1. 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.

2. 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

3. Increase in Rehabilitation Services Budgets *, 2000-2009 3 * 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.

4. Budget Distribution for Mental Health Services 2009*- 1999 *Budgets include changes during the year. Source: State Budget years 1999-2009 4

5. 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

6. 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

7. 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

8. Decline in the number of Inpatient days, 1999-2009 8 Source :Inpatient Institutions and Day care units in Israel. Department Of Health of Information, Ministry of Health.

9. 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?

10. 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. 10

11. 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 11

12. Package of Rehabilitation Services Housing Employment Adult education Social and leisure time activity Assistance to families Dental care Coordination of services (case management) 12

13. 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 13

14. 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 14

15. 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 15

16. Major Issues Population served Budgets Personnel Services 16

17. 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 17

18. Increase in Budgets‘ Allocations 1999-2009 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 18

19. 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 19

20. 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

21. Average Per Capita Budget for Rehabilitation of Mentally Disabled in the Community by planned annual growth, demographic adjustment and constant prices* *executed budget, Based on constant prices of health index 2005. Source :State budget, 2005-2010.

22. 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

23. 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 23

24. 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 24

25. 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 25

26. Thank you For you attention 26