The Rehabilitation in the Community of Persons with Mental Disabilities Law of

Israel:Challenge and Opportunity in a Changing Mental Health Service

System

Uri Aviram

International Workshop: Rehabilitation and Community Integration of Persons with Psychiatric Disabilities: The First Ten Years and Beyond, The

Israel National Institute for Health Policy Research, Caesarea, Israel October 13-14, 2010.

The Mental Health Rehabilitation Reform in Israel, 2000-2010

A major change in mental health services in the country

• 16,000 persons (X4 increase)• 550 programs• $125 M. annual budget ( X10 than in 2000)• 25% of the total MH budget (compared to 4%

in 2000)

2

Increase in Rehabilitation Services Budgets*, 2000-2009

3

55,311

115,525

250,215

328,663357,201

396,695418,272

444,818

050,000

100,000150,000200,000250,000300,000350,000400,000450,000

NIS

1999 2001 2002 2005 2006 2007 2008 2009

year

*Budgets include changes during the year .Constant prices based on prices of the health index of 2009.Source: State Budget, 1999-2009 and Department of Planning and Budgeting, Ministry of Health.

Budget Distribution for Mental Health Services 2009*- 1999

*Budgets include changes during the year .

Source: State Budget years 1999-20094

2009

12.30%

25.70%

62%

Inpatient Rehabilitation Other Expenses

1999

78.40%

3.80%

17.70%

Inpatient Rehabilitation Other Expenses

Number of people in rehabilitation services in the community, 1999-2009

Source: Ministry of Health, Department of Information and Evaluation and the Department of Mental Health, rehabilitation unit

5

4362

7,921

14,061

15,555

0

2000

4000

6000

8000

10000

12000

14000

16000

1999 2002 2007 2009

year

Numberofpeople

The MH Rehabilitation Act, 2000• One of the most important social laws

in Israel• Progressive by international standards• Contributing to the country's efforts to

shift the locus of treatment and care from mental institutions to the community

6

Rates of Psychiatric Hospitalizations Per 1000 people, 1999-2009

Source: Statistical Annual 2008 and personal communication, Department of Information and Evaluation, Ministry of Health.7

1

0.5

00.10.20.30.40.50.60.70.80.9

1

1999 2009

year

per 1000

Decline in the number of Inpatient days, 1999-2009

2,011,289

1,726,8561,583,202

1,414,106

1,204,6281,189,063

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

days

1999 2001 2003 2005 2007 2009

year

8

Source :Inpatient Institutions and Day care units in Israel.

Department Of Health of Information, Ministry of Health.

Objectives

• Discuss the principles and innovative approach of the Law

•Assess the opportunities and risks as the RMD law enters its second decade

• What are the Major Issues and challenges?

Outline

• The RMD Law• Effect on major changes in the mental health

service system• Methods of analysis• Focusing on population served, financial

resources, personnel, services, legislation, interest groups.

• Discussion on major issues.

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The Rehabilitation Law- 2000

• Entitlement• Package (“Basket”) of services by Law• Professional decision• Legislature must approve changes in the

“basket”• National council to monitor and advice

government

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Package of Rehabilitation Services

• Housing• Employment• Adult education• Social and leisure time activity• Assistance to families• Dental care• Coordination of services (case management)

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Changes in the viability of the coalition that supported the law

• Enactment of the law: Coalition of interests, opportunity, circumstances.

• Unholy Alliance• Treasury changed position.• Effort to change the RMD law• Other interest groups and changing

circumstances

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Maturation of the System and Necessary Organizational Changes

• Characteristics of an organization in its early development

• Needed consolidation• Rules and regulations• Personnel• Monitoring and controls• Reliable data base• Research and evaluation• Evidence based interventions

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Major Issues of the Rehabilitation Services in the Community

• Consolidation of the system• Administration• Monitoring and control• Target population: Criteria, implementation• Budget• Market failure of privatization• Personnel• Data base, research and evaluation

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Major Issues

• Population served• Budgets• Personnel• Services

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Clients

• System covers only 15-20% of eligible population

• 25-30% of those who were allocated with rehab. package, never use it.

• No adequate long range plans• Changing nature of the second wave of

potential users

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Increase in Budgets‘ Allocations1999-2009

• Budget for rehabilitation increased 10 times• Proportion of rehabilitation in MH budget

increased from 4% to 25%However

• No decrease in government hospitals’ budgets• No government hospital was closed• Decline in budget for community MH clinics

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Budget for Mental Health Service: Inpatient* and Rehabilitation in the Community,

1999-2009**

*Inpatient includes: psychiatric hospitals, acquisitions from hospitals, and acquisitions of hospitalization substitutes.

**In thousands of NIS, constant prices based on prices of the health index of 2009.

Source: State Budget, 1999-2009

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921,472

55,311

1,004,714

115,525

1,004,256

328,663

1,013,229

396,695

1,071,935

444,818

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1999 2001 2005 2007 2009

yearInpatient

Rehabilitation

Budgets

• Principles• need to increase base (broader coverage of eligible population).• Should reflect general population growth in the country• Must has adjustments for inflation• During the last 5 years decline in per capita budget

Average Per Capita Budget for Rehabilitation of Mentally Disabled in the Community

by planned annual growth, demographic adjustment and constant prices*

12,500

23,243

13,855

22,470

15,225

20,541

16,573

21,665

17,933

21,286

0

5,000

10,000

15,000

20,000

25,000

NIS

2005 2006 2007 2008 2009

year

number of users

average NIS percapita

*executed budget, Based on constant prices of health index 2005.Source :State budget, 2005-2010.

Potential effects of Insurance Reform

• Improvement of ambulatory services• Efforts to avoid hospitalization.• Increased demands on the rehab. Services• Possible neglect of severely mentally disabled.• “leakage” of MH money to other medical

specialties

22

Personnel

• Relate to size and quality of personnel, tasks and professional training

• Lack of headquarters personnel• Not sufficient monitoring and control• Private market tries to save money. Affects

quality of personnel• No adequate training

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Services

• Privatization and Market Failure• Need to assess present package• Need to adapt to change in nature of

recipients• Need to adapt to changing circumstances• Need to assess current knowledge and

promote evidence-based knowledge

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Conclusions

• Achievements are to be proud of• No assurance of continued success• Circumstances have changed• Future is unpredictable• Weak, excluded, stigmatized and weak clientele• Need political and public lobbies• Must have Long term planning• Need a flexible organization that will be able to

adjust fast

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Thank you For you attention

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