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

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

HMO promotion and the privatization of health care in Chile

Since 1973 the Chilean junta has privatized sectors of the national economy. This paper analyzes the country's policy process of promoting private medical programs through HMO-like plans (ISAPREs, or Institutes of Provisional Health). These plans have captured less than half of their originally anticipated market share. It is argued that the future performance of ISAPREs will be undermined by their limited maternal benefits, their targeting to a small upper-income group which cannot sustain many private medical programs, and competition with less expensive yet equally competent public medical programs. The paper briefly compares privatization in Chile with the experiences of other countries, and specifically contrasts the restructuring of health services under military rule in Chile with those of Argentina and Uruguay. The paper concludes that the Chilean experience with HMOs epitomizes the perils of planning health care during short-term periods of economic prosperity as well as failing to consult medical care providers and consumers.     

The new Israeli health care reform: an analysis of a national need

This paper describes the current situation of health care services in Israel. Major problems are discussed and analyzed in terms of the dualism of the main health organizations (the Ministry of Health and the General Sickness Fund), the multiplicity and discontinuity of health care delivery, quality-of-care problems, and the uneven geographical distribution of facilities. A proposal for a reform of the health care system is outlined, and its principles enumerated. This reform, suggested by the Ministry of Health, reflects a new approach of separating the direct provision of care from the executive functions of planning and control of services. The Ministry's proposal is analyzed, and its implications are discussed in relation to the American health care system.     

The labor impacts of policy change in health care: how federal policy transformed home health organizations and their labor practices

Health care organizations are highly labor-intensive; policies designed to stimulate organizational change are likely to have labor impacts. This paper examines the labor effects of policy change in home health care. Major federal home care policy trends since 1980 have spurred the evolution of the typical home care provider toward greater organizational and market rationality. Greater managerial sophistication has introduced changes in management/labor relations. Survey data from the 1986 DRG Impact Study are used to show how the pressure of cost-containment policies has pushed agencies to cut labor costs by increasing workloads, managerial supervision, and control of the work process. Research on the effects of recent policy change in health care has to date focused primarily on potential client effects. Labor impacts are rarely examined and are poorly understood at the time that policy is made. Findings in this article suggest that these issues deserve greater, more systematic attention, because unanticipated labor impacts may prove to be significant impediments to the realization of intended policy goals.     

List of designated primary medical care health manpower shortage areas (HMSAs); list of withdrawals from primary medical care HMSA designation--PHS. Notice

This notice provides two lists. The first is a list of all areas, population groups, or facilities designated as primary medical care health manpower shortage areas (HMSAs) as of December 31, 1989. Second is a list of previously-designated primary medical care HMSAs that have been found to no longer meet the HMSA criteria and are therefore being withdrawn from the HMSA list. HMSAs are designated or withdrawn by the Secretary of Health and Human Services (HHS) under the authority of section 332 of the Public Health Service Act.     

The Proposed 100 by 50’ Act: Protecting Collective Bargaining of Workers in a “Just Transition” to a Clean-Energy Future

There is a longstanding misconception that any overlap between environmental policy and labor rights results in conflict. With the intensifying threat of climate change and the decline of fossil fuel development, international labor and climate groups have collaborated to develop a framework for a just transition to sustainable development that emphasizes social dialog between stakeholders. An increasing number of nations are guided by this framework as each incorporates its own transition model. The United States, however, remains on the sidelines. This article proposes that the U.S. enact recently proposed legislation to transform its energy sector, while also protecting its workers and the environment.     

List of primary care and dental health manpower shortage areas designated under section 332 of the Public Health Service Act

This notice provides a list, updated as of March 31, 1982, of primary care and dental health manpower shortage areas designated by the Secretary of Health and Human Services under the authority of section 332 of the Public Health Service Act. (At a later date, an update of the lists of psychiatric, vision care, podiatric, pharmacy, and veterinary health manpower shortage areas will be published).     

Introduction: International Perspectives on Health Policy

This special issue of Law & Policy examines legal, bioethical, and social science perspectives on the critical problems and choices arising from the rapid changes in the health care systems throughout the industrialized world. Advances in medical technology, the rising costs of health care, and the aging of the industrial populations have made health care a crucible for many of the broader policy concerns facing the world in the new millennium. The purpose of the special issue was for these issues to be addressed in a multidisciplinary forum, to add to the broader spectrum of socio–legal scholarship. Scholars from diverse countries examined a variety of issues from ethical, social science, and clinical perspectives.     

An end to a consensus on health care in the Federal Republic of Germany?

Over the past fifteen years the national government in the Federal Republic of Germany has animated the political debate about rising health care expenditures. However, it has only provided health policy leadership by shifting the burden of financing health and medical care to others. This paper presents three cases that illustrate the political and institutional constraints inherent in the German policy process that limit the proposal and implementation of appropriate policy solutions to rising health care costs. Cost controls have been inhibited because of the near-universal entitlement of national health insurance, the access all social groups have to advanced medical care, and policies targeted at providers rather than users of health services. The paper also underscores the past and future importance of regional policy coalitions in shaping national health policy.     

Punctuated equilibrium and path dependency in coexistence: the Israeli health system and theories of change

Israel's enactment of national health insurance was clearly a breakthrough. However, other aspects of reform that were supposed to be implemented simultaneously were stymied, in particular, the conversion of government hospitals to independent trusts and removing the Ministry of Health from the direct provision of services such as mental health and long-term care. This article explores how punctuated equilibrium and path dependency coexist in the Israeli case. In doing so, it examines the relevance of concepts provided by various theories of social and institutional change. Aside from path dependency and punctuated equilibrium, we discuss other notions derived from related theories, such as political leadership and the role of ideas. Applying these theories to the Israeli case helps better understand the coexistence of punctuated equilibrium and path dependency.     

Access to health care for undocumented migrants: a comparative policy analysis of England and the Netherlands

The presence of undocumented migrants is increasing in many Western countries despite wide-ranging attempts by governments to increase border security. Measures taken to control the influx of immigrants include policies that restrict access to publicly funded health care for undocumented migrants. These restrictions to health care access are controversial, and evidence suggests they do not always have the intended effect. This study provides a comparative analysis of institutional, actor-related, and contextual factors that have influenced health care policy development on undocumented migrants in England and the Netherlands. For undocumented migrants, England restricts its access to care at the point of service, while the Netherlands restricts through the payment system for services. The study includes an analysis of policy papers and semistructured, in-depth interviews with various actors in both countries. Findings confirm the influence of such contextual factors as immigration considerations and cost concerns on health care policy making in this area. However, these factors cannot explain the differences between the two countries. Previously enacted policies, especially the organization of the health care system, affected the kind of restrictions for undocumented migrants. Concerns about the side effects of generous treatment of undocumented migrants on other groups played a substantial role in formulating restrictive policies in both countries. Evidently, policy development and implementation is critically affected by institutional rules, which govern the degree of influence that doctors and professional medical associations have on the policy process.     

List of primary care health manpower shortage areas designated under Section 332 of the Public Health Service Act

This notice provides a list, updated as of September 30, 1984, of primary care health manpower shortage areas designated by the Secretary of Health and Human Services under the authority of section 332 of the Public Health Service Act.     

国际法视野下的企业社会责任与劳工权益保护——兼论社会责任标准在我国的实施

企业社会责任运动要求公司尤其是跨国公司在参与市场竞争的过程中应承担其应尽的社会责任以保障基本人权和劳工权利。考查企业社会责任运动的发展及相关国际法律文件的规定、实施及影响,相较于我国法律的相关规定,企业社会责任标准并非高不可攀的道德苛求,只要我国建立起规范、明确的约束体系,切实实施劳动法等相关法律的规定,劳工权益得到切实维护,企业社会责任的标准也就基本达到了。     

Physicians' conflicts of interest in Japan and the United States: lessons for the United States

Japanese health policy shows that even with physician ownership and the absence of for-profit, investor-owned health care, physicians' conflicts of interest thrive. Physician dispensing of drugs and ownership of hospitals and clinics were justified in Japan as ways to avoid commercialization of medicine. Instead, they create physicians' conflicts and fuel patient overuse of services. Japan's Ministry of Health and Welfare (MHW) has responded by introducing per-diem payment, thereby creating incentives to decrease services in ways similar to those of American managed care organizations, but with none of their benefits, such as coordination of care, oversight of physicians practices, and quality assurance. Although the United States and Japanese health care systems are organized and financed differently there is convergence in the source of their physicians' conflicts and the way they are addressed. The United States is starting to integrate institutional and physician payment and align their incentives, in a traditional Japanese way. In so doing, the United States creates new physicians' conflicts and reduces the role of countervailing incentives and power, an advantage of previous policy. Japan, in turn, has combined incentives to increase and decrease services, thus moving closer to the U.S. policy.     

Specific forms of human trafficking in Slovenia: overview and preventive measures

Abstract

Paper presents a research study on specific forms of human trafficking in Slovenia. The research indicates that the vulnerability of migrant workers in Slovenia results from their social vulnerability and deteriorating social conditions in the countries of origin. Employers are aware of these conditions and take advantage of the situation, which results in planned recruitment of workers in countries of origin. Furthermore, cases of human trafficking for the purpose of forced criminality and forced begging, as well as trafficking in children, are also indicated in the research. However, in the time period under review the Slovene police detected only a few underage victims of crimes that can be considered as trafficking. No evidence of trafficking in human organs, tissues and blood was found, but the research unveiled some cases indicating illegal intercountry adoptions. The research results and recommendations can guide further action and the planning of preventive activities.     

Validation of main notions of flaws in medical care

The authors define the notions of defects in medical care (DMC) in accordance with the new Criminal Code and Regulations for Estimating Harm to Health (Order No. 407 of Ministry of Health of the Russian Federation of December 10, 1996). Definitions of DMC, flaws in organization, diagnosis, and treatment, etc., at the prehospital and hospital stage of medical care are defined. List of the main components of DMC and their causes is presented.     

Hidden convergence: toward a historical comparison of U.S. and U.K. health policy

The social science literature on the comparative history of the welfare state offers conflicting accounts of the relationship between the United States and the United Kingdom. At first blush, the comparative history of health care policy in the United States and the United Kingdom seems to affirm the dominant view that the U.S. and U.K. welfare states have diverged substantially during the twentieth century. A comparison of U.S. and U.K. health policy, however, suggests that there are more parallels and points of tangency between the two systems than are readily apparent. The comparative history of health policy over the past century reveals common political and policy challenges and frequent interchanges of policy ideas, and helps uncover the political dynamics behind the development of health policy in the two countries, which can, in turn, help illuminate the contemporary politics of reform in both countries.     

Regulating physician supply: the evolution of British Columbia's Bill 41

This paper traces the development of British Columbia's controversial Bill 41, which empowers that province's Ministry of Health to restrict the issuance of billing numbers entitling physicians to seek payment from the provincial medical services plan. The bill and its predecessors have been the subjects of two court challenges by the medical profession, and the legal battles continue. The bill has also taken on a role in the evolving interpretation of Canada's new Charter of Rights and Freedoms. Meanwhile, the policy appears to be slowing the rate of growth in physician supply in the province, but its impact on the real target--medical care costs--is still uncertain.     

Planning the health care system in a decade of economic decline: The Ghanaian experience

Health and medical care in Ghana is examined from the broader issues of development and underdevelopment. Ghana's dependent, peripheral standing has created a serious bottleneck in the domestic economy. The mounting debt crisis and the need to respond to International Monetary Fund (IMF) policies on economic stabilization have worsened the precarious health resources of Ghanaians. In an attempt to repond to Western pressures as well as Western taste, Ghana has also blindly followed the Western model of health care with no attempt to address the immediate health needs of her population. This paper concludes by calling for the integration of traditional, and Western medical practices as the foundation for any future effective health planning.     

List of primary care, dental and psychiatric health manpower shortage areas designated under Section 332 of the Public Health Service Act

This notice provides a list, updated as of December 31, 1982, of primary care, dental, and psychiatric health manpower shortage areas designated by the Secretary of Health and Human Services under the authority of section 332 of the Public Health Service Act.