So many conferences, commissions and committees have deliberated over the past four decades on how to reform Israel's health system that even the experts are unable to list them all. But as most of the resultant reports and recommendations lie unimplemented on dusty shelves, one wonders why new generations are willing to make yet another attempt at change. After convening nine annual "Dead Sea Conferences" (not all actually held at the Dead Sea) on proposals for improving the system, the Israel National Institute for Health Policy and Health Services Research held yet another 10 days ago. This time, the rather ironic title was "Barricades Preventing Changes in the Health System." "For the 10th anniversary," said institute chairman Prof. Shlomo Mor-Yosef, "we are conducting a self-examination. We wondered why so many of the reforms we proposed over the years have not been carried out," noted the director-general of the Hadassah Medical Organization. The institute, funded by a small fraction of health taxes collected by the National Insurance Institute, was established as part of the 1994 National Health Insurance Law to monitor the implementation of that major piece of legislation. The day-and-a-half event at the Daniel Hotel in Ein Bokek attracted about 100 top decision-makers from the Health and Finance Ministries, the four health funds, hospitals, business and academia. The participants do not have the power to change laws, but their recommendations - in printed summaries and position papers - have some influence on officials and the Knesset. "We do not decide anything here, but moving from our regular positions and trying to create documents for the future, expressing a variety of views in an informal setting can be beneficial," noted Mor-Yosef. In such a setting, representatives of authorities are able to voice views independent of their official policies. (And for this health reporter, who observed the non-stop discussions, it was beneficial to see a ministry official jogging in the searing heat and to notice whether public-health experts preferred the dining room's salads to its gooey desserts.) Establishing a committee to propose reforms and then ignoring them can be worse than not appointing an investigating body at all. About 15 years ago, the Health Ministry formed the Elon Committee, headed by retired Supreme Court Justice Menachem Elon, to look into complementary medical techniques from acupuncture to homeopathy to iridology. Although many sessions were held, evidence collected and liberal proposals prepared, the ministry ignore them because they were opposed by the Israel Medical Association. Now, the practice of complementary medicine by both "quacks" and legitimately trained people has led to complete confusion among the public and practitioners. THREE SEPARATE topics have been discussed at each Dead Sea Conference. A 44-page summary of the tenth meeting, written by Ben-Gurion University health economist Prof. Gabi Bin Nun (a former Health Ministry deputy director-general in charge of economics) was published by the national institute. He noted that every health system in the world needs to adapt to new realities such as the ageing of the population, growing demand and expectations by residents, and the availability of new technologies. Among the themes of conferences since 2000 have been community medicine; gaps and lack of equity in the supply of health services; public hospitals' financial problems; competition and regulation; encouraging healthy behaviors; manpower problems in the health professions; and turning hospitals into non-profit corporations. This year, the subjects were the failure of the Health Ministry to end its ongoing conflict of interest caused by owning government hospitals while also supervising them; its failure to transfer responsibility for mental health services from the ministry to the health funds; and the lack of a consistent, automatic mechanism to update the basket of services. All these structural reforms had been raised in previous conferences, but none has been implemented. The phenomenon of studying an issue from all perspectives, making proposals for change and having them ignored is not unique to the health system - especially in Israel, where governments like to show they are "dealing" with crisis while avoiding difficult decisions. Why proposed reforms are ignored could be explained by experts in game theory. Barricades are erected by "veto players" who include labor union leaders, lobbyists, politicians, Treasury bureaucrats and others who have a vested interest in preserving the status quo. Prof. Yitzhak Galnoor, a former Civil Service Commissioner who is now at the Hebrew University of Jerusalem and the Van Leer Foundation, told the participants that over the years, there have been attempts to reform everything from the educational system and pensions to public-service wages, the capital market and the tax system, but actual changes have been rare. While committees have produced proposals, he said, very few have described how to carry them out. Such descriptions alone can take a year to prepare, he said, while actually implementing major reform can take as much as a decade. Since the 1980s, the only real economic reform to be carried out - and it remains on the agenda - is privatization of state-owned services and companies such as El Al, Galnoor noted. Prime Minister Binyamin Netanyahu has now (and previously as finance minister) pushed for the establishment of a fifth - but for-profit - health fund, but Galnoor commented: "There has been no explanation as to why this is supposedly needed. One of the major barricades against reform is the lack of long-serving senior civil servants devoted primarily to the public and not to a specific ministry; there is territorialism. There is no manpower policy. There is no comprehensive wage system. What specific 'bonuses' some civil servants earn is like a state secret. There is a centralization of power that paralyzes; not everything should be coordinated from [government offices] in Jerusalem all the time." Galnoor targeted the Arrangements Bill, composed annually by the Finance Ministry's budgets division officials to bypass the Knesset, make major structural changes and cut ministry budgets. But these bills have not always represented wise policies, he declared. Shlomo Dovrat - the hi-tech businessman who devoted much time to heading a committee to reform the schools - said he was uncomfortable that the resultant comprehensive plan is known by his surname. "The Dovrat Force" is thus short for an ambitious reform prescribed in a 300-page volume plus 1,000 pages of documents that was almost totally dumped by decision- makers due to opposition by teachers' unions and some parents' groups who never understood the plan, he said. "There is great distrust and suspicion among institutions. The Treasury thinks everyone else is a crook. The Education Ministry thinks the Treasury doesn't know anything about education. Failure to implement our plan was an opportunity lost." Today, Dovrat heads the Israel Democracy Institute, where he hopes to have more influence on society. "The Health Ministry has responsibility for the health system, but the Treasury has the authority," bemoaned Prof. Yehoshua, former director-general of the Health Ministry and of Maccabi Health Services, and now chairman of Assuta (private) Hospitals and dean of Tel Aviv University's School of Public Health. "We have one of the best health systems in the world, but reforms are needed that often involve bloody battles; your family may even be threatened. To push change through, you must go into minute details, promote communication among all the elements, and inspire your partners. You have to be honest and set a personal example as well." Shemer said he is infuriated when health fund members don't get drugs and treatment to which they are entitled. "It's shameful. I know that poor people with chronic diseases go to the pharmacist and say: 'My doctor prescribed five different medications for me. I have only NIS 20, so you decide which of them I should take.'" THE ONLY REAL reform of the health system, said Israel Medical Association (IMA) chairman Dr. Yoram Blachar, was the 1994 National Health Insurance Law. It separated political affiliation from health-fund membership, entitled all residents to a set basket of health service regardless of age, physical condition and income, was based on equity and is widely admired abroad. However, since it went into effect in 1995, the Treasury has done its best to cut public benefits so that today, 43% of all medical expenditures are paid by individuals as health taxes, copayments and private fees. That reform was largely based on the (retired Supreme Court Justice Shoshana) Netanyahu State Commission on Reform of the Public Health System established in 1989, he said. However, while national health insurance was established, other major recommendations of her commission were never carried out: Among these were giving the health funds responsibility for supplying psychiatric and geriatric care to their members (with health taxes supplemented by state subsidies) and boosting preventive medicine. Blachar said equity in health care is rapidly declining, along with the quality of medicine in hospitals during the afternoons and evenings; the ministry's conflicts of interest; the lack of money to update the basket of services; and the growing shortage of doctors and nurses, especially in the country's periphery. "The Treasury thinks: 'Who needs the headache of making reforms? All one has to do is write an Arrangements Bill.' But this is wrong," the IMA chairman said. There is no general feeling in the public and the Knesset that there is a crisis in the heath system, declared Raviv Sobel, the young deputy director of the Treasury's budgets division, who for seven years has been responsible for approving health budgets. "Small reforms occur," he said, "but there haven't been major changes for years. Healthcare is a very sensitive system and has a very high public profile, as it affects everybody. Incorporation of the state hospitals had been discussed for almost 20 years, but even today, nobody understands why it is necessary. The medical association opposed it, so it was never implemented," Sobel claimed. Former Clalit Health Services director-general Avigdor Kaplan, today the chairman of Clal Insurance, said that even though Israel's health system is much better than that in the US, "we can learn from them. They know how to make complicated things simple by dividing them into elements. We know how to take simple things and make them more complicated. We need reform proposals and proper leadership, but we also need the right organizational infrastructure. And if the finance and health ministers don't agree on something, you won't get anywhere. The Health Ministry's influence has been weakened in recent years, as the Treasury's has grown. There is a lack of balance. I'm not optimistic about the chances for reform unless a more independent national health authority with more powers is established." THE LACK OF continuity of health ministers is another major barrier to long-term planning, said Health Ministry director-general Prof. Avi Yisraeli, who has served under four (including the new deputy minister, MK Ya'acov Litzman, who is in charge) in less than six years. While there have been only a few major reforms in the past generation, "there have been many smaller changes that make a difference." Examples he gave are moving most people with psychiatric illness from mental hospitals to treatment in the community, and setting diagnostic-related groups so hospitals are paid more for treatments for which there is a long waiting list. Another is requiring the health funds to report various health indicators among their members. But Yisraeli, who says he doesn't intend to remain at his post much longer, describes the Treasury as the "chief pilot" and himself as only the "chief steward" - who can't make major decisions but still "gets yelled at by all the dissatisfied passengers."