Commentary on the Structural Reform of Mental Health Services

By Shamir, Eli | The Israel Journal of Psychiatry and Related Sciences, October 1, 2003 | Go to article overview

Commentary on the Structural Reform of Mental Health Services


Shamir, Eli, The Israel Journal of Psychiatry and Related Sciences


Abstract: The stated goal of the reform is to transfer the focus of mental health resources from psychiatric hospitals to the community. The editorial dwells at length on numerical aspects of the hospitalization shrinkage, but glosses over failures to shift resources to suffocated community clinics, and other severe shortages of the national health policy management.

By developed world standards, and those of the World Health Organization (WHO), (1, 2) the reform in Israel is severely blocked, because:

1. The share of mental health in the national public health basket is much too small.

2. The available resource allocation is grossly distorted - community services are too meagre.

3. Exclusion prevails - management of mental health is separate from general (somatic) health in insurance, budget and facilities.

4. On the positive side, significant progress was made (since 2000) in rehabilitation. Also, a definite improvement is felt in the attitude of many professionals towards patients, families and the crucial role of rehabilitation.

Elaboration

The grave shortcomings of the public mental health system is more astonishing considering the high number of psychiatrists and (even more so) of clinical psychologists. There is some shortage in child experts, and concern due to low attraction of psychiatry to Israeli medical students. The general public and policy makers are unaware that in developed countries the "burden" of mental illness is as heavy as that of cancer or heart illness, each one about 15% of the total "burden of illness" on society. Moreover, in childhood and early years, mental illness inflicts the heaviest burden. Some western nations already allocate over 10% of their public health basket to mental health. Israel currently allocates about 5%. During 1990-2000 it was even lower, but raised somewhat in 2000-2004 due to rehabilitation allocation. Closing the gap with, say, cancer resources seems like a lunatic dream.

Shrinkage of mental hospitalization was accompanied by an increase in rehabilitation, but did not change the distorted allocation in medical treatment resources. Only 20% goes to public community clinics and subsidized medicines, compared to 50% in all other health sectors managed by the Sick Funds (Kupot Holim). Why is that?

One obstacle to the resources shift is the better compensations, conditions and prestige in hospital positions. Another fact is that most of the shrinkage was in the very long post-acute beds, whose cost is low (very low in the "private" hospitals). The size of the more expensive acute hospitalizations (about 20,000 admissions each year, 15,000 repeating ones) changes very slightly. Their cost is the bulk of the mental health budget. Moving them to a continuous and effective community treatment (where patients reside at least 95% of the time), is the main challenge of the reform.

Public clinics (State and Sick Fund owned) are visited each year by 1.3% of the population, compared to an estimated need (or demand) of 4%-5%. The majority of ambulatory treatments in Israel (and 70% of its funding) are made in the private market, paid "out of pocket" of the clients. Most of those are "soft patients," suffering from depressions, anxieties, traumas and other disturbances. But too many severe and chronically ill are also forced to pay for private treatments or fail to get treatments, due to the extreme shortage in the public clinics. …

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