Update on the Family Health Centers Pilot Program

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments Issue 5

Abstract

In 2005, the Israeli cabinet initiated a pilot program to transfer family health centers and preventive care in schools from the government to the health plans in approximately 40 localities, to assess effects towards nation-wide implementation. The transfer sought to reduce government involvement, increase continuity of care and improve efficiency. The pilot encountered significant implementation difficulties, and as a result and was delayed, down-scaled and ultimately aborted.

Neue Entwicklungen

The implementation of the pilot encountered both political and practical obstacles. Opponents of the reform included the Public Health Division (PHD) of the Ministry of Health, the Israel Nurses Association, the Israel Medical Association, the National Council for the Child and several influential Knesset members. The practical obstacles included difficulties in developing quality standards in light of the PHD's opposition and difficulties in identifying available public use land or buildings for new clinics to be operated by the health plans. These practical obstacles slowed down the pace of implementation and gave opponents of the reform time to mobilize allies and identify new ways to promote their cause. They were then able to bring about a series of changes in the reform plan (downsizing both its programmatic depth and geographic scope), and ultimately, a full cancellation of the pilot plan to transfer responsibility for family health services from the government to the health plans.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral
current    previous

Most of these assessments remain the same as they were in the original report on this reform. The exception is public visibility, which went from very low to high, as the debate heated up and spread from professional to public forums.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Initiators of idea/main actors

• Regierung

• Parlament

• Leistungserbringer

• Bürgergesellschaft

• Meinungsführer

• Andere

Stakeholder positions

Note: The original report to the health policy network includes an extensive stakeholder analysis, so we do not repeat it here. For this update, we have only reported on changes in stakeholder positions and the emergence of new stakeholders.

CHANGES IN STAKEHOLDER POSITIONS

MINISTRY OF HEALTH

In the years 2005-7 the position of the Ministry of Health became more ambiguous and complex. In essence three different positions emerged:

• The public health division as a whole, as well as many members of the Ministry's top management team strongly opposed the reform. Their opposition seems to have derived from a mix of a concern for the effects of the mother and child health (MCH) center pilot on population health, a concern about the loss of Ministry jobs and power, and a concern that this transfer would serve as a dangerous precedent for the transfer of additional health care services and an erosion of governmental funding and commitment to health care and other social services.   
• Some of the other members of the Ministry's senior management team supported the transfer because they believed that the health plans could do a good job of providing MCH services, and that the government should not be in the business of providing personal preventive services. Without that responsibility, the Public Health Divisoin could focus more on broader public health initiatives (such as environmental health) while regulating those non-governmental providers who will directly provide MCH services.
• Yet other senior MoH managers, including the director-general, apparently took a middle position. In principle, they believed that governmental provision of MCH services would be better for population health than health plan provision of those services. Nonetheless, in practice they grudgingly supported the transfer due to the perception that this would result in greater governmental funding of these vital services. In the wake of recent cutbacks in MoH funding, they believed that the MoF would be more willing to provide budgetary support for MCH services if they would be provided by the health plans than to a government-run service.

Interestingly, the Minister of Health appeared to waver between these positions, sometimes supporting the pilot and at other times criticizing it.

HEALTH PLANS

The Maccabi health plan became increasingly supportive of the pilot, apparently for both financial and health care reasons.

EMERGENCE OF NEW STAKEHOLDERS

THE KNESSET COMMITTEE ON LABOR, SOCIAL AFFAIRS AND HEALTH

The committee passed a resolution stating its opposition to the pilot transfer. However, at the time, it did not develop legislation preventing the transfer, and as such, its resolutions had declarative and moral value rather than an immediate practical effect.

Interestingly, in 2008 (i.e. after the Cabinet had halted the pilot) the Knesset is considering a private members' bill that would preclude any such transfers in the future.

THE ISRAEL MEDICAL ASSOCIATION (IMA)

In the 2005-7 period, the IMA emerged as a forceful, articulate and effective opponent of the pilot. Its involvement in the issue was spearheaded by its affiliate - The Association of Public Health Physicians - but then spread well beyond that affiliate. The IMA's opposition is noteworthy in that it appears to have been motivated almost exclusively by a principled concern about population health. Very few physicians work in the government's family health centers and as such, in contrast to the nurses association, the IMA had almost no parochial guild/professional interests in the issue.

THE NATIONAL COUNCIL FOR THE CHILD

This respected non-profit advocacy organization argued strongly against the pilot on the grounds that it would adversely affect child health and welfare. While limited in resources, the Council and its leader have a record of achievement in significantly impacting public opinion and public policy, including through effective use of the mass media. This was again the case with regard to the MCH pilot and its cancellation.

THE PRIME MINISTER

As indicated above, the Prime Minister intervened personally to cancel the pilot. Apparently, as noted above, his position was influenced, in part at least, by concerns put forward by his wife, a major advocate of child welfare programs. 

LOCALITIES SCHEDULED TO PARTICIPATE IN THE PILOT

Originally, 39 localities (including many very small localities in the West Bank) were scheduled to participate in the pilot. Many of them were dropped from the pilot primarily due to the Ministry of Health's unwillingness to do battle with the nurses' union over their inclusion. In some cases, the leaders of these localities also indicated that they did not want to participate in the pilot, and this probably contributed significantly to the decision to exclude their localities.

Actors and positions

Regierung
Minister of Health and Director general	sehr unterstützend		stark dagegen
Prime Minister Ehud Olmert	sehr unterstützend		stark dagegen
some members of management team	sehr unterstützend		stark dagegen
Other members of management team	sehr unterstützend		stark dagegen
Public health division	sehr unterstützend		stark dagegen
Parlament
Knesset Health Labor and Social Affairs Committee	sehr unterstützend		stark dagegen
Leistungserbringer
Clalit sick fund	sehr unterstützend		stark dagegen
Other sick funds	sehr unterstützend		stark dagegen
Bürgergesellschaft
National Council for the Child	sehr unterstützend		stark dagegen
Adva Center	sehr unterstützend		stark dagegen
Meinungsführer
Ms. Aliza Olmert	sehr unterstützend		stark dagegen
Andere
Israel Nurses Association	sehr unterstützend		stark dagegen
Israel Medical Association	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

The planned transfer of responsibility from the government to the health plans did not require legislation and hence the Knesset had relatively little direct influence on the process. 

On the other hand, the Knesset's Labor, Social Affairs and Health Committee did serve as an important public forum for opponents of the reform to voice their reservations. Moreover, the Committee came out with a resolution (whose significance was declarative rather than operational) opposing the transfer.

Actors and influence

Regierung
Minister of Health and Director general	sehr groß		kein
Prime Minister Ehud Olmert	sehr groß		kein
some members of management team	sehr groß		kein
Other members of management team	sehr groß		kein
Public health division	sehr groß		kein
Parlament
Knesset Health Labor and Social Affairs Committee	sehr groß		kein
Leistungserbringer
Clalit sick fund	sehr groß		kein
Other sick funds	sehr groß		kein
Bürgergesellschaft
National Council for the Child	sehr groß		kein
Adva Center	sehr groß		kein
Meinungsführer
Ms. Aliza Olmert	sehr groß		kein
Andere
Israel Nurses Association	sehr groß		kein
Israel Medical Association	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

The implementation of the pilot encountered both political and practical difficulties.

Mounting opposition on the political level

On the political level, the nurses' union and the Ministry of Health's Public Health Division continued to vigorously oppose the transfer. They voiced this opposition through the media, in their direct contacts with the general public, and via meetings with the Knesset, the Minister of Health, other health system leaders, and elected officials in the localities slated to participate in the pilot. They also recruited additional organizations to join them in opposing the pilot, most notably the National Council for the Child and the Israel Medical Association (starting with its Public Health Physicians Association). Several of the organizations opposed to the change asked the courts to intervene and halt the pilot.

In addition to the traditional arguments against the transfer (which were summarized in our prior report on the family health centers pilot project), over time additional arguments were put forward. These included the contentions that continued direct provision by the government would give Israel a better basis for responding to large-scale public health emergencies and that "privatization" of preventive health services would encourage similar moves regarding other vital health and social services.

Many of the opponents of the pilot believed that if the pilot would be implemented, it would lead to a nation-wide transfer of MCH services to the health plans - irrespective of the results of the pilot. They rejected the contention that the pilot constituted an experiment whose objective was to enable policymakers to determine whether to move ahead with a nation-wide transfer. This could explain, in part, the vehemence of the opposition to the pilot.

Practical difficulties in planning and implementation

In parallel with these political and rhetorical processes, the pilot began to encounter a series of practical difficulties, both "on the ground" and at planning levels.

The first such difficulty to emerge was the absence of appropriate facilities or public spaces for new family health centers in the main pilot localities. In some of these localities, the need for new space was the result of shifting from a single governmental provider to four health plan providers, each requiring its own space. In others, the challenge was compounded by the fact that, even prior to the pilot, there were no appropriate facilities and the government services were provided in makeshift clinics in caravans. Furthermore, some of the pilot localities had rapidly growing populations and their initial master plans had not set aside enough spaces for many different types of public uses, including health care, education and religious activities.

Another major issue that emerged involved the job security of clinic staff, and this was particularly significant in Tel Aviv-Yafo (TA), where the municipality rather than the national government had traditionally provided the services. This arrangement existed only in two municipalities - TA-Yafo and Jerusalem. Several years ago, the TA municipality had decided that it wanted to get out of the business of providing maternal and child health services, as it was a major money loser and was not among those services that most Israelis expect to receive from their municipal governments. The TA municipality's preference was to transfer the MCH responsibility to the national government, along with all its workers, who would continue to benefit from governmental job security. With the decline in funding for MCH services in the national government this option evaporated. Hence, when the pilot transfer plan was announced, TA signed on to the pilot, albeit with reservations. It had hoped that the health plans would agree to take on most if not all of their MCH staff. The health plans were willing to consider individual TA workers for positions, and were willing to select those they considered most qualified and most in tune with the health plans' organizational cultures. However, the plans were unwilling to take on all of the TA employees, automatically and en masse.

At the planning level, the ambivalence of the Ministry of Health (MOH) leadership regarding the pilot, and the opposition of its Public Health Division, greatly complicated efforts to transfer the services to the health plans. Because of this ambivalence, in effect it was the Ministry of Finance, rather than the Ministry of Health that led the reform effort, in both its planning and implementation phases. The expertise of the three professionals who comprise the MoF's health care unit did suffice for moving things ahead at the macro level (e.g., securing governmental support) and in terms of the financial arrangements with the health plans. However, they clearly did not have the expertise needed to develop the clinical process and outcome standards to which the health plans would be held accountable. For this, they required the active involvement of the MoH's public health division. However, as the latter opposed the transfer, they deliberately moved slowly in developing the standards and sought to set them at very high levels. Moreover, the three professionals involved had many other health care issues on their agenda, leaving them little time to work with the mayors on finding appropriate facilities, with the health plans on the transfer process, with the MoH on the regulatory framework, maintain a steady stream of communication and updates with all involved etc. etc. This greatly slowed down the reform process and created confusion and a sense of neglect among many key professionals in the health plans and the relevant municipalities .

Strong opposition leads to changes...

The slow pace of implementation gave opponents of the reform time to mobilize allies and bring about a series of changes in the reform plan, including, ultimately, its demise.

The first major change introduced into the pilot plan was the abandonment of a key component - the transfer of school health services to the health plans. The health plans had never been excited about this component of the plan and from objective public health and management perspectives it had always been the most problematic component. This is because, to be efficient, all the children in any given school must receive school health services from the same provider, irrespective of their health plan affiliation. However, none of the plans has a strong interest in providing services to non-members. This is in contrast to the situation with family health center services that are primarily directed at individuals rather than clusters, and as such each health plan can restrict its services to its own members.

The second major change was a reduction in the number of localities participating in the pilot. The original plan sought to involve 39 localities, reflecting a wide range of different types of localities from across the country. Initially, this had the support of the mayors of most, if not all, of the localities chosen. Over time, many of the mayors changed their views, in the wake of pressure applied on them by both local MCH clinic workers and local residents more generally. In addition, the Ministry of Health sought to down-size the scope of the pilot, due to pressure from its employees and the nurses' union. By early 2005 it appeared that at most four localities would participate in the pilot:

• The two localities where services were provided by the municipality rather than the Ministry of Health (Jerusalem and Tel Aviv-Yafo) and hence were less susceptible to pressure from the nurses' union, and
• two localities with young, rapidly growing populations where the MOH's increasingly poorly-funded services were falling far short of the population's  needs (Elad and Modi'in).

Moreover, Jerusalem's participation remained uncertain, and proposals were developed where the transfer would be restricted to only some of the city's neighborhoods.

It is important to note that the Tel Aviv-Yafo municipality changed its position after it became clear through the negotiations with the health plans that the plans were unwilling to take on the bulk of the nurses in the clinics.

...and finally failure of reform

Nonetheless, preparations for the pilot continued to move forward and to many of those involved it appeared that it would be implemented (albeit on a smaller scale than originally planned). Then, in February 2007 Prime Minister Ehud Olmert dramatically announced that the pilot would be halted. How did this happen? Apparently, in early 2007 opponents of the reform came up with both a new concept (multi-service centers) and a new strategic ally (Aliza Olmert, the wife of the Prime Minister). In recent years, Ms. Olmert had been very active in promoting better social and educational services for pre-schoolers, including efforts to develop inter-disciplinary, multi-service centers for them. Apparently, nursing leaders who were close to Ms. Olmert convinced her to expand her vision to include preventive health services and even to consider using family health centers as the base for many of the multi-service centers. They apparently also made the point that such inter-sectoral collaboration was more likely to take place if the providers of the health service continued to be governmental agencies rather than the health plans (which tend to be less concerned about social and educational issues).

It subsequently emerged that, as the original decision to carry out the pilot was made by the full cabinet, the Prime Minister could not decide on his own to cancel it. Accordingly, he presented his new plan to the cabinet, which adopted the plan in the summer of 2007. In addition to halting the pilot, the plan also provided the governmental family health centers with additional funding and staff position, and called for a new pilot project in which multi-service centers for pre-schoolers (including preventive health services) would be established in selected localities throughout the country. 

Monitoring and evaluation

In 2005, the government asked the Myers-JDC-Brookdale Institute to plan and implement an extensive evaluation of the pilot. In mid-2007 when the pilot was aborted, the evaluation effort was naturally halted as well. 

As the pilot was never implemented, the evaluation team could not determine its impact. However, in the period before the evaluation effort was halted, the team did manage to gather valuable information that will be useful to any effort to improve the MCH system, whether or not this will involve changes in ownership. Information was gathered, analyzed and disseminated on three main topics:

• The level of the services provided throughout the country and by all the major providers, as perceived by a large random sample of service recipients
• The characteristics of the government's efforts to monitor and ensure quality of MCH services in both governmental and health plan facilities
• The process of implementing the reform

Interestingly, the survey of service recipients (Rosen et al, 2007) revealed that there were no significant differences in the rates of immunizations and developmental tests between infants cared for by the Ministry of Health and those cared for by the health plans. Nor were there significant differences with regard to how quickly new mothers brought the children to the clinic for the initial visit. With regard to other dimensions of service examined in the survey, there were some in which the Ministry of Health had an advantage (such as home visits) and others in which the health plans had an advantage (such as satisfaction and continuity of care). 

Of course, performance differences among service providers could be due not only to differences in the identity of the provider and the service model, but also to differences in the level of resources invested in the different models. Several Ministry of Health professionals have claimed that in recent years there have been substantial cutbacks in the Ministry's Public Health Service (including a 15% reduction in the number of nurses), and that this has reduced the level of the preventive services provided by the Ministry. At the same time, health plan professionals note that they receive no funding from the MOH for the well-baby services that they provide. 

In any case, the survey demonstrated that several of the claims of opponents of the transfer (e.g., that immunization rates would plummet and that mothers would be hesitant to bring their children into the clinics for well-baby care) were unfounded.

Expected outcome

The transfer was cancelled, so we will never know how it might have affected costs, quality, and equity. By leaving provision of care in the hands of the government, policymakers have probably ensured that the system will be better able to respond to wide-scale public health emergencies and better able to work cooperatively with educational and welfare agencies. At this same time, they have probably lost the opportunity to take advantage of the health plans' relative strengths in computerization, health behaviour change, and ability to link between preventive and curative care.

The planned addition of resources and manpower could contribute significantly to quality of care, if implemented.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch
current    previous

The cancellation of the transfer, like the original transfer plan, is not expected to have a major impact on quality, efficiency or equity. 

The planned addition of resources and manpower could contribute significantly to quality of care, if implemented.

References

Sources of Information

Rosen, B.; Elroy, I.; Nirel, N. (2007). Key Findings from a National Survey of Mothers Regarding Preventive Health Services for Children in the "Tipat Halav" Framework. (RR-497-07), Myers-JDC-Brookdale Institute. Jerusalem. 

Revital Gross, Bruce Rosen, Reuven Kogan (Reviewer: Gabi Ben Nun). "Family Health Centers Pilot Program". Health Policy Monitor, March 2005. Available at www.hpm.org/survey/is/a5/4

Reform formerly reported in

Family Health Centers Pilot Program Process Stages: Idee, Pilotprojekt

Author/s and/or contributors to this survey

Rosen, Bruce, Irit Elroy and Revital Gross

Bruce Rosen: Director, Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute

Irit Elroy: Researcher, Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute

Revital Gross: Senior Researcher, Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, and Associate Professor, Bar Ilan University

Empfohlene Zitierweise für diesen Online-Artikel:

Rosen, Bruce, Irit Elroy and Revital Gross. "Update on the Family Health Centers Pilot Program". Health Policy Monitor, November 2008. Available at http://www.hpm.org/survey/is/a12/3