was the fact that the health care system was based on a strong medical model emphasizing curative medicine. Jewish physicians who immigrated to Palestine, and later to Israel, did not bring with them a tradition of public health approach, prevention, or medicine for chronic illnesses. There are perhaps cultural and historical reasons for this situation. Public health requires a strong attachment to a country. The uncertainty of Jewish life in many nations created a preference for curative medicine and for medical specialties that were useful even if the person had to leave one physical place and move to another. The reluctance of medicine to develop programs for chronic illnesses was a reflection of the circumstances in the Jewish community in its formative years. Socially and economically, the community could not afford to care for chronic illnesses. As long as the gates of the countries of origin of the Jewish immigrants were open, sending back those who could not cope with the harsh conditions or who might have become a burden on their family or community was preferred over developing special health services for long-term care. The physicians, many of whom came from central Europe, had an orientation of a medical model based on curative medicine. Professional orientation of the first psychiatrists in the country leaned heavily toward the clinical model and the psychoanalytic school (Winnik, 1977). These enhanced the social, cultural, and economic factors, and affected the orientation of the mental health service system. Finally, the fact that ever since its establishment Israel has been faced with major security problems affected the mental health scene. Wars that Israel had to fight caused psychiatric casualties, and the stresses and tensions that Israelis were experiencing brought about other mental health problems (Yishai, 1993). Some of the mental health services were developed in direct response to this special situation. Miller (1977) claims that one of the factors responsible for the development and organization of the mental health system in the country was the military mental health services established during the war of independence. Later, the Israeli Defence Forces (IDF) established the branch of mental health services. This unit employed many psychiatrists, social workers, and psychologists and provided a variety of mental health services. It had important effects on the development of knowledge, expertise, and personnel. Concerns over security issues have affected mental health policy and services in another way. Security issues occupy a central part in Israeli life and its political system, so not much interest of energy was left to deal seriously with matters related to the mental health service system, such as comprehensiveness of mental health care, civil liberties, coverage, priorities, etc. (Aviram, 1990a).

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The Beginning of Mental Health Services The beginning of mental health services in Israel dates back more than 50 years before the state was established. The first institution designated specifically for mentally disordered patients was the Ezrat-Nashim shelter, established in Jerusalem in 1895. Medical care, when available, was provided by general practitioners. It was not until 1921 that a trained psychiatrist practiced in the country (Dagan, 1988; Hailprin, 1937). Prior to independence, mental health services were very limited. The primary facilities providing these services were mental hospitals or other forms of inpatient institutional shelters for mentally disabled individuals. At the time of independence, there were 1,200 psychiatric beds in Israel, representing a rate of 1.32 beds per 1,000 persons in the general population. Only 200 of these beds were provided by the government. About two-thirds of the psychiatric beds were provided by private, for-profit institutions. There were two government mental hospitals, which had been established by the British Mandate Administration during the prestate era, two public* mental hospitals, and two inpatient psychiatric units in general hospitals (Miller, 1977). Mental health services were far from able to respond adequately to the hundreds of thousands of immigrants-mostly Holocaust survivors and Jews fleeing from Arab countries-that poured into the newly established Israeli state. It seemed that a disproportionate number of the mentally ill were among the many immigrants who came into the country following independence (Aviram & Shnit, 1981). In addition, mental health needs among Holocaust survivors were believed to be enormous. Although the image of mental illness among the general population continued to be negative (Zohar, Floro, & Modan, 1974), similar to the one in the prestate era (Hailprin, 1937; Aviram & Shnit, 1981) attitudes regarding the mentally ill changed. Both the general public and the government were sensitive to the needs of the concentration camp survivors and felt a moral commitment to provide them with services (Ramon, 1981). Expansion

of Inpatient Service

The major efforts of the mental health services during the first decade of the new state were to provide more psychiatric beds in response to the increased demand for inpatient care. Also, the General Sick Fund changed its policy regarding mental health services and opened its second mental hospital in 1949. In one decade the number of beds increased more than 2.5 times, and the rate of beds per general population increased by 70%. In 1958 the rate of beds was 2.2 per 1,000 population (Aviram, 1991). Until 1963 the increase in the number of psychiatric beds was proportionately higher than the general increase in the population (Chesler-Gampel, 1970). This achievement is indeed impressive, especially in view of the tremendous increase of the general population of Israel during this period, and the enormous security and economic problems that the newly established country faced.

% Israel the term “public”

mental

hospital

denotes

nongovernment,

not-for-profit

mental

hospital.

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During the first half of the 1950s another process that shaped the mental health services for years to come was taking place. This was passage of the Treatment of the Mentally Sick Persons Law, which in 1955 replaced the antiquated and inadequate Ottoman law that was in effect since the nineteenth century. Although at the time mental health services in Israel already represented different types of treatment and care, the Israeli legislature chose to enact a law that related exclusively to inpatient hospitalization. The orientation of the law was based on the medical model, providing physicians with broad discretionary power regarding mental hospitalization and commitment (Aviram & Shnit, 1981; Bazak, 1972,1979; Shnit, 1982). Development

of Community

Services

During the 1960s new mental health services were added, and the system was consolidated. The major increase in ambulatory mental health services occurred during the second half of the 1960s and the beginning of the 1970s. Between 1965 and 1977 the number of outpatient service units increased by 70%. The increase during the following decade was only by 10% (Popper & Rahav, 1984a). The structure of mental health services as it exists today in Israel was mostly in place by the early 1960s. Mental health services included special psychiatric hospitals, inpatient psychiatric units in general hospitals, outpatient clinics, child guidance clinics, day hospitals, transitional facilities, institutions for longterm care, and some rehabilitation services. During the 1970s several community mental health centers were established, a few drug rehabilitation services were opened, and mental health hotlines began operating (Miller, 1977; Aviram & Shnit, 1981). The addit.ions of the 1980s were primarily in the after-care and rehabilitation services-social clubs (Moss & Davidson, 1980; Naftally, 1986) sheltered homes (Hammerman, 1984) sheltered employment (Eshet, 1995; Ministry of Finance, 1995) and other rehabilitation services (Moss & Davidson, 1984; Levy & Davidson, 1988). Inpatient services have been provided mainly by governmental hospitals or by private (for-profit) hospitals, paid for by the government. The General Sick Fund’s share in the provision of ambulatory mental health services was larger than its share in the provision of inpatient psychiatric services (Popper & Rahav, 1984a; Kupat Holim, 1980, 1983). However, while the government was hardly involved in the provision of ambulatory general medical services in the country (those services were provided mainly by the Sick Fund), a substantial proportion of ambulatory mental health services had been provided directly by the Israeli government. Reorganization

Plans and Policy Changes

During the 1970s two major policy changes were undertaken. In 1972 a plan for the reorganization of mental health services was announced by the government (Ministry of Finance, 1973). In its basic approach this “Reorganization Plan” was similar to the American model of the Community Mental Health

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Centers program. It called for the delivery of comprehensive mental health services in a geographically defined community (Tramer, 1975; Falik, 1978). Five years later a second policy change occurred. Its major objective was to implement fully the 1972 reorganization plan. According to the agreement reached in 1977, and implemented in 1978, psychiatric services provided by the government and the General Sick Fund should have been allocated on a regional basis, according to medical needs, and been free of charge. The government assumed the costs of providing mental health services to everyone without charge (Aviram & Shnit, 1981; Aviram, 1994). Following this agreement, the General Sick Fund amended its insurance coverage policy and eliminated coverage for psychiatric services for its members as of 1978 (Kupat Holim, 1986). Although there were no immediate practical consequences, this policy change represented a major retrenchment of the Sick Fund from its previously accepted responsibility toward the insured population, and it created problems that surfaced later. This act was congruent with the traditional stand of the Sick Fund that viewed mental health care as the responsibility of the state. Furthermore, the agreement between the Sick Fund and the government had little impact on the provision of mental health services because the adherence of the Sick Fund with the agreement was rather limited. Because the Sick Fund insured about 80% of the population, the leverage of the Israeli government vis-a-vis the Sick Fund was limited (Yishai, 1993). In 1989, the government (by then based on a right-wing power structure different from the one that made the agreement in 1977) changed its policy of providing psychiatric services free of charge, and attempted, with little degree of success, to collect fees for psychiatric services. Mental Health Legislation In 1991, new mental health legislation went into effect (Treatment of Mental Patients Law, 1991) reforming the 195.5mental health law. The old law was based on the medical-psychiatric model, and the “need for treatment” standard. The authority to commit individuals to, and discharge them from, mental hospitalization was considered within the domain of the medical profession. The involvement of the judiciary was minimal. The law focused on regulating hospitalization and disregarded community services (Aviram & Shnit, 1981; Shnit, 1982). Over the years this law was criticized for failing to create a balanced system of providing treatment and care for mentally ill persons, protecting public safety, and at the same time safeguarding the civil liberties of patients (Aviram, 1990a; Aviram & Shnit, 1981, 1986; State Comptroller, 1980,1988). Procedural safeguards of the law were found to be ineffective (Aviram & Shnit, 1986). From time to time this situation caused some public concern and brought about demands for reforming the law (e.g., Aviram & Shnit, 1984; Levy & Davidson, 1986; State Comptroller, 1980, 1988; Yishai, 1993). The 1991 legislation addressed some of the criticisms and changed several provisions governing mental health care and treatment in Israel. Although the new law was attempting to reach a better balance between providing care for the mentally ill and guarding their civil liberties, its basic tenets continued to

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be based on the medical model, providing physicians with broad discretionary power regarding mental hospitalization and commitment (Levy, 1992). The new mental health law included several changes. First, commitment could not take place without an examination. Although District Psychiatrists retained their authority to commit persons to mental institutions, this authority was somewhat reduced. The criterion for involuntary hospitalization was now based on dangerousness, and an indefinite period for enforced hospitalization became impossible. Also, the law included a new provision for involuntary outpatient treatment. The role of the Psychiatric Committee as a body considering appeals and reviewing first involuntary admissions was expanded. Furthermore, the law dealt directly with patients’ rights, explicitly stipulating that a patient has a right to information and should take an active part in his or her medical treatment. Finally, the law established the nomination of a head of the mental Health Services Division within the Ministry of Health (Levy, 1992; Yishai, 1993). Traditionally, Mental Health Services central administration was a separate branch of the Ministry of Health. Until 1991, its independent status was not established by law and was rather an administrative arrangement. Efforts of the Ministry of Health during the late 1980s to change this organizational structure and to incorporate Mental Health Services, including its inpatient and outpatient services, into the Hospitalization Service Branch of the Ministry of Health failed. Various mental health professionals and legislators were successful in assuring the independent status of the Mental Health Services Division by incorporating a special clause to that effect into the 1991 new mental law. According to this legislation (Sec. 22) the Minister of Health shall appoint a psychiatrist in the civil service to be head of Mental Health Services (Treatment of the Mental Patients Law, 1991). Israel Mental Health Service System

There are about 7,000 patients in the total Israeli population of about 5.5 million. They are hospitalized in 40 psychiatric inpatient facilities. About 14,500 admissions annually were reported by these facilities during 1993. Mentally ill people occupy more than one-fifth of the total number of inpatient beds in the country (Central Bureau of Statistics, 1995a; Ministry of Health, 1994a, 1994b). It has been estimated that during 1995, about 100,000 persons received ambulatory mental health care in the country (Feinson, Popper, & Handelsman, 1992; Levinson, Popper, Lerner, Feinson, & Mark, 1995). An estimated close to l,OOO,OOO psychiatric patient care contacts take place each year in about 60 outpatient mental health services (Levinson, Popper, & Handelsman, 1993; Levinson et al., 1995; Siegel et al., 1993). There are about 120 other mental health services in the community, such as day care unties, social clubs, drug treatment programs, sheltered housing, and rehabilitation services (Popper & Rahav, 1984a; Ministry of Health, 1989a, 1989b, 1994a). Mental health services are allocated a substantial part (12%) of the state’s health budget. Although mental health services have not been at the top priority list of the public agenda, these services and the condition of the mentally ill have drawn public attention. The disability and vulnerability of the mentally ill and

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the quality of services provided for them have been, from time to time, a cause for public concern (Aviram, 1991). Changing

Trends

Mental health services, especially those for the severely and chronically mentally ill, have been traditionally within the government domain. Most of them were provided directly by government hospitals and other government facilities. The majority of those provided by other institutions were financed by the government. As already noted, the major efforts of mental health services during the first 15 years of the new Israeli state, until about the mid-1960s were to increase the number of psychiatric beds and to organize the psychiatric inpatient services. During the 1960s as immigration into the country decreased and economic conditions improved, attention shifted to ambulatory services. The number of outpatient clinics almost doubled, and the number of visits in them quadrupled between the years 1965 and 1977 (Rahav & Popper, 1980). Day care programs3 unavailable until the late 1960s became available. The number of day care unit beds tripled during the 1970s and in 1985 exceeded 1,000 (Central Bureau of Statistics, 1978,1995a). Although after-care services, rehabilitation, and community-care programs for the long-term mentally ill have been recognized needs and declared objectives of the various mental health services (Tramer, 1975; Miller, 1977; Ministry of Finance, 1973,1979), not until the 1980s could one observe some action in this arena. During this period social clubs and rehabilitation services were developed, and increased attention was given to the establishment of sheltered housing for mentally ill people in the community. A noticeable decline has occurred in the numbers and rates of inpatients in mental hospitals during the last 15 years (Popper & Horowitz, 1989, 1990; Central Bureau of Statistics, 1995a). The number of patients in mental institutions in Israel continued to climb and peaked in 1978, with close to 9,000 resident patients. By the end of 1993, the number dropped by roughly 23% (6,866). The trend of decline was a modest one at the beginning of the period, accelerating to an average of 4% decline per year during the later part of the 1980s. The decline in the rates of patients per 1,000 of the population is even more impressive. The highest rate of inpatients per population was measured in the second half of the 1960s. It was 2.7 per 1,000 of the general population. After 1970 the rate started to decline. From 1970, the decline in the rates of inpatients per general population dropped by about 50%, to 1.3 per 1,000 in 1993 (Popper & Horowitz, 1989; Central Bureau of Statistics, 1995a; Ministry of Health, 1995a). The decline in the number of resident patients in institutions was for both short-stay and long-stay patients (Aviram, 1994; Popper & Horowitz, 1990). The decline in the rates of inpatients continued until 1991, and then, probably due to the higher hospitalization rates of new immigrants from the former Soviet Union, it stopped (Lerner & Popper, 1993; Popper & Horowitz, 1992; Shemesh, Horowitz, Levinson, & Popper, 1993). lThe term that is synonymously

used in Israel for a day hospital

is day care unit (used henceforth).

MENTAL HEALTH

TABLE 1 Inpatients and Day Patients in Psychiatric Care Facilities in Israel: Numbers and Rates of Resident Patients and Admissions in Selected Years, 194&19938 1948

1958

1970b

1978

1988

1993

7,036

6,866 1,906

Absolute numbers End of Year Inpatients Day patients During the year Admissions for Inpatient Care Total First admissionsC ReadmissionsC

1,197

n/a n/a n/a

4,188

4,619 2,593 2,026

8,038 303

10,577

n/a n/a

8,925 896

12,995

4,853 8,139

1.220

11,035 2,933 8,102

14,488 3,699 10,789

Rates per 1,000 population End of year Inpatients Day patients During the year Admissions Total First admissions Readmissions

1.3

2.1

2.7 0.1

2.4 0.3

1.6 0.2

1.3 0.4

n/a n/a n/a

2.3 1.3 1 .o

3.6 n/a n/a

3.5 1.3 2.2

2.5 0.7 1.8

2.8 0.7 2.1

“Data based on the Psychiatric Case Register reports, Ministry of Health (1994): Central Bureau of Statistics (1989.1995) for 1958,197O; 1988; 1993; Chesler-Gampel(l970) for 1948; Popper & Horowitz (1989) for 1978. “From 1970. numbers do not include developmentally disabled. cSome figures are based on estimates.

The decline in the number and rates of admission to mental hospitals during this period is less impressive than the data on the decline in inpatient population. The number of admissions fluctuated during the second half of the 1970s and early 1980s averaging about 13,000 annually. It started to decline after 1981, dropping by about 1.5% between 1981 and 1988; however, it increased again in the last few years and reached 14,488 admissions during 1993. Rates of admission declined by 36% between 1973 to 1988, from 3.9 to 2.5 per 1,000 of the population. After 1988 we witnessed an increase in the rates of admissions. Between 1988 to 1993 the rates of admission increased by about 15%, from 2.5 during 1988 to 2.8 per 1,000 of the population during 1993. The increase in admissions is due to an increase in readmission. The rate of new admissions, which dropped by about 45% between 1978 to 1988, remained stable between 1988 and 1993. However, the rate of readmissions increased from 1.8 per 1,000 of the general population in 1988 to 2.1 in 1993 (Popper & Horowitz, 1989; Lerner & Popper, 1993; Table 1). The decline in inpatient hospitalizations is indeed impressive. Although the rate of decline is not so high as in the United States, it is similar to the rates in other countries (Goldman, 1983) such as Britain, where deinstitutionalization trends were present during the last 25 years (Brown, 1985). In assessing this trend, Popper and Horowitz (1989, 1990) attributed the changes to a conflu-

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Psychiatric

TABLE 2 Inpatient Facilities by Type and Ownership,

Special psychiatric hospitals Governmentb Private (for private) General Sick FundC Other not-for-profit Psychiatric units in general hospitals Government General Sick Fund Other not-for-profit Total

in Selected Years, 1975-1993a

1975

1980

1987

1993

12 22 3 3

15 21 3 3

12 12 3 2

14 9 3 2

3 1 1 45

4 1

5 3 1 38

7 4

1 48

1 40

aSource: Popper & Horowitz (1989); Ministry of Health (1989a, 1994). %cludes a forensic unit in a prison. ‘Kupat Holim Klalit (in Hebrew).

ence of factors-demographic, social, as well as clinical-and they pointed out the increase in the number of patients in day care units and the development of alternative-care facilities in the community during the same period. The increase in admissions in the last several years has been attributed mainly to higher rates of admission of new immigrants from the former Soviet Union (Popper & Horowitz, 1992; Shemesh et al., 1993). Statistics on mental hospitalization show an impressive increase in the number of day hospital patients. The number, which was a minute 300 in 1970, increased to nearly 2,000 in 1993. Whereas in 1970, day care beds were less than 4% of the total number of psychiatric beds (inpatient as well as day hospital beds) in the country, in 1993 they surpassed 20% of the total number of beds. As we will discuss later, similar growth took place in outpatient-care services. Also, as already mentioned, during the last decade the number of rehabilitation services, social clubs, community residences, and sheltered workshops increased. The following sections describe in more detail the mental health service delivery system. It starts with a description of inpatient services and moves on to discuss community services, both ambulatory and rehabilitation services. This section will also include some details about the financing of the system and personnel, and will conclude with a discussion of the Israeli mental health law. Institutional

Care

Psychiatric institutional treatment and care are mainly provided by two types of facilities: special psychiatric hospitals and psychiatric inpatient units in general hospitals. Considerable variability exists within these facilities by the type of care, patient characteristics, costs, staff, ownership, and level of care. At the end of 1993, there were 40 psychiatric inpatient facilities in the country (Table 2). Half of the beds were in special government psychiatric hospitals. The second largest providers were private (for profit) psychiatric facilities. About 40% of the beds were in these hospitals (Table 3). As the Israeli

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TABLE 3 Number and Proportion

Special psychiatric facilities Government Number %b Private Number % General Sick Fund Number % Other not-for-profit Number % General hospitals Psychiatric unitsC Number % Total Number %

of Psychiatric Beds in Israel by Type and Ownership, Selected Years 1975-l 9938

1975

1977

1983

1987

1993

3,593 44.1

3,796 42.9

3,881 46.5

3,513 47.2

3,569 50.5

3,644 44.7

4,094 46.3

3,571 42.8

3,080 41.4

2,721 38.5

498 6.1

516 5.8

481 5.8

451 6.1

424 5.9

250 3.0

248 2.6

192 2.3

143 1.9

125 1.8

168 2.1

210 2.4

221 2.6

257 3.4

234 3.3

8,153 100.0

8,846 100.0

8,346 100.0

7,444 100.0

7,073 100.0

“Source: Popper & Horowitz (1989); Ministry of Health (1994b). bPercentages are for columns. ‘Includes units in governmental. General Sick Fund, and other public. not-for-profit

hospitals.

government pays for most of the patients in private hospitals (as well as regulates these hospitals) (Halevi, 1984; Ministry of Finance, 1989), one could say that about 90% of the psychiatric beds in the country are government beds. During the last 15 years, in spite of a substantial increase in the general population of the country, the number of inpatient psychiatric facilities, as well as the number of psychiatric beds, declined. Between 1980 and 1993 the number of facilities decreased by about 20%, from 48 in 1980 to 40 in 1993. The major decline occurred in the number of private hospitals. Of the 21 facilities in 1980, more than half were closed by 1993 (Table 2). The total number of beds in private psychiatric hospitals diminished during this period by about a third. This figure accounts for about 75% of the total decline in the number of psychiatric beds in the country. At the end of 1993, there were 7,073 psychiatric inpatient beds in Israel (Table 3; Central Bureau of Statistics, 1995a). The public (other than government) sector provides about 8% of the beds in special psychiatric facilities (Table 3). These beds are provided by not-for-profit organizations, of which the largest is the General Sick Fund. Considering that this health organization covers about 70% of the population and provides 31% of general hospital beds in Israel, both the number and the proportion of psychiatric beds provided by the Sick Fund (6%) are relatively small (Ministry

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of Finance, 1995). Also, the proportion of 3.3% of psychiatric beds provided by psychiatric departments of general hospitals is small. Contrary to trends in other Western nations (Siegel et al., 1993) this sector has not grown over the past 15 year (Tables 2 and 3). On the eve of the reform, the distribution of psychiatric beds by function and type of recipients in the country shows that close to one-half (43%) were for long-term care, about one-fourth (24%) for acute treatment, 14% for psychogeriatric, 9% were for rehabilitation, 5% were for children and adolescents, 3% were in psychiatric wards of general hospitals, and 1% were for emergency and intensive care (Mark, Rabinowitz, Feldman, Gilboa, & Shemer, 1995b; Ministry of Finance, 1995). Psychiatric beds are not distributed equally throughout the country. Central regions have disproportionately many more beds than do the northern and southern extremes of the country (Levinson, et al., 1993; Mark et al., 1995). This center/periphery imbalance of psychiatric bed distribution has been a subject for public concern (State Comptroller, 1991; State of Israel, 1990). Acute and Long- Term Care Facilities Almost 75% of the patients in mental hospitals in Israel in 1990 were in long-term care (defined as being in inpatient care over 1 year). On February 1, 1995, the total number of these patients reached 4,800 (Aridor, 1995; Siegel, 1995). Occupancy rate in mental hospitals was in 89% in 1994 (Ministry of Finance, 1995). It was highest (about 100%) during the 1960s and 1970s. Average hospitalization days for those discharged from inpatient facilities have been declining since 1980. In 1994 it was 134 days (Ministry of Finance, 1995). This decline was especially significant for those staying less than a year. In 1990 it was 54 days (Lerner & Popper, 1993; Ministry of Finance, 1995). Psychiatric units in general hospitals and in Sick Fund hospitals provide mostly acute psychiatric inpatient services. About 40% of the admissions to inpatient psychiatric services in Israel during 1988 occurred in these facilities, which comprise only about 10% of the psychiatric beds in the country (Popper & Horowitz, 1990). Only 4% of inpatient care occurs in general hospitals. This proportion is lower than in other countries (Siegel et al., 1993). Private psychiatric hospitals mainly provide long-term care (Popper & Horowitz, 1989). Although 38.5% of the psychiatric beds in the country are in these hospitals, their proportionate share of the total yearly psychiatric admissions in the country was only 1.4% in 1993. A recent Ministry of Health Policy decision discouraged new admission to private hospitals. Ninety-six percent of patients in these hospitals were hospitalized for periods longer than a year (Lerner & Popper, 1993). These institutions are similar to nursing homes. They provide shelter and maintenance, with relatively little medical, social, or rehabilitative services. Staffing ratio per patient and cost of care are much lower than in other hospitals. The government sets up the fee schedules (which varies according to the type of population cared for) and regulates these institutions (Halevi, 1984). The average cost per day in these hospitals in 1992 (about $40) was only 45% of the average cost for the government and Sick Fund hospitals. The quality of care in some of these institutions caused,

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from time to time, public concern, and it has been considered by some to be a disgrace (Neumann, 1982).

Admissions

and Resident Patients

As already mentioned, the rate of admission per 1,000 population for 1993 was 2.8 (Table 1; Central Bureau of Statistics, 1995a). If one adds admissions to day care units the rate in 1994 was 3.2 per 1,000 of the general population (Central Bureau of Statistics, 1995a). The modest increase in admissions in recent years was attributed to higher rates of admission of immigrants from the former Soviet Union (Lerner & Popper, 1993; Popper & Horowitz, 1992). The majority of the admissions (74.5%) were readmissions. About 55% of all admissions were male, and about one-quarter of all admissions were between the ages of 18 and 24 (Ministry of Health, 1995). Admission data by age groups and type of hospital reveal other interesting distinctions. Almost 60% of all admissions to private hospitals are for the 65 + age group, compared to 9.5% of this group for the entire country. These hospitals also differ from others in the diagnostic categories of their admissions. Fifty-eight percent of first admissions to private hospitals in 1988 were diagnosed as organic conditions, compared to 9.2% of this diagnostic category for all psychiatric admissions. These two figures further emphasize the fact that the private hospitals are mainly geared to the care of chronic, long-term patients (Popper & Horowitz, 1989; Ministry of Health, 1989~; Lerner & Popper, 1993). The number of admissions during a year per bed increased by 25% between 1988 and 1993 (2.34) (Popper & Horowitz, 1989; Ministry of Health, 1994b). This change reflects a decline in the number of beds, an increase in the number of admissions, and shorter hospitalization stays. As already noted, both the number and the rate of inpatients have dropped considerably during the last 15 years. In 1994, the rate of inpatients per 1,000 population was 1.3. The aged (65+) constitute almost one-fourth (22.3%) of the inpatient population, compared to 9.5% of this age group in the general population. Another 35% are those between the ages of 45 and 64. The total number of hospitalization days during 1994 was about 2.3 million days (Central Bureau of Statistics, 1995a; Ministry of Finance, 1995). Mental Commitments The majority of admissions to Israeli mental hospitals are voluntary (82%). About 14% are admitted as civil commitments, and 4% are committed under the criminal code. Civil commitment is defined by Israeli Law within the realm of medicine, authorizing specially appointed District Psychiatrists to issue commitment orders. Individuals can be admitted involuntarily in emergencies without a commitment order. However, they must be released within 48 hours unless a commitment order is issued (Treatment of Mental Patients Law, 1991; Levy, 1992). About 70% of all civil commitments were admitted with a commitment order issued by a District Psychiatrist, whereas the remainder were

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admitted involuntarily as emergencies by a director of inpatient facility. About 75% of those committed by the court were admitted for observation (Ministry of Finance, 1995). Based on earlier data, the proportion of involuntary hospitalization may actually be higher, at about 24% of all admissions (Aviram & Shnit, 1984). This proportion is more compatible with other countries (National Institute of Mental Health, 1987). These earlier data were collected prior to the enactment of the new mental health law in 1991 and may indeed reflect an actual decline in the number and proportion of involuntary hospitalizations. The size of the difference in the decline might also be a result of reporting practices or to the level of the reliability of data collected at either one of the two periods. Diagnostic Categories and Chronicity Schizophrenia is the major diagnostic category of persons admitted to institutions in Israel; 55% were so classified. Affective disorders are the second largest category, constituting 14% of all admissions. The proportion of this category among women is twice as high as for males (19.2% and 9.5%, respectively) (Ministry of Health, 1989~). Only 2.6% of the resident patients did not have any of the psychotic diagnoses (Siegel et al., 1993). In a recent study based on a random sample of all patients first admitted to psychiatric hospitals in Israel over the last decade, Rabinowitz et al. (1994) reported that about 27% of first admissions to mental hospital were diagnosed with schizophrenia, and 14% with affective disorders. About 14% were diagnosed as having a paranoid state or other nonorganic diagnosis. Organic condition consisted about 5% of the admissions, and 18% were diagnosed neurotic or personality disorder. There is no accurate information regarding the proportion of chronically mentally ill persons in the country. Chronicity is a matter of definition, and it varies according to theoretical approach and interpretation of findings (Lerner & Popper, 1993; Shinaar, Rothbard, Kanter, & Yung, 1990). A recent study estimated that the total number of chronically mentally ill persons (ages 18-64) in Israel is between 30,000 and 35,000 or about 1% of total population of the same age group (Aviram, Lerner, Popper, & Zilber, in press). In that study, chronically mentally ill were defined by two major criteria: hospitalization history and functional disability. A person who met any one of these two criteria was defined as chronically mentally ill. About a third met both criteria. About two-thirds had a chronic hospitalization history and 85% were hospitalized in a mental institution at least once in their lifetime. About 60% of the group had functional disability defined by being a recipient of a permanent disability insurance from the NII. Only about 2% of those defined as chronically mentally ill did not meet any of the two major criteria but had continued ambulatory care for mental illness. About 40% of the chronically mentally ill were hospitalized for all or part of the year. The study estimated that on any one day during the year about 70% of the chronically mentally ill were in the community. this finding emphasizes the importance of providing community-care programs for this rather disabled population group. Data on the length of stay of patients in mental hospitals reveal that about 75% are hospitalized for more than a year (Lerner & Popper, 1993, Ministry

of Health, 1994b, 1995). About 50% of all patients were hospitalized for 5 years or longer (Ministry of Finance, 1995). Long-stay patients (over 1 year) use 65% of the total hospitalization days in mental institutions in the country during a given year (1993) (Ministry of Health, personal communication, 1995).

Length of Hospitalization The rate of hospitalization days per 1,000 of the general population has been steadily declining since 1970. Between 1970 and 1994 it declined by 54%, from 915 to 424 days in 1994. The average duration of stay for those discharged from psychiatric inpatient facilities has also been declining, dropping from 155 days in 1970 to 135 days in 1993 (Central Bureau of Statistics, 1995a). In recent years, in an effort to reduce the reliance of the system on inpatient care and to discharge persons from inpatient care into the community, the Mental Health Services Division undertook ambitious projects of introducing the use of clozapine in treating inpatients in mental hospitals. In addition, the service started a large-scale reassessment project of long-term-stay patients. The objective of the project is to review the status of each patient and assess whether he or she might be ready for discharge (Mark, 1995; Mark et al. 1995a). At the time of the writing of this paper, no evaluation of outcome was available.

Mental Health Services in the Commumnity

The decline in the number and rates of mental hospitalization in Israel during the last decade has been attributed by some to the development of mental health services in the community (Lerner & Popper, 1993; Popper & Rahav, 1984a, 1984b; Popper & Horowitz, 1989,199O). Indeed, the addition of outpatient clinics, day care units, community mental health centers, and some after-care and rehabilitation services has changed the nature of mental health services in Israel. However, there is a need for studies assessing the direct influence of the community mental health services on the reduction of the resident population in inpatient care, and the exact contribution of the development of mental health services in the community to mental health services in general. It has been pointed out, however, that the development of community mental health services has fallen much shorter than needed, desirable, and possible. These are the views of the state Comptroller Report (1991), the Netanyahu Commission (State of Israel, 1990) as well as the opinion expressed by the head of the Mental Health Service, saying that according to the estimates made by the service, between a quarter and one-third of those who are inpatients in mental hospitals could be discharged to a less restrictive environment (Mark, 1995). By his own claim, too little (16%) of the mental health budget has been allocated to community services (Mark et al., 1995b). According to Siegel and colleagues (1993) 68% of the mental health care contacts delivered in the week of the survey were in community facilities. Because the survey was restricted to mental health facilities and because many patients receive care from other social and rehabilitation services such as the

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TABLE 4 Outpatient and Other Communtiy Mental Health Facilities by Type and Affiliation, 19938 Government

Day care units, total At inpatient psychiatric facility In the community Ambulatory units, total At inpatient psychiatric facility In the communityd Follow-up outpatient unit (at psychiatric facility) Occupational rehabilitations units, total At inpatient psychiatric facility In the communtiy Drug treatment and consultation, total Outpatients Day treatment Social clubs, total Hot line, total Sheltered residential programs in the community,f total Total

21 16 5 53b(2) 15 34

Sick Fund

Public (other)

10 5 5 25c(3) 8

3 3

15

18

1 17

Total 34 24 10 98 24 66

4

2

6

14

2

18

6 8 8 6 2

2

8 8 14

8

1 1

5 4e 1 43 119

3 43 11

4

12

11

226

aSources: Ministry of Health 1989a, 1994a; Figures do not include consultation services for students at institutions for higher education. bIncluding clinic branches. ‘In addition, Two clinic branches. dMost units are administratively connected to psychiatric inpatient facilities. ‘Consultation services “al-Sam.” ‘Total for 1989, 177 residences; 285 residents. From: Report of the Committee on Sheltered Residence for Mentally Ill (1989); Hammerman (1984). Information for 1993 was not available. Qrcluding three hot lines for Russian-speaking persons.

National Insurance Institute local social service departments, as well as from private mental health practitioners, one may conclude that the number of care contacts of mental patients is substantially larger. Although a more recent survey on outpatient services was conducted in 1994, no reliable data were available at the time of this writing. The bulk of the nonresidential community services was provided by outpatient clinics, which represented 80.8% of the patient’s care contacts during the week of the survey. Day care units provided 9.6% and social clubs 4.5%. The proportion of mental health consultation was 5.2% of patient-care contacts. About half of the patients receiving care in community facilities had psychotic diagnoses, major affective or organic diagnoses, or were recipients of disability insurance. Collectively, they were considered as a dependent group of patients. The other were rated as less dependent (Siegel et al., 1993). Psychiatric consultation was provided during 1994 in 17 of the 21 general hospitals in the country. These services were also available for emergencies.

MENTAL HEALTH SERVICES

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Day Care Units

There were 1,906 patients receiving treatment in 34 day care units at the end of 1993. These units were budgeted by the number of approved beds. The total number of beds amounted to 1,218. Seventy percent of the day care units and about 80% of the day care beds were either in, or administered by, inpatient facilities. About 75% of the day care beds were in governmental facilities (Table 4; Ministry of Health, 1995). The number of day care beds has steadily been increasing since 1970. In the 10 years since 1983, the number increased by 25%, from 975 in 1983 to 1,218 in 1993 (Ministry of Health, 1994b). Day care is mainly provided by the government and the Sick Fund facilities. The proportion of day patients per inpatients was higher in the Sick Fund facilities than in the government ones (1 day care bed for 1.5 inpatient beds in the Sick Fund compared to 1 day care bed per 4.2 inpatient beds in governmental facilities, in 1993). The 1986 survey revealed that 80% of the day patients were adults, 11% were aged, 6% were adolescents, and 3% children (Ministry of Finance, 1989). There has been an impressive change in the proportion of day care patients compared with the total number of inpatients, form 10% in 1980 to 27% in 1993. This change is a result of both a decline in the number of inpatients and an increase in the number of day care patients during this period. However, one should see that while the rate of inpatients per the general population declined from 2.2 per 1,000 persons in 1980 to 1.3 in 1993, the changes in the rates of day care patients were much smaller, from 0.3 per 1,000 in the general population to 0.4 during the respective period. Outpatient Mental Health Services

As already mentioned, during the past several years there has been a noticeable increase in the number of outpatient mental health services. It has been estimated that about 100,000 individuals or 19 out of 1,000 people in the population, received ambulatory care during 1995. Of those, 45% were new admissions (Levinson et al., 1995). The total number of outpatient clinics (including clinic branches) increased by almost 50%, from 62 in 1988 to 90 in 1993 (Table 4; Aviram, 1994). Approximately two-thirds of these facilities are located in the community, while the rest are in, or attached to, inpatient facilities. The growth in this sector could reflect in part the realignment of the system in anticipation of the national health insurance legislation. Until recently, before the reform, outpatient services were provided free of charge. A new policy instituted a small fee for service. Decisions regarding the treatment and its duration are within the discretion of each clinic (Ministry of Health, 1984). Information regarding the number and characteristics of patients receiving outpatient mental health services is less comprehensive than about inpatients. Data on outpatient care is primarily based on the 1986 survey of psychiatriccare utilization in the public sector (Siegel et al., 1993; Feinson et al., 1992; Levinson et al., 1993,1995). No data are available on the use of private outpatient mental health services. The 1986 survey data provided indications of de-

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mands for and patterns of use of outpatient clinics before the reform went into affect. It is important probably because it reflects accurately the true demands for services and professional and administrative decisions regarding outpatient care, when this type of care was free of charge and before insurers and providers imposed controls because of financial and administrative considerations due to the mental health reform. The number of contacts in outpatient services increased from 144,000 during 1965 to 555,300 contacts during 1977 (Ministry of Health, 1984) and was estimated to reach between 700,000 to 800,000 in 1986 (Ministry of Health, 1990; Levinson et al., 1995). Based on the 1986 survey, Levinson and colleagues (Levinson et al., 1995) assessed patterns of use of outpatient mental health services for adults (18+) in the country. They reported that the majority (55%) were in the 25 to 44 age group. The elderly (65-t) were only 8% of the population receiving services. Forty-nine percent of recipients were married. Thirty-one percent were not employed. About half completed at least 12 years of education; three-quarters lived with family members; and about a quarter of the total clinic population received disability insurance. Some 70% of the new admissions terminate their contact with the clinic after an average of 6 to 8 visits. The population receiving care in outpatient clinics was about equally divided between those with psychotic and affective disorders, and those diagnosed with neurotic and personality disorders. The types of services differ between the two groups. About 50% of the contacts of the psychotic and affective group are for medicine follow-up. In comparison, only 10% of the contacts of the second group are for medication follow-up. About three-quarters of the contacts of this group are defined as individual, family, or group therapy. About a third of the outpatient population were self-referrals, 23% were referred by a mental health service, and 31% by general health services. Onethird of the population had a history of inpatient psychiatric care. Also, about one-third had previous ambulatory mental health service. Most of the services for the group of those diagnosed with psychotic and affective disorders were provided by psychiatrists and nurses, whereas services for the second group were provided mainly by psychiatrists, psychologists, and social workers (Levinson et al., 1995). A study of mental health outpatient services in Jerusalem illuminates additional characteristics of outpatients and types of services provided for them. About 40% of all patients who had attended the adult outpatient clinics in Jerusalem during a j-week period in 1986 were in regular contact with the clinics for at least 1 year. More than 90% of those diagnosed with major psychiatric disorders received psychotropic medication. The modalities of treatment for the majority of these patients were nonpsychodynamic. About 75% of them received treatment such as medication follow-up, supportive treatment, social clubs, etc. (Lerner, Wittman, Zilber, & Barash, 1991). Community mental health centers (CMHC) were one of the central components of the 1972 Reorganization Plan of the Israeli Mental Health Services (Tramer, 1975). The first CMHCs, which were intended to serve as models for the rest of the country, were established in two cities, Ashkelon and Jaffa. Al-

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though other mental health outpatient clinics bear the title of CMHC or provide some of the services envisioned by the Reorganization Plan, the concepts of the CMHC program are far from being implemented in full. As already mentioned, the 1978 agreement between governmental Mental Health Services Division and the General Sick Fund was reached to enhance the community mental health plan in order to assure delivery of comprehensive mental health services on a regional basis throughout the country. However, so far no systematic assessment of the changes and their effect as been done. There is no study reporting effectiveness and efficiency of outpatient services. The decision as to who gets outpatient service, what type of service, and how long the service is provided is left to a great extent to the discretion of the professionals. It is not known, for example, what proportion of the recipients are severely disabled and what proportion of resources each type of recipient uses compared to the total resources allocated to outpatient clinics. It could very well be that the increase in the number of contacts in outpatient services reflects services delivered to a new identified clientele rather than an increase in services to former clients or to those recently discharged from mental hospitals. Emergency

Mental Health Services

Emergency mental health services on a 24-hours-a-day, 7-days-a-week basis are provided mainly by inpatient mental health facilities and by emergency rooms of general hospitals. Several years ago, the General Sick Fund psychiatric hospitals and some of the government hospitals developed special admission units with emergency holding facilities that proved intensive care on a short-term basis. In addition, an emotional first aid hotline service is provided by Eran, a public (not-for-profit) organization, in 11 locations in the country. Some outpatient community mental health services provide emergency services; however, these are limited to regular working hours. There is rather limited information on these types of services. Many mental health emergencies are first seen in the emergency rooms of general hospitals. Eighty percent of mental health visits in emergency departments end up in hospitalization (Rabinowitz, Mark, & Slyuzberg, 1995), a much higher rate than the 30% to 40% in other countries (Friedman et al., 1981; Way, Evans, & Banks, 1992). Another study of psychiatric referrals to a general hospital emergency room revealed that about two-thirds of the referrals were unjustified. The study suggested that a combination of (a) poor understanding by general practitioners or family doctors on what constitutes a mental health emergency situation, (b) efforts by these physicians to bypass clinic waiting lists, and (c) lack of alternative community facilities might have accounted for the finding (Vigiser, Apter, Aviram, & Maoz, 1984). Rehabilitation Services

Increased interest of policymakers and some program administrators in mental health rehabilitation during the last decade resulted in several new policies and programs. However, the scope of these services and the budgetary allocations for mental health rehabilitation services fall short of the needs. Re-

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habilitation has yet to assume its appropriate place on the mental health services priority list of policymakers in Israel (Levy & Davidson, 1988). Prior to the last decade the few rehabilitation programs were more or less a result of individual or local interest (e.g., Spivak, 1977) and not an outcome of a concerted policy effort. Policies and programs in the area of psychiatric rehabilitation are within the domain of three governmental agencies: 1. Rehabilitation Services of the Ministry of Labor and Social Affairs 2. National Insurance Institute 3. Mental Health Services of the Ministry of Health. Former mental patients are considered within the target population of the Rehabilitation Services of the Ministry of Labor and Social Affairs. However, the number of ex-mental patients among the clients of the rehabilitation centers administered by the Ministry of Labor and Social Affairs throughout the country is rather small. Two factors may account for this situation: scarce resources and concerns about the potential negative effect of mentally ill clients on the programs and their public image. In view of the scarce resources and, perhaps, other policy considerations, no specific programs were developed by the Ministry of Social Welfare (later incorporated into the Ministry of Labor and Social Affairs) for people with psychiatric disability, and present facilities are limited in their ability to cater to the special needs of this population group. Also, program administrators and counsellors prefer investing their efforts in individuals whom they consider as having better chances for success (Aviram, 1990b). The stigma attached to mental illness is another consideration. Concern has been voiced that inclusion of large numbers of mentally disabled people among the clients of the rehabilitation centers might drive away nonmentally ill disabled persons. As a result of the General Disability Law of 1973 (National Insurance Law, 1973 [Henceforth, the Disability Law]), the National Insurance Institute (NII) assumed a central role in rehabiiitation programs for the mentally ill. This agency administers disability benefit programs, including income maintenance payments, and rehabilitation services. Any person who becomes eligible for disability benefits is also eligible for rehabilitation services. Although one of the criteria for the benefits is a minimum of 40% medical impairment, those with 20% or more medical impairment were eligible for rehabilitation services. Services of the NII Rehabilitation Department can include special training, placement services, and payment of salary of the disabled employee for a limited time so as to provide an adjustment period for employment, and also offer incentives to employers to hire disabled persons. The NII did not develop special rehabilitation services for psychiatrically disabled persons and instead focused on the occupational aspect of rehabilitation. The Ministry of Defence provides similar rehabilitation services for disabled veterans. In addition, the Fund for the Development of Services for the Disabled, established by the NII in 1976, has been providing grant supports for the development of new rehabilitation programs in the community. This fund has supported quite a few innovative programs and has become an important factor in the development of mental health rehabilitation programs in the community

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during the last decade. Also, The Trust Fund for the Development of Psychiatric Services in Israel had devoted in recent years a portion of its budget for the development of rehabilitation programs. An indication of the increased interest of the Mental Health Services in rehabilitation services is the fact that since 1978, 10% of the disability benefits that the mental hospital receives for its patients from the NII is allocated for rehabilitation services. Most of these funds support rehabilitation services provided within hospitals or administered by the hospitals. Additional efforts of the Ministry of Health in 1985 resulted in the establishment of Eshet, a nonprofit organization for occupational rehabilitation of mentally ill people, which supports the development of sheltered workshops for former mental patients in the community. Psychiatric rehabilitation services focus on the development of skills in three areas needed for successful community living-employment, social life, and housing. In the following sections, each of the services in these areas will be discussed more specifically. Occupational Rehabilitation. Occupational rehabilitation services have been considered relatively better developed than the other types of rehabilitation services (Levy & Davidson, 1988). There are two types of psychiatric rehabilitation services: 1. Transitional occupational 2. Sheltered workshops.

rehabilitation

and training agencies.

While the first type emphasizes the education and training aspect of rehabilitation and integrates their programs with treatment services, the second type focuses on the provision of a stable and sheltered workplace for disabled mentally ill people. Occupational rehabilitation has been provided by different organizations and at different levels of occupational training. The least demanding facilities in which occupational rehabilitation has been provided are the psychosocial clubs of Enosh, the day care rehabilitation services provided within outpatient clinics, and day care facilities. In the sheltered workshops, the world of labor is emphasized in a higher degree than in the former type of facility. Occupational rehabilitation is most intensive in those special facilities that prepare the person for a competitive job outside the mental health system (Levinson, 1995). There are no studies reporting the nature of these services, or the characteristics of the persons involved in these programs nor do we know the level of their success. Currently, there are close to 2,000 individuals in the sheltered workshop system across the country (Ministry of Finance, 1995). In 1993 there were 16 transitional rehabilitation services in Israel, providing services for more than 600 people. Eight of these were provided in the community, whereas the other eight were part of hospitals (Table 4; Ministry of Health, 1994a). The first and most developed one was established in 1974 at the CMHC in Jaffa, and it has been serving as a model for other services. The involvement of the General Sick Fund in rehabilitation services is much more limited than the government’s one, and the services are partial.

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About 50 individuals received occupational rehabilitation in the Sick Fund facilities. In addition, several sheltered workshops have been developed during the last several years as a result of special efforts of the government’s Mental Health Services, in cooperation with the NII and the Ministry of Labor and Social Affairs. These efforts led in 1985 to the establishment of Eshet. Currently, there are nine such workshops in nine cities across the country. At the end of 1994, some 520 mentally ill persons were employed in these workshops, compared to only 230 in 1989. The sheltered workshop activities grew during the last 4 years by an average of 20% annually. In 1994, the number of clients of these workshops reached 520 (Eshet, 1995). In addition, there are some mentally ill persons among the 15 general sheltered workshops operated in Israel by Hameshakem, a nonprofit public rehabilitation agency.

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creased government control over the services (Nachmias, personal communication, May 9,1995). Sheltered Residences. Although early efforts in the development of sheltered care residences in the community started in Israel about 35 years ago, major efforts in this area occurred during the late 1970s and 1980s (Hammerman, 1984; Levy & Davidson, 1988). The majority of the first sheltered residences were developed by individual mental hospitals, and administration and services for these residences have been provided by the mental hospitals. This early development was not related to central policy efforts. Community mental health services were hardly involved in the development of these residences. Only in recent years have concerted central policy efforts been undertaken by the office of Mental Health Services. Also, Enosh has been devoting some effort of late in the development of sheltered residences (Ministry of Health, 1989b). A more recent estimate indicated that in 1994 there were about 1,350 individuals in sheltered residences (Ministry of Finance, 1995). Sources of financial support for these facilities vary greatly. Some are budgeted in total by mental hospitals; others are supported by public, nonprofit, and voluntary organizations; whereas still others are paid for in full or in part by the residents. Disabled and dependent people are entitled to up to 95% of their rent (up to a certain level). Rental payments are provided to eligible individuals by the Ministry of Housing. In view of this fact, it is rather surprising that the number of mentally ill patients in sheltered facilities is not larger. residents in some of the facilities that have been operated by hospitals continue to receive other services from the hospitals. Hospitals get 50% of the disability NII benefits for those residents living in sheltered residences under the direct supervision of the hospital. Substance Abuse Pmgrums. Substance abuse is considered in Israel as a social problem and not as a specific medical or mental health problem. It is not defined exclusively within the domain of any specific profession or field of service. Services for alcohol and drug abuse are provided by different social agencies such as social welfare, health, law enforcement, and education. In order to coordinate and direct the national efforts to deal with the problems of substance abuse, Israel, in 1988, established a national statutory authority, the Anti-Drug Authority of Israel. Although the problem exists on a much smaller scale than in the United States or other Western countries, substance abuse has attracted wide public attention and has been placed on the political agenda because of the consequences that drug abuse would have on Israel’s security and defense posture (Yishai, 1993). Until the 1960s substance abuse was limited to small marginal groups and was considered a problem of the individual and his or her family. After the SixDay War, along with changes that took place in the Israeli society, drug abuse began to be considered as a social problem (Tiechman & Rahav, 1995). In contrast to relatively lower rates of drug and alcohol abuse among the general population in Israel, epidemiological surveys show that in recent years there had been an increase of substance abuse among specific groups such as prisoners, juvenile delinquents in institutions, and disengaged youth, and among the non-Jewish population (Bar & Eldar, 1987; Barnea, 1995; Barnea,

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Teichman, Rahav, Gil, & Rosenbloom, 1990; S. Levy, 1982,1993; Rahav, Teichman, Gil, Rosenbloom, & Bar-Hamburger, 1993; Teichman & Rahav, 1995). It is beyond the scope of this paper to analyze in great detail the problem of substance abuse in Israel. Assessments of law enforcement agencies, treatment, care agents, and researchers indicate several current trends. There is an increase in the use of substance abuse in the country, especially hard drugs (Peled, 1989). Also, it has been estimated that the rate of alcohol abuse among new immigrants from the former Soviet Union is much higher than that of the general Israeli population (Barnea, 1995). Finally, the most affected groups are those who belong to lower socioeconomic strata of society, broken families, and in those families or communities where drug abuse is normative behavior (Ben Yehudah, 1989). During the last 7 years since the establishment of the Anti-Drug Authority of Israel, a great deal of progress has been achieved in the number and types of services available for the treatment of drug abuse problems. These facilities include both institutional care and community treatment and prevention programs. In a directory listing substance abuse facilities in 1994, one can find 24 different facilities, including inpatient, outpatient, day care, methadone clinics, treatment communities, and detoxification units (Ministry of Health, 1994a; Anti-Drug Authority of Israel, 1995).

Mental Health Service Expenditures, Expenditures

Budgets, and Personnel

for Mental Health Services

Proportionately, Israel has been spending much less on mental health than on other medical services. While the number of general medical beds in the country was 1.8 times higher in 1993 than the number of psychiatric beds, the proportion of the national expenditures on general medical hospitalization was almost 10 times higher than for psychiatric hospitalization (30.3% and 3.4%, respectively). Figures regarding average cost per hospital day reveal similar gaps. Costs for a psychiatric day of hospitalization have varied between one-fourth and one-fifth of that in a general medical bed (Halevi, 1984). Using an index of 100.0, representing the average current cost per day for all hospitals, the average cost per day in a mental hospital for 1994 was 38.8 compared to 174.0 for that in a general hospital (Central Bureau of Statistics, 1995a). Mental health services were allocated 11.5% of the total budget of the Ministry of Health for 1993 (Table 5). This amount was the equivalent of about $135 million (Ministry of Finance, 1994). There are no comparative figures for the budgets for mental health services provided by other sectors. Based on the fact that government expenditures for hospitalization in government hospitals and private hospitals are about 80% of all national expenditures on mental hospitalizations, a rough estimate for total expenditures for mental hospitalization would put the yearly figure at about $170 million. Analysis of the budgets of the Ministry of Health shows that during the last 15 years (1979-1994) the proportion allocated for mental health services of the total Ministry of Health budget declined by 15%, from 13.6% in 1979 to 11.5% in 1993.

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TABLE 5 Changes in Inpatients, Budgetary Allocations, and Personnel in Israel Mental Health Services, 1979-1993’

Patients Resident patients Numbers Ratesb Admissions Numbers Ratesb Budgetary allocations Percentage of mental health services of total Ministry of Health budget Percentage of community mental health services of Mental Health budger: Personnel Ministry of Health, Total

1979

1993

a,774 2.3

6,866 1.3

12,958 3.4

14,488 2.8

13.6

11.5

5.0

2.8

19,176

Change

21.032

- 21.7% - 43.5% + 11.8% - 17.6%

-

15.4%

- 44% +1856 -t9.7%

Mental health services. Total

3.040

3,503

+463 +15.2%

Psychiatric hospitals

2,763

3,292

+529 +19.1%

Community

277.5

211

-66.5 -24.0%

15.9

16.7

+5%

9.1

6

mental health

Percentage of mental health service of total Ministry of Health personnel Percentage of community mental health services of total Mental Health personnel

-34%

aSources: Inpatients (1979; 1988; 1994): Popper & Horowitz (1989); Mental Health Services (1989); Ministry of Health (1994). Budgets and personnel (1979; 1989; 1994): Ministry of Finance (1979; 1989; 1994). bRates per 1,000 of general population cIncluding also drug abuse treatment and community mental health services administered by hospitals.

Mental health services are the second largest item of direct costs (not conditional on income from outside resources) in the budget of the Ministry of Health. The government directly operates 60% of mental hospitalization beds in the country and has been financially responsible for about 80% of these services. This proportion is quite different from the government proportion of the operation and financing of all medical expenditures. In 1993, the Israeli government was responsible for the operation of 19.6% of total health service expenditures. It was financially responsible for 44% of these expenditures (Central Bureau of Statistics, 1995a). Distribution of Budget Between Inpatient and Outpatient Services

Assessment of the government budget for mental health services reveals that inpatient services take 90.4% of the budget. Calculating only direct ser-

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vices, excluding central administration and central services, inpatient services take up an even larger portion of the budget (93.5%). Community services are allocated about 5.3% of the total budget. Another source put the percentage allocated for inpatient services at 84% (Mark, 1995). Two factors might explain this difference. First is the fact that hospitals provide some community services although these services do not appear as a separate budgetary item. It has been estimated that more than 25% of community services are provided and administered by hospitals. The second reason for the difference is that a larger portion of mental health services purchased by the government from the nonprofit sector are allocated for community mental health services. About one-fourth of the budget of the Ministry of Health for 1996 was appropriated for this item. Analysis of allocation within this budgetary item shows that about 24% of the total amount of this item were for community services, and 4.5% were for drug abuse clinics. The high proportion of mental health service budgets allocated to inpatient services is in sharp contrast to the distribution between inpatient and ambulatory care in the general medical service budgets and expenditures. Expenditures for ambulatory medical services and preventive medicine are proportionally a little higher than those for general hospital care (34% and 30%, respectively) (Central Bureau of Statistics, 1995a). The uneven distribution of the mental health budget has always been the case (Aviram, 1983; Halevi, 1984).

Staff In May 1986 more than 6,247 equivalent of full-time positions were employed in all mental health services in Israel. About 10% were physicians, 29% nurses, 8.3% psychologists, 5.4% social workers, 5.3% occupational therapists, and 42% nonprofessional, including orderlies, nursing aids, maintenance personnel, and administrative personnel (Ministry of Health, 1990). About 50% (3,160 in 1988) of the mental health personnel were employed directly by the Ministry of Health. Only about 9% of all the people employed by various mental health services within the Ministry of Health were in community mental health facilities. Training professionals for community mental health services has encountered difficulties. It seems that professionals prefer the more traditional inpatient and outpatient mental health services. Mental health services are considered among social workers as a relatively desirable place for employment (Aviram & Katan, 1989). However, the prestige of psychiatry among physicians in Israel is rather low. Neumann (1981, 1982) asserted that a very small percentage (much smaller than in the United States) of graduates of medical schools in Israel choose psychiatry as their specialty, and that most of the psychiatrists in Israel are immigrants from Europe or the Americas. Because about half the population in Israel is of Asian or African origin, it creates a cultural gap between patients and doctors. Similar gaps develop with regard to Holocaust survivors and their families. For many years the problem received minimal attention (Yishai, 1993; Israel 2nd Television & Radio Authority, 1995). Several changes have taken place in the number and the distribution of mental health personnel during the last decade. Data on mental health man-

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power in governmental services reveal that since 1979 the number of physicians increased by more than 50%, the number of nurses and other professional personnel also increased, while the number of maintenance and administrative staff remained the same (Ministry of Finance, 1979,1995). If the numbers of professionals employed in mental health services and their ratio to nonprofessionals are an indication of the quality of the services, then we must conclude that there has been an improvement in the mental health care services during the last decade. In view of the fact that during the same period the numbers of resident patients in the government mental hospitals declined considerably, changes in the number and the distribution of the professional and nonprofessional staff are even more impressive. However, the major part of the increase in the number of personnel occurred in inpatient services (Table 5). If, indeed, money would have followed the patients to the community, the 22% decline in the numbers of resident patients in all mental hospitals between the years 1979 and 1993 should have resulted in drastic changes in budgetary and personnel allocations for community mental health services. Instead of the present 5% or 6% budgetary allocation for community services, and 6% for personnel positions in community services, the figure would be close to 25%, and the expenditures for community services would be more than four times higher than the current level.

Disability Insurance

and Income Maintenance

Programs

The Disability Law, implemented in 1974, had a paramount effect on services for the mentally ill and continued to affect the system for years. Discussing this law and its effect is beyond the scope of this paper. Briefly, the major effect of the law on the mental health service system is threefold: 1. It provided income maintenance benefits to disabled mentally ill persons. 2. It established rehabilitation services within the National Insurance Institute, financed them with a portion of insurers’ contributions, and offered rehabilitation services to mentally ill people who meed eligibility criteria. 3. It established, and continuously financed, the Fund for the Development of Services for the Disabled, which has become one of the major funding sources for innovative programs in mental health rehabilitation. Eligibility for disability benefits is based on two criteria: medical impairment and loss of income-earning ability. A 50% loss of income-earning ability as a result of the impairment and a medical impairment of at least 40% are the minimum requirements for disability benefits eligibility. The level of disability benefits is based on the proportionate loss of earning ability. A full disability benefit for a disabled individual is 25% of the average wage in the country and is periodically adjusted. A married disabled person is eligible for 37.5%, with additional 5% for each of the first two children. On April 1995, about 27,000 persons received disability insurance pensions for psychiatric conditions. They constitute about 30% of all disability insur-

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ante recipients in the country (National Insurance Institute, personal communication, June 8,1995). About 75% of this group were defined by the NII standards as eligible for a pension on a permanent basis (Aviram et al., in press). A mental hospital, where a person has been hospitalized for 3 months or longer, is entitled to 80% of the disability benefits of the individual. The patient is entitled to the other 20%. In recent years disability benefits have become a substantial portion of hospital budgets (Ministry of Finance, 1995), and special efforts have been made by mental health services to submit claims for disability benefits for eligible mental hospital patients. One might question whether this financial arrangement does not hinder the financial incentives of the hospital to attempt as early as possible a discharge of patients. The Social Security Administration in the United States disallowed financing mental institutions through disability benefits because of such concerns. Discussion

Continuing Problems of the Mental Health Service System The Israeli mental health service system cannot escape the major issues faced by any modern mental health system. It has to contend with basic disagreements in society in general and among the mental health professions in particular over values and priorities. The limited knowledge on the etiology of most disorders and treatments has greatly affected the field of mental health. David Mechanic, in discussing the priorities of mental health, observed: “Mental health, more than most other areas of medicine, offers a very wide latitude in treatment approaches, and, in the absence of convincing research evidence, established interventions often cannot be distinguished from the latest fads” (Mechanic, 1994a, p. 503). These factors help explain the lack of consensus about the domain of the mental health service system regarding problems that it should cover, populations entitled to be served, and the range of services that should be rendered. On top of these issues, the system has continuously confronted scarce resources as well as disagreements among factions, professions, and organizations about the distribution and use of these resources. In addition to these common issues, the Israeli mental health service system faces three specific interrelated problems: 1. Limited development of community mental services. 2. Dominance of the mental hospital in the provision and administration mental health services in the country. 3. Medicalization of mental health services.

of

These problems reflect, on the one hand, current organizational and financial issues, and on the other hand deeply embedded cultural factors and traditional belief systems (Aviram, 1991). Although the current reform in mental health services holds some promises it presents difficulties that may exacerbate these three problems and hinder the possibility of providing quality mental health care to those who need it. In the following section we will discuss the major problems of the system prior to

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the reform, and assess the promises and pitfalls of this reform on the mental health service system. Contrary to official policy since the early 1970s development of community mental health services in the country was rather limited. The significant decline in the number and rates of inpatients has not been accompanied by an equivalent increase in the resources provided for community services. Although, as has been already noted, some positive changes occurred in the provision of mental health services in the community, data indicate that those developments lag far behind what might be considered as justified and necessary (Aviram, 1983,199 1; State Comptroller, 1980,1991; Elizur, 1994a, 1994b; Neumann, 1993, Shefler, 1995). The slow pace of the development of community mental health services, and their relative weakness, is both a reflection and a consequence of the dominance of mental hospitals in the mental health service system. The dominant position of the mental hospital in the system has been attributed to several factors: organizational and professional interests, the legal arrangements that affect the flow of patients into the system, the principles that determine the financing of hospitals by bed occupancy, the structure of the budgetary system that budget hospitals directly and not through Mental Health Services, personnel policies that give financial advantages to hospital staff over community mental health workers, and historical tradition (Aviram, 1991; Aviram & Shnit, 1984; Elizur, 1994b; Ginath, 1992; Shefler, 1995). This situation is far from being conducive to the development of community services, and is in contradiction to the knowledge regarding community care and rehabilitation programs for former mental patients. Admittedly, the control over a large budget provides the mental hospital with the resources and flexibility needed for the development and the running of new programs. Indeed, many innovative community programs were launched and are currently administered by mental hospitals. However, one must remember that the raisoyl d’&e of the hospital is inpatient services, and community services have lower priority. In a budget crunch, community services would be more vulnerable than would inpatient services. These two trends of lack of appropriate development of community mental health services and the dominant position of the mental hospital in the system have been accompanied by a strong current of medicalization of mental health services that recently has been shaping the system. This trend has been influenced by ideological and theoretical convictions as well as by administrative considerations and professional-political interests (Aviram, 1994). Medicalization of mental health services is not unique to Israel. Indeed, recent changes in orientation have been similar to trends in other countries (Aviram, 1990b). It reflects findings of bio-medical research on mental iflnesses especially during the last two decades, as well as the strong trends of psychiatry to fully reintegrate itself into medicine. These medicalization trends have also been reflected in the law and regulations governing mental health services in Israel. The 1955 Treatment of Mentally Sick Persons Law was based on a medical model (Aviram & Shnit, 1984). While including many positive changes, reform of the mental health law in 1991 (Levy, 1992) did not divert from the basic propositions of the medical model (Aviram, 1990a).

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Reform in the mental health service system is in its early stages. It holds many promises to improve the system of treatment and care, but at the same time dangers and pitfalls lie ahead: The standards for entitlement of services that would be established, the criteria for service provision, the structure of services as well as financing it would affect the implementation of the reform and its success or failure. As this article is being written, the reform has not been fully implemented, and many of its details are not yet clear. It is impossible to predict whether it will be successful or to even know how it is going to be implemented. In the following section a few remarks will be made regarding some of the objectives and potential advantages of this major change and the uncertainties and dangers that lie ahead. Major attention should be given to persistently and severely mentally ill individuals. It is this group that, despite the many promises made by the reformers, seems to be in danger of falling between the cracks and not being provided the type, level, or quality of service they need. Objectives, Promises, and Advantages. There is no doubt that the reform holds great promise. Integrating mental health services into the health care system, and giving an entitlement to every resident in the country to receive mental health services as part of the “basket” of health services, which, according to the law, every insurer must provide, is indeed a great achievement. Although, as some claimed, even before the reform, mental health services were available free of charge to all (Neumann, 1993), their availability and accessibility were limited and were not based on the law. The reform requires that Sick Funds provide basic mental health services, as defined by the legislature and the government in all regions of the country, including those areas that currently lack adequate services. Mental health services, provided by the Sick Funds, will be financed by the government through National Insurance Institute (NII) according to a capitation scheme (that as of the end of 1995 has not yet been agreed upon [Segev, 19951). Introducing economic considerations, free market competition, and managed-care principles into the mental health service system holds promise of improving the system of care and treatment, and providing policymakers with a better grasp of setting up priorities. This is an improvement over the situation that mental health services were provided according to the discretion of the practitioner with very little interference of the insurer or the government. Although the principles by which the system was operated prior to the reform might be considered by some as preferable (Neumann, 1993), it is an illusion or a myth that no financial restrictions were present, or that only medical considerations were guiding the service without any outside interference (Elizur, 1994b). Transferring mental health services into independent economic entities that must compete for their survival would no doubt increase productivity of mental health organizations in delivering direct services; services would become more client oriented and would create mechanisms by which these agencies would monitor the provision of services. The reformers hoped that through

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the introduction of economic considerations and competition, and by setting certain standards for financial compensation for specific types of services, policymakers would be able to change the direction of the system, converting the flow of patients from inpatient to the community and enhancing community care instead of hospital care (Mark & Shani, 1995). However, it must be stressed that this approach does not assure that all those who need the services will receive them, nor receive the quality of services. Also, it may adversely affect other important functions of the mental health organizations such as providing training to new cadre of professionals (Shefler, 1995). Dangers, Shortcomings, and Concerns. There is no doubt that the reform holds many promises to improve the system. However, one must not ignore the dangers ahead. There are still many undecided issues, and there are many uncertainties. Many people are concerned that the reform will worsen the level of mental health treatment and care in Israel, and will adversely affect what has been achieved thus far (Neumann, 1993; Shefler, 1995). The basic tenets and directions of the current mental health reform undertaken within the National Health Insurance Act have strengthened the medicalization trends of the mental health service system. In designing the reform as well as in the process of implementing it, the medical orientation and the profession of medicine have not only been the dominant sector but also appear to be the sole ones. It seems that despite declared intentions mental hospitals would retain their central role and strong position in the system. Organizational arrangements and principles of financing the system put many community services under the administration and authority of mental hospitals, creating a great deal of uncertainty for these services. This may further stifle the slow development process of community-care programs that did take place in Israel especially during the last 10 to 15 years despite many hindering conditions that existed in the system. Traditionally, mental health services in Israel have been considered within the domain of medicine. However, since 1972, other concepts influenced policies toward broader community-care and rehabilitation programs (.4viram, 1983,1994; Elizur, 1994b). These policies were congruent with what was found as necessary for the improvement of the care and treatment of long-term mentally ill persons. No one should minimize the central role of the medical profession in the treatment of mental illnesses. However, many of the problems of the seriously mentally ill are clearly related to other systems of care and services (Aviram, 1990a; Mechanic, 1993,1994a, 1994b), and interpreting them in strictly medical terms would be counterproductive to the social efforts to deal with the problem of mental illness. Many fear that the reform will result in neglect of the chronically mentally ill (Neumann, 1993). The low tariff set for the long-term mentally ill, and the heavy caseload planned for case managers, as well as the social marginality of these patients, may lead the Sick Funds into providing care for this group of mentally ill at a minimum level either at the hospital or the community. The proposed per diem tariff of financial compensation for hospitalization of the chronically mentally ill has been set at about the current level of payments for mentally ill in private hospitals. The quality of care in these hospitals was a

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matter for much criticism (Netanyahu Commission [State of Israel, 19901; Neumann, 1982). How can one expect improvements? The reformers expected that economic considerations would create an incentive for the Sick Funds to discharge patients (Mark & Shani, 1995). However, this does not assure that the money will follow the patient into the community nor the quality of care that they will be provided with is improved. Data shows that these patients are greatly disabled and need a wide range of community services (Aviram, Minsky, Smoyak, & Gubman-Riesser, 1995; Aviram, et al., in press). Even if the Sick Funds do decide to use all the money saved on hospitalization for community services, it is doubtful whether the tariffs set for the long-term mentally ill will provide enough funds to establish services at the level these patients need. One of the critics of the reform warned that redistribution of the budget does not mean that it would be directed toward development of community services; according to the Israeli experience, redistribution might result, in fact, in shrinkage of the budget for mental health services (Levy, 1994). Contrary to the financial incentives for the Sick Funds to discharge patients, there are strong organizational incentives to prolong hospitalizations and maintain chronic patients permanently in the hospital. The size of these mental hospitals and, in fact, the very existence of some of them depends of retaining patients in the facility. The stigma still attached to mental illness, and communities’ reluctance to accept chronically mentally ill persons (Aviram, 1993), may further hinder efforts at discharging patients into the community. Faced with such strong currents working against discharge of patients, and in view of the low level of payments that a Sick Fund would have to pay to hospitals for chronic patients, it might decide not to be bothered with rehabilitation efforts and retain the chronically mentally ill in hospitals. Given these facts it is hard to predict the organizational behavior of the Sick Funds. Their efforts to attract a middle-class, young, and healthy population may indeed create an adverse selection on their part (Neumann, 1993) trying to avoid the chronically mentally ill or, at least, retaining them away in mental hospitals. It seems that unless money is earmarked for services for this population group, and unless arrangements are made for this money to follow the patients when they are discharged into the community, quality of care for the long-term mentally ill will be far from what should be desired and from what they deserve. Two principles established for financing the reformed mental health services create uncertainty regarding the amount, level, and quality of the services. The first principle was the restriction imposed by the Ministry of Finance placing a cap on the amount that can be allocated by the government for mental health services. The amount cannot exceed what was budgeted in 1995, adjusted for cost-of-living increases. This amount was 675,544,OOONIS (about US $225 million). Admittedly, savings resulting from a better managed system, as expected by those leading the reform efforts, can be transferred toward improving the services. Also, the K’nessett (Israel’s parliament) is allowed to decide whether to add services to what has been included in the basket of services. However, the likelihood of this action, which will require either raising taxes or transferring money to mental health services from other branches of health care services, is slim.

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The second principle should worry mental health policymakers even more than the first one. The proportion of Sick Funds expended on mental health services has not been fixed at a certain level. In fact, the Sick Fund is allowed to transfer resources that are provided for its services and that are based on a capitation scheme, to other types of health services, as long as the minimum basket of services required by law is provided. In the competition for resources, psychiatry has not been doing well compared to other branches of medicine. Evaluating the budgets of the Ministry of Health shows that during a 1.5year period since 1979, the proportional allocation for mental health services in the total Ministry of Health budgets dropped by 15% (Table 5). There is a danger that in the future the budgetary allocations for the Sick Funds for mental health services may decline owing to two operating forces: demands of other branches of medicine to increase their slice of the pie, and the competition between Sick Funds in attracting clients. Mentally ill persons, especially the chronically ill, have always been at a low priority. A free market approach in health care services does not automatically insure improvement of services to all clients. In fact, it may result in the development of sophisticated and lucrative health care services for the few at the expense of improving basic services for the many. Preventive services and services for chronic illnesses have not always fared well in the competition with curative and emergency medicine. Interests of the Sick Fund, and the absence of a policy earmarking funds for the care of the chronically and severely disabled mentally ill population, may lead the Sick Fund to provide services for this population at a minimum level and restrict it to emergencies and episodic acute care. This in turn would result in neglecting the broad social and community needs of this group of mentally ill persons. The expected behavior of the Sick Funds vis-A-vis the chronically mentally ill would increase the burden on the local authorities and the social welfare agencies to provide care for these people. As resources of these agencies are limited and have been overstretched, one may assume that many of the mentally ill would be neglected. If no corrective measures are urgently taken, Israel should be prepared to see such phenomena as homelessness (Bachrach, 1992; Bassuk, 1984; Baxter & Hopper, 1981; Lamb, 1984), criminalization (Teplin, 1991; Torrey et al., 1992), and general neglect (Appelbaum, 1994; Grob, 1995; Isaac & Armat, 1990) of the chronically mentally ill persons, from which thus far the country has been spared. The reform attributes a central role to the primary care physician in the mental health service system. The general practitioner (GP) or the family doctor is to assume the role of case manager, who will determine the care package that patients receive, and of gatekeeper (Mark & Shani, 1995). No doubt this policy holds a great potential for improving the delivery of comprehensive health care services. Furthermore, there are hopes that Sick Funds will upgrade the knowledge and expertise of GPs in mental health areas. However, introducing this filter between the mentally ill person and mental health services may prevent people from applying and receiving services (Shefler, 1995). For example, there is a great concern that substance abusers will refrain from applying for services through the GPs. Services for this segment of the users of mental health services have used an open policy encouraging direct application.

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The plan for reorganization of the Mental Health Services Division as a result of the reform is a long awaited and much desired change. Accordingly, the Mental Health Services Division should cease to be a direct service provider and should assume its main responsibility of setting policies, coordinating services, controlling and supervising the system (Mark & Shani, 1995; Ministry of Finance, 1995). However, the fact that the reform plan calls for the services to continue to provide direct care to long-term mentally ill through the RUT Fund jeopardizes the reorganization objective. According to the plan, the RUT Fund should retain about 40% of the total allocation for various mental health services in the budget of the Ministry of Health. This allocation is about the same as the allocation for the Sick Funds for mental health services that would be provided according to a capitation scheme. Together with the 20% retained for the operation of the central administration of the Division of Mental Health Services, the larger part of the budget would remain under the direct control of the Mental Health Services Division, and contrary to the original intentions of the reform. Although this situation was, at least in part, a result of the refusal of the Sick Funds to assume responsibility for the care and treatment of the longterm mentally ill, the fact still remains that the Ministry of Health will continue to be a direct provider for about 70% of the current resident population of mental hospitals. One may expect that strong organizational interests would create incentives to retain the money and power that goes along with it at the Ministry of Health level rather than transferring it to the Sick Funds. Because the definition of long-term mentally ill entitled to the RUT services is based on past history of patients, Sick Funds might put pressures on the Ministry to add the future chronically mentally ill into the Fund. This, coupled with survival interests of hospitals wishing to maintain their bed capacity, may indeed retain the Mental Health Services Division as a major provider of services for a long time. There are other concerns as well. Mental health professionals are concerned that economic considerations of the Sick Funds will reduce budgetary allocation for professional training (Shefler, 1995). Also, efforts to reduce costs may limit mental health services to emergency and acute cases, and limit the availability of preventive services along with access to services of less urgent cases yet in need for mental health care (Neumann, 1993; Shefler, 1995). There is no doubt that an important attribute of the reform is the regionalization of mental health service provision. The Netanyahu Commission (State of Israel, 1990) attached great importance to the provision, monitoring and supervising services on a regional basis. However, the plan to combine the job of Regional Psychiatrist to the one of District Psychiatrist creates a mixture of two roles that should be separated (Aviram & Shnit, 1984). The District Psychiatrist should be responsible only for involuntary hospitalization. Assuming that the same person can undertake the two roles, combining the supervision and coordination of services with the legal responsibility of involuntary commitment without creating conflict of interests is an illusion. Furthermore, depositing so much power in one person seems to be unhealthy for a system that should be sensitive to preserve a balance between individual liberties and the provision of psychiatric services of high quality.

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The reform may create upheavals in the labor relations arena and adversely affect the quality of community mental health care. The reform plans to divert patients from hospitals to communities, and to transfer the locus of care to the community (Mark & Shani, 1995; Ministry of Finance, 1995). As a result, the number of needed hospital beds will decline, and mental hospitals or wards will have to be closed down. The direct consequence of these trends would be a large number of inpatient staff whose jobs would become obsolete. In trying to avoid labor-related problems during the early stages of the reform process, the Israeli government was wise to maintain mental hospitals (now required to compete in the market) with subsidies at the same level of budget as that of the prereform period so as to avoid firing hospital staff and creating upheavals in the system. However, this policy is time limited. In order to allow for a smooth implementation of the reform, the government is bound to try to transfer hospital personnel to community services. As much as this seems a sensible approach from a labor relations point of view, critics (Shefler, 1995) have pointed out that it may adversely affect the quality of community services owing to the fact that individuals trained for, and accustomed to inpatient services, do not fit the needs of community-care programs, and their adjustment to their new roles might be rather difficult. Conclusion

The recent mental health reform in Israel is attempting sweeping changes in the structure and processes of the mental health service delivery system. Its success or failure depends on its implementation. The reform is still a plan, and the process of implementation has just begun. In fact, as the writing of this paper is being concluded, the Minister of Health announced postponement of the implementation of the reform until April 1996 (Segev, 1995) and later further postposed it to January 1997 (Israel, Knesset, 1996). This was done because of disagreements among the Ministry of Health, Mental Health Services Division, and the General Sick Fund regarding capitation levels and principles of financing different components of the service delivery system. Assessing the effectiveness of the reform depends on the values and interests of the assessor. This reform was introduced because at a certain point in time a coalition of different interest groups viewed themselves as being able to bring about changes according to what was considered by each party as benefiting the values or each one’s interests. However, this congruency of interest groups can prove to be an “unholy alliance,” one that might dissolve as circumstances change or as their interests diverge. The final evaluation of whether the reform was successful or not must be assessed according to the improvement in the service delivery system for, and the quality of life of, the clients of the mental health system. As the domain of the mental health system is broad, and the definition of the eligible clients is wide, priorities should be established. Evaluation of the effect of the reform, and whether it was successful, must be done according to these priorities. The severely and persistently mentally ill are at the top of this priority list. Certain actions can be undertaken early during the implementation process in order to assure the success of the reform. One must guarantee that in addition to medical services a wide range of social and community services will be

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provided to the severely disabled clients of the mental health service system. Society should not simply accept the demand of the health care system that the provision of these services is the responsibility of the social welfare system. Social services must be well integrated into the health services for the benefits of the disabled mentally ill. To avoid the “escape” of resources toward healthier parts of the client population, a strategy of earmarking funds for the chronically mentally ill should be adopted. The disabled chronically mentally ill need strong case-management services. Assuring the provision of such services requires a high level of support for these services. One of the major goals of the reform is to change drastically the direction of the flow of patients from inpatient care to community care. The attempt is to make sure that most inpatient care will be episodic rather than lifelong. To effect this change, community care must be supported by organizational efforts and financial backing. Mental hospitals cannot be expected to lead the change in the locus of care. Community-care agencies, administratively independent of hospitals, must be established. Discharging patients and placing them in the community must be provided with organizational incentives and financial support. In view of the fact that stigma still hampers the provision of mental health services and, as the Epidemiological Catchment Area study found, a large proportion of the population who was defined in need of mental health services actually has not been receiving mental health treatment and care (Shapiro et al., 1984), new strategies for providing mental health services must be developed. Services must be easily accessible. Limiting all referrals to those done by the GPs may be counterproductive to realizing the objective of this reform. It is doubtful whether economic competition and the free-market approach can produce mental health care and dedicated service delivery system for the most disabled and weak segments of its clients. The government should not rely solely on its legislative and regulatory powers, but should also retain some financial controls and special funds that can be directed or diverted toward special areas or tasks that the free-market approach might neglect. Finally, strong client and citizen advocacy groups must be developed. These groups should be independent of professionals, bureaucracy, and the government. Only full financial and organizational independence of established interests has a chance that the cause of mentally ill individuals will be served well. Changes and improvements in the care and treatment of the mentally ill in Israel require action in certain directions in the implementation process of the reform. The medicalization trends and the strong position of the mental hospital may hinder the process of reform and stifle the transformation of the system into one emphasizing community care and effective comprehensive services for the most needy mentally ill persons.

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