2.4. Decentralization and centralization
Israel has a unitary, as opposed to a federal, system of government. While the government has administrative divisions at the regional level, these do not have independent authority in the same way as the states in the United States or the länder in Germany.
Although the Ministry of Health’s Public Health Division operates through regional and district offices, which have some leeway in responding to local conditions, the ultimate source of authority is the national office. The regional and district offices serve primarily to implement the policies and strategies developed at the national level, both in the public health field and in terms of the regulation of LTC and psychiatric care.
The same is true of the HPs; all have regional administrations but authority rests with their national headquarters. In recent years, the HPs have been undergoing a process of decentralizing authority and responsibility to the regions and branches. This was particularly true of Clalit, which underwent an ambitious programme of decentralization down to the clinic level.
The Ministry of Health and its institutions have one set of regional structures and the HPs each have their own. There is little coordination between these bodies at regional level.
The NHI Law called for the role of government to be reduced in terms of service provision in three key areas of activity: personal preventive care, LTC and mental health care. The Law stated that within a three-year transition period, these responsibilities would be transferred to the HPs. The original decision to transfer responsibility for personal preventive care (discussed in greater detail in section 5.1) was reversed by the Knesset in 1998 and it is only recently that the transfer of responsibility for mental health care has been implemented (section 6.1.2). A relatively recent effort by a health minister to similarly transfer responsibility for LTC did not succeed because of a mix of budgetary concerns and jurisdictional disputes (section 6.1.5).
A major effort was undertaken in the early 1990s to transform the government hospitals into independent, non-profit-making trusts. This was a top priority of the Minister of Health at the time. However, the effort failed, primarily because of opposition from the health care unions (see section 5.1). Instead, the government hospitals have been gradually given far more autonomy than they had in the past.
Until recently, efforts were under way to establish a government hospital authority, which would supervise all of the government’s hospitals; the current plan calls for the authority to report to the Minister of Health but not to be part of the Ministry of Health, per se. However, this process has been halted in the wake of the change in government.
Most analysts interpret the NHI Law as increasing government control of the health care system. Previously, the HPs were largely unregulated. Now, the government has substantial regulatory powers regarding the benefits to be provided and to what extent to finance HP activity. Nevertheless, the HPs remain separate legal entities with considerable latitude for strategic and managerial discretion. The change is less radical than that which was envisaged by competing approaches to NHI, such as abolition of the HPs and institution of a unitary health insurance system run by the government. It is also evident that HPs have significantly less independence than they had prior to 1995.
The change in law enhanced the public’s right to a defined benefits package and increased equity in the health care system. What is less clear is the magnitude of the costs of the change in terms of reduced innovation, responsiveness and diversity.
In summary, since the mid-1990s the Israeli health care system has undergone:
- some deconcentration of central government authority to lower administrative levels of central government, particularly in the case of the government hospitals;
- no significant devolution of authority to regional or local governments;
- no significant delegation of responsibilities to quasi-public organizations (on the contrary, NHI constitutes a process of transfer of authority from the HPs to the government); and
- some privatization, in the sense of transferring responsibilities for service provision (e.g. mental health care) from the government to the voluntary sector, as well as some expansion of government responsibility (e.g. dental care for children).
Questions remain as to the desirable extent of deconcentration, devolution, delegation and privatization in Israeli health care. There continue to be vigorous debate as to the desirability of the changes that took place in the 1990s. Similarly, there is no clear consensus as to how Israeli health care should evolve with regard to these issues in the decade ahead.