The instability of Israeli governments means that more than 90 percent of government decisions are not implemented, even though many administrators in public service are at least as good as those in the private sector, according to Yossi Kucik, a former director-general of the Prime Minister's Office. He was one of the former ministry directors-general who spoke Wednesday at the 10th annual conference of the National Institute for Health Policy and Health Services Research. About 100 of the most influential people in the health system - Health Ministry and Finance Ministry officials, health fund administrators, hospital directors and academics - attended the two-day conference. This year's theme was "Why reforms are not carried out: Obstructions to change in the health system." All the speakers agreed that it was very difficult to carry out major or even minor reforms in the country's public policy in general and in the health system in particular. But some, like Kucik - who began his public career three decades ago as Absorption Ministry spokesman and ended it as director-general of the Prime Minister's Office before going into private business - offered some of the most pessimistic and discouraging views. "Running the system today is almost impossible," he said at the conference, which is being held at the Daniel Hotel at Ein Bokek along the Dead Sea. "There is no lack of ideas and plans. There is a sea of them. The main reason is disintegration of the ability to rule. You can't take a decision and run with it for five or 10 years. You can talk of reform, but nobody is home. "Just as you can't run a big business without a board of directors, you are usually unable to make decisions in the public sector because there is nobody standing behind them," he said. The structure of the political system and the government has to be reformed, he stressed. The Finance Ministry's budget division hold the monopoly on medium- and long-term planning, he said, and a multitude of "veto players" who automatically come out to exercise their vested interests thwart change. He advised professionals such as those in his audience to "get together despite your different interests and try to promote reforms" to the public and the government that they will not oppose. Shlomo Dovrat, a hi-tech executive who spent a year preparing a comprehensive reform of the educational system, said it floundered when disengagement from Gaza became the top public issue. The teachers unions then launched a battle against the 300-page, apolitical report it even before the public understood what it entailed, he said. Although few of his committee's proposals have been implemented, Dovrat said he was still "a believer in big reforms," which can be carried out if governments last longer and ministers have vision and the time to make positive changes in accordance with a major "road map." But Avigdor Yitzhaki, another former director-general of the Prime Minister's Office, said that if leaders focused on a handful of points and achieved needed reform on those, the rest would fall into place. Getting the agreement of public service workers, he said, was key in achieving nay reform, even if you had to "pay them off" with financial benefits, he said. Prof. Yehoshua Shemer, former director-general of the Health Ministry and of Maccabi Health Services who is now head of Tel Aviv University's School of Public Health, declared that Israel's health system is among the best in the world, but that reform can be achieved if you are brave enough to fight "bloody battles." A senior administrator must go into the small details, work hard, bring all the various elements together and infect his partners with enthusiasm so they will line up behind him, he advised. "You must also be ethical, serve as a personal example and share responsibility," Shemer said. Among the health reforms that most of the speakers advocated were the cancellation of copayments for health services by Israelis in the bottom two income deciles, continued reform of the psychiatric system and revamping the Health Ministry to serve as a supervisory body, so it would no longer be locked into hopeless conflicts of interest by supplying health services as well.