Policy Entrepreneurs and the Design of Public Policy: The Case of the National Health Insurance Law in Israel

Abstract

How do policy entrepreneurs implement in practice the things theory suggests they should do? This article suggests various insights into the influence of policy entrepreneurs on the formulation of public policy. Using a broad definition of the concept of policy entrepreneur, the article identifies the main characteristics of entrepreneurial activities, describes various strategies that the policy entrepreneur may employ, and develops a model of successful and effective policy entrepreneurship. Using an analysis of the design of the Israel National Health Law of 1994 as a case study, the article emphasizes the importance of policy entrepreneurs in the public policy arena and provides several insights into the conditions for their activity, their motivations and main strategies. [PUBLICATION ABSTRACT]

Headnote

Abstract2

How do policy entrepreneurs implement in practice the things theory suggests they should do? This article suggests various insights into the influence of policy entrepreneurs on the formulation of public policy. Using a broad definition of the concept of policy entrepreneur, the article identifies the main characteristics of entrepreneurial activities, describes various strategies that the policy entrepreneur may employ, and develops a model of successful and effective policy entrepreneurship. Using an analysis of the design of the Israel National Health Law of 1994 as a case study, the article emphasizes the importance of policy entrepreneurs in the public policy arena and provides several insights into the conditions for their activity, their motivations and main strategies.

Keywords: Policy Entrepreneurship, Policy Change, Health Care Policy, Reform.

Introduction

Over the last decades the concept of entrepreneurship has diffused into the scholarly discourse that deals with public policy and management (Roberts & King, 1991). Since the 1980's, a variety of studies have used this idea to explain various case studies and policy results. Many scholars use concepts such as political entrepreneur (Meydani, 2008; Schneider & Teske, 1992), institutional entrepreneurship (Campbell, 2004; DiMaggio, 1988), public entrepreneurs (Ostrom, 2005; Schneider, Teske & Mintrom, 1995; Schnellenbach, 2007), policy entrepreneurs (Kingdon, 1984/1995), evolutionary policy maker (Witt, 2003) and executive entrepreneur (Roberts & King, 1991) to provide a new perspective on various phenomena related to politics and administration. However, the literature often uses the same concepts to explain different phenomena, making it difficult to clearly define and understand policy entrepreneurs.

Recently, Mintrom & Norman (2009, pp. 654-658) presented an integration of policy entrepreneurship and five different theories of policy change. At the end of their article, they claim that this concept is yet to be broadly integrated within analyses of policy change. New insights have also started to emerge concerning the sequencing of policy entrepreneurship over long periods of time, how the broader political climate can affect the context for policy entrepreneurs, how they frame problems, and how they work with others. Nevertheless, room remains for more conceptual development and empirical testing. Mintrom & Norman suggest two directions for fruitful future work. First, there is a need for closer study of the motivations and strategies of policy entrepreneurs. Second, there is also a need for more study of the interactions between policy entrepreneurs and their specific policy contexts. This paper focuses on these needs.

On June 15, 1994 the Israeli parliament (Knesset) passed the National Health Insurance Law (hereafter: NHIL) after decades of attempts and efforts to legislate or devise national health insurance. The application of the NHIL to all residents of Israel marked the end of a struggle of almost 70 years' duration, which began even before the State of Israel was established (Shvarts, 1998). The primary aim of this article is to analyze the design of the NHIL on the basis of a conceptual framework using theoretical tools taken from public policy and administration, and new institutional approaches, while focusing on the concept of entrepreneurs. In this context, we will outline the main characteristics of entrepreneurial activity and describe various strategies available to the policy entrepreneur. The theoretical insights developed in this article could, without extrapolating too far, offer some tentative lessons for other healthcare systems and reforms.

The textual sources used in the empirical analysis include legislative documents, reports and the minutes of various committee meetings in and outside of the Knesset, print and online press sources and professional and lay literature (e.g. biographies, autobiographies and non-research related books on political topics), including excerpts from the draftof a currently unpublished book by former Health Minister Haim Ramon. Also comprising part of the analysis are 43 interviews with politicians, bureaucrats, decision makers and researchers. The interviewees were selected based on their willingness to participate in the research (convenience sampling) and through snowball sampling (Cohen & Arieli, 2011).

The article is structured as follows. Chapter 2 defines the policy entrepreneur as a special player in the policy arena. This section also offers a broad definition of entrepreneurial activity, and describes the characteristics and principal action strategies of policy entrepreneurs. Chapter 3 reviews the main rationales behind the formulation of the NHIL as provided in the literature to date. This review also provides the reader with the historical background that preceded the period when the Law was formulated. In Chapter 4 the article goes further into the historical background, describing the main processes involving in formulating the Law. The heart of this article, Chapter 5, examines the conceptual framework that we developed. The final chapter is devoted to a summary and discussion.

Policy entrepreneurs: Characteristics, strategies and motivations

Policy entrepreneurs may be in or out of government, in elected or appointed positions, in interest groups or research organizations. However, their defining characteristic, much as in the case of a business entrepreneur, is their willingness to invest their resources - time, energy, reputation, and sometimes money - in the hope of a future return (Kingdon, 1995, p. 122). Following Kingdon's work, Mintrom & Norman (2009, pp. 652-654) suggest four elements that are central to policy entrepreneurship:

* Displaying social acuity means that the entrepreneurs are well-versed in the social-political context in which they are interacting and demonstrate high levels of social acuity in understanding others and engaging in policy conversations. Thus, the entrepreneur can identify "windows of opportunity" (Kingdon, 1995) for introducing innovative policy within the existing social order.

* Defining problems refers to the act of problem description, which affects how people relate specific problems to their own interests. Viewed in this way, the definition of policy problems is always a political act.

* Building teams underscores the fact that policy entrepreneurs are team players. Their real strength comes from their ability to work effectively with other players in the policy arena. Thus, they operate within a tight-knit team composed of individuals with various knowledge and skills, who are able to offer mutual support in the pursuit of change, as well as use their personal and professional social networks to create a political coalition to challenge the status quo (Schneider & Teske, 1992, p. 742).

* Leading by example means that the policy entrepreneur often takes action intended to reduce the perception of risk among decision makers. When they lead by example - taking an idea and turning it into action themselves - the entrepreneurs signal their genuine commitment to improved social outcomes.

Mintrom & Norman suggest that in order to break a theoretical impasse, policy entrepreneurship must be studied in a manner that pays attention simultaneously to contextual factors, to individual actions within those contexts, and to how context shapes such actions (Mintrom, 1997, 2000; Mintrom & Vergari, 1996; Schneider, Teske & Mintrom, 1995). Indeed, following their important suggestion, this article will focus on contextual factors and their influence on policy entrepreneurs' actions. However, as the political environment is dynamic and changes over time, the notion of policy entrepreneurs may change with it. Hence, including elements taken from business administration entrepreneurship in the concept of policy entrepreneurs may increase our insights into this phenomenon.

Hart, Stevenson & Dial (1995, p. 53) identify three elements in the activity of an entrepreneur who acts out of choice: 1) exploiting an opportunity; 2) creating a profit; 3) acting without regard for alienable resources currently not in their control. In other words, an entrepreneur always acts under conditions of risk and uncertainty. Hence, entrepreneurship is a process by which individuals - either on their own or inside organizations - pursue opportunities without regard to the resources currently controlled by others (Stevenson & Jarillo, 1990, p. 23). This definition, indeed, does not always suit the definitions suggested in the fields of public policy and political science. However, it increases our understanding of the motivations and strategies of policy entrepreneurs significantly. Hence, in this article we define a policy entrepreneur as an individual who exploits an opportunity in order to influence political results for his/her own benefit, in the absence of the resources required for accomplishing this goal alone.

According to this broad definition, and based on the above review, we can identify three main characteristics for the timing of an entrepreneur's appearance: the desire to maximize personal interests as a result of activity whose purpose is to influence policy outcomes; a total absence of the resources needed to influence policy outcomes; and the existence of an opportunity to influence policy outcomes. It should be noted that a policy entrepreneur might also choose not to take action to promote a given institutional change and, in fact, act to prevent it. However, given that one of the main conditions of such entrepreneurship is the existence of an opportunity, it is reasonable to assume that entrepreneurial activity will strive to bring about a political change that influences political outcomes. Thus, it is also reasonable to assume that the opportunities will lead to a change in the status quo rather than its preservation.

The desire to maximize personal benefit

Much as in the case of a business entrepreneur, policy entrepreneurs will usually not invest their resources without hoping to receive a future return. In addition to ideologically-based motivations, entrepreneurs who are (or intend to become) politicians will probably act primarily to increase their chances of election, whereas entrepreneurs who are bureaucrats will seek to ensure that the results of their actions will serve their interests (i.e., increase their centrality and administrative power). It is important to be aware that benefit may derive both from change itself (the results obtained) and from the actual activity (even if the results obtained are less than ideal in the eyes of the entrepreneur). Thus, when entrepreneurs recognize the activity itself as being in their interests, they deem it appropriate to compromise on the nature of the results of the change, even if these are not considered ideal. Given that according to our broad definition, a policy entrepreneur does not have all the resources needed to realize the goals of the entrepreneurial activity, it is clear that successful entrepreneurial activity must be based on persuasion, pragmatism and willingness to compromise.

Absence of all of the resources needed to influence policy outcomes

Given that entrepreneurs do not have access to all of the necessary resources, they need to negotiate, persuade, compromise and be flexible in a variety of areas. Hence the entrepreneur's skills, ability to distinguish between the essential and the non-essential in the nature of the proposed institutional change, and willingness to relinquish the non-essential in order to succeed in implementing the policy change are clearly the recipe for successful entrepreneurial action. The non-essential, in this sense, refers to various elements related to policy change that the entrepreneurs do not consider likely to cause material damage to realizing their interests. Policy entrepreneurs are therefore frequently characterized by their instrumental approach to policy making - meaning that they are willing to compromise and concede maximization of the social welfare if that will enable them to realize their personal interests.

In order to succeed, policy entrepreneurs have to attract the support of key players in the policy arena, especially when factions opposing the change and favoring the preservation of the status quo are powerful. Even where the entrepreneurial activity, by definition, carries a calculated risk, consolidating a coalition in support of change could reduce risks. Furthermore, the more politically powerful the supporters, the easier it will be for the entrepreneur to recruit the resources needed.

The existence of an opportunity to influence policy outcomes

A third important condition for success is the existence of an opportunity, which automatically includes the potential to create value for the entrepreneur, from the point of view of both timing and results. Such an opportunity may arise from developments in the political system (the political arena), in the socio-economic power system (the local, regional or global arena) or both (a combination of opportunities). The greater the opposition to change, the more likely the entrepreneur will maintain that such a change will be socially beneficial compared to the existing reality.

The combination of motivation and a window of opportunity is the key to the entrepreneur's success in effecting policy change. Successful entrepreneurial action is therefore characterized by identifying the needs of significant groups in society and the political potential inherent therein to fulfill their needs. Identifying an opportunity for change could also take the form of identifying dynamics different than those of the entrepreneur (e.g., a conflict of interests between other players) and exploiting these in effecting change. The existence of an opportunity could also affect the entrepreneur's willingness to take risks. Therefore, to a certain extent and in a calculated manner, entrepreneurs can be expected to adopt strategies that may appear outwardly to entail greater risk than the entrepreneur estimates because they could produce greater benefit due to the opportunity identified. We will use the creation of the National Health Insurance Law in Israel to illustrate the validity of this theoretical framework, focusing in particular on the role of policy entrepreneurs in formulating the bill and realizing its passage into law.

The design of the National Health Insurance Law in Israel - The common explanations

The literature is divided as to the reasons that led to the passing of Israel's NHIL in 1994. At one extreme, Shvarts (1998, 2000) attributes the passing of the NHIL to Haim Ramon, Israel's Health Minister at the time, and his activities to promote the Law out of a desire to further his personal interests as a politician (interview: Shvarts). Rosen and Bin-Nun (2005, p. 122) adopt a more centrist position, explaining that the legislation "cannot be attributed to a single central factor" and that Ramon's activity is not the key or the sole explanatory variable (interview: Bin- Nun). Moreover, in its final format, the Law differed from preceding bills, mainly in its capitation formula and in more controlled competition (interview: Rosen). Rosen and Bin-Nun claim that the crisis in the healthcare system, the publication of the recommendations of the investigation commission (the Netanyahu Commission), the impact of other reforms around the world, political backing (especially from the Minister of Finance), the impotence of factions opposing the Law (the General Labor Federation - Histadrut and the established health funds), pragmatism and compromises made in the process of its formulation, and economic growth (together with the euphoria of the Oslo peace accords) were the factors that created the window of opportunity that made legislation possible and without which the Law would not have been passed (ibid, p. 123).

In fact, Rosen & Bin-Nun, as well as others attribute the success of the legislation to support from Avraham Shochat, Israel's Minister of Finance at the time, rather than to Haim Ramon (ibid, p. 115; Geva-May & Maslove, 2000; interview: Israeli). Similarly, Bin-Nun, Berlovitz & Shani (2005, p. 175) claim that the Histadrut's declining power, the profound economic crisis of Clalit, the largest healthcare fund in Israel, and the Finance Ministers' support of the Law were the main contributing factors to the NHIL legislation. These scholars suppose that "if it had not been Haim Ramon it would have been someone else... the situation was catastrophic..." (interview: Shani). Some even believe that the many crises would have led to passing the Law within a few years, even if Ramon had not taken action (interview: Oron). On the other hand, the literature examining the success of reforms in public administration indicates that this type of reform is most likely to succeed with the backing of the Prime Minister (Galnoor, 2011, pp. 159-164). Along with the focus on Ramon's activity and Shochat's influence in passing the NHIL, a key question is: what was the role of former Israeli Prime Minister, Yitzhak Rabin, throughout this process?

Chinitz does not agree that the structural conditions were sufficient to pass the Law, even without Ramon's activity (interview: Chinitz). He and Chernichovsky attach more weight to the change in political power ratios and the declining power of the Histadrut (Chernichovsky & Chinitz, 1995; Chinitz, 1995) that, inter alia, blocked the ability of various interest groups to promote the Law. Likewise, along with an examination of the roles of the stakeholders in implementing the Law, Horev & Babad (2005) explain that in addition to the financial collapse of the Histadrut, which controlled Clalit, as well as many strikes by doctors, the Labor Party's (Haavoda, hereafter: LP) power surge in 1992 was also a contributory factor in passing the Law (interview: Horev).

Zalmanovitch (1997) emphasizes that beyond the desire to devise a single overall healthcare insurance program, the main reason for passing the NHIL was actually the desire to deal with the major crisis facing Clalit. Focusing on policy networks (Zalmanovitch, 1998), he further suggests the rise of the Likud Party in 1977 was a turning point that changed the relationship between strong players in the field. Likud wanted to reduce the state funding of the healthcare system in order to undermine the Labor alignment (Zalmanovitch, 2002, pp. 123-130). In this vein, Geva-May & Maslove (2000) argue that it was not economics but political factors that led to the passing of the NHIL. The economic crisis in fact provided a window of opportunity for political groups seeking to introduce reform. Accordingly, the Likud's attempt to weaken the power of the Labor Party was also a major factor deserving attention in any analysis of the success of the reform. Shirom (1995) points to Israeli lawmakers' pragmatism and compromises throughout the legislative process as an additional contributing factor to the passage of the NHIL. For instance, the lawmakers sacrificed the expansion of the basket of healthcare services and accepted those offered by Clalit in order to avoid arousing greater opposition from the Finance Ministry. Thus, according to Shirom, it was the choice of the decision makers to adopt the incremental changes that made it possible to pass the NHIL (interview: Shirom).

While other analysts have somewhat differing views on how crucial Ramon was, they all seem to agree that he played an important role in breaking a log jam that had existed for many decades. Nevertheless, despite the many political explanations offered, an analysis of the legislative process using public policy tools could shed light on additional aspects and provide more insights, especially in comparison with the failure of initiatives in other public policy areas. The majority of the above studies also refer to the existence of a "political constellation" that was created alongside the reform as a principal explanatory variable in passing the Law. However, in order to provide a more in-depth, systematic analysis of such a constellation, as well as the strategies, considerations, constraints and structures within which the players comprising it acted, we suggest using policy entrepreneurs as a theoretical tool.

Background to the formulation of the NHIL - Ongoing crises and attempted reforms

Two primary reasons are suggested for the historical failure of most legislative healthcare reform initiatives in Israel. The first reason is the effective opposition of the Histadrut, the powerful national labor union, which felt that severing the connection between it and Clalit would be a mortal blow. The Histadrut was afraid of losing members who, under the existing system, were required to become members of the union in order to be entitled to Clalit's healthcare services. In addition, the Histadrut wanted to preserve its alliances with the National Religious Party (Mafdal) and the extreme religious parties that benefited from the LP's control of the Histadrut (Ramon, un-published). Apart from that motivation, there was also a fear in Clalit that its nationalization could create a reduction in its budget and its autonomy. The second reason is the traditional, long-established, opposition of the Finance Ministry, particularly the Budget Department, to changes in the healthcare system. As a powerful bureaucratic body, the Finance Ministry feared a move that would increase public expenditure for healthcare would create an adverse effect on its own control and centrality. Interviews with politicians (Oron; Eldad; Ramon), bureaucrats (Ziloni; Lifshitz; Spivak; Cogan; Shani), and researchers (Doron; Chernichovsky; Kaye) further reinforce this claim.

Despite the highly problematic nature of the healthcare system in Israel on the macro level, for most players connected with it, a change in the status quo meant a worsening of their situation. Even among those who called for a change, there were many who benefited from the lack of any legal basis for the system's activities, from the lack of clarity about the scope of services to which every citizen was entitled, and from the fact that the Health Ministry was also a service provider (interview: Haber). The power of those opposing change to block the initiation of such change froze the existing institutional status, at least superficially, and for some time. However, beneath the surface many events were underway to pave the way for changes in the healthcare system.

When the right wing Likud Party came to power in 1977, government support for Clalit waned. The Histadrut was traditionally identified with the Israeli Labor Party, the Likud's political opponents. Likud government members "drained the healthcare funds... there were drastic cuts in funding and in particular the Histadrut..." (interview: Ziloni). Nevertheless, there were also quite a few Likud members (especially members the Histadrut) who benefited from the existing situation. Given this set of circumstances, and despite the problematic nature of the situation and their outward declarations, policy makers were in no hurry to make changes (interview: Haber). Thus, the rise of Likud contributed to the economic crisis at Clalit, which had begun even before Likud came to power.

During the 1980's the Israeli healthcare system was plagued by financial crises that led to growing dissatisfaction in Israeli society (Chernichovsky, 1991; Chinitz & Israeli, 1997). Long lines, strikes and various sanctions became routine during that period (interviews: Doron; Oron; Shemer; Sneh). However, despite the crisis situation, which was described as "anarchic" (interview: Haber), the strong interest of dominant players in the arena in leaving the status quo undisturbed prevented the introduction of change.

In 1988, the then Finance Minister, Moshe Nissim, proposed setting up a State commission to investigate the causes of the breakdown of the healthcare system and make recommendations to build a new and effective system (the Netanyahu Commission). In his proposal, Nissim hoped that this commission would submit its conclusions within one year, until which time the system would get by on a kind of "industrial quiet" status (Haaretz, August 21, 1990, p. 5a). The Netanyahu Commission differed from its predecessors in that it was a government commission and was headed by a judge, two characteristics that contributed to its widespread public perception as an apolitical State commission. The commission was structured in this fashion because of the understanding that any other solution would fail to achieve the "industrial quiet" its initiators sought. As described above, the initiators of the commission formed the solid foundation of the supporters of the NHIL. Thus, short-term considerations led to the creation of a critical junction that in the long run would affect the form of the policy change that was to come.

Design of policy change and policy entrepreneurs: The NHIL

On June 26, 1994, the Official Government Gazette (Codex 1994, no. 1469) published the enactment of the NHIL, thus heralding a rare, formal, institutional change in the country. In an age when the economic trend in Israel favored privatization, cuts, and a withdrawal from welfare policies towards neo-liberal trends, a universal welfare state law was passed that promised basic healthcare services to all of the country's residents (Shalev, 2003, p. 3). The Knesset Chairman at the time called it "a law that would go down as a cornerstone in the annals of social legislation in Israel" (Yedioth Ahronoth, June 16, 1994, p. 5).

How did the historical process that preceded the policy change pave the way for policy entrepreneurs who exploited structural conditions as a window of opportunity in order to promote their ideas? We suggest that such a change, which ran counter to the general neo-liberal trend, occurred less because of ideological shifts or economic crises and was due much more to the successful activity of Haim Ramon as a policy entrepreneur in an environment ripe for change.

Identifying windows of opportunity

As noted earlier, one of the characteristics of policy entrepreneurs is their ability to identify a window of opportunity. In his efforts to pass the NHIL, Haim Ramon certainly identified and took advantage of such an opportunity. The Ministry of Health does not attract many Israeli politicians (interview: Haber). Among other reasons, they are deterred by the fact that it is harder for politicians to reap benefits there for themselves and their supporters (interview: Shani). It is hardly surprising, then, that for a large part of the twenty-first century Israel has had no Minister of Health. Indeed, since the mid-1980's there were only two politicians who sought and aimed intentionally and of their own free will to serve as Health Ministers: Ehud Olmert and Haim Ramon (interviews: Bin-Nun; Eldad; Leventhal; Lifshitz; Pinchasi; Sneh).

Ramon decided to push for the enactment of the NHIL even before he became a Member of Knesset, after he understood that "State healthcare insurance was the only thing that Ben Gurion [Israel's first prime minister, author] did not have time to implement..." (interview: Ramon). However, it was not only ideologically-based considerations and motives that appear to have guided Ramon's actions. The claim that he was concerned about the uninsured public is refuted by many. They argue that this public constituted only 300,000 people, the large majority of whom were Arabs and ultra-Orthodox Jews, and for whom a solution could have been reached even without enacting the Law (interviews: Doron; Elkayam; Gafni). A greater understanding of what was going on in the LP and the Histadrut, as offered here, is based on that claim.

At the end of the 1980's, the Israeli LP was divided between supporters of the Shimon Peres and supporters of Rabin (Beilin, 1997, p. 63). Generally speaking, the Histadrut was identified with the Peres camp (interviews: Gelman; Maor; Ziloni), although - like Ben Gurion - Peres did not want the Histadrut to grow too strong. Accordingly, had Peres beaten Rabin in the 1992 primaries, there was no chance that Peres would have appointed Ramon, a man who opposed the Histadrut system and was identified with the Rabin camp (Greenberg, 2007, p. 180), as Minister of Health.

Ramon, like Olmert before him, was aiming for the top of Israel's political pyramid, hoping for a "major maneuver" that would lead him to the head of the Party (Klein, 2002). While still serving as the Secretary of Young Labor, he was singled out as someone who might later replace Rabin (Kadmon, 2009, p. 7). However, the major role that the issue of security plays in Israeli society presented both Ramon and Olmert with a similar problem: they both lacked military experience. Ramon was not unaware of this disadvantage and on more than one occasion declared: "... it is impossible to achieve national leadership if you are not an army man... without bringing about at least one significant revolution is some area..." (interview: Oron). Even in his first years in Israeli politics, Ramon recognized that a confrontation with the Histadrut could serve as his springboard to political leadership (interview: Ziloni). Not only did he succeed in presenting himself as someone who succeeded where Ben Gurion had failed (interview: Gelman), but when a player chooses such a major and powerful opponent on an equal level, he becomes much more powerful (interview: Doron).

This is a classic example of a policy entrepreneur exploiting an existing opportunity to sway the political outcome to his benefit in the absence of the requisite resources for action. In this case, it was an opportunity to create a revolution in the healthcare system and the existing institutional structure in Israeli society, in order to increase his chances of election at a stage when he lacked any of the necessary resources to effect institutional change. Ramon identified the healthcare system as a lever in a broader game (interview: Belsher), a lever that could raise him to the very peak of the political leadership pyramid. However, whether he saw healthcare as an important political area from an ideological point of view is doubtful. His confrontation with the Histadrut was not coincidental; it took place "in the knowledge that this was the brick in the wall which, if knocked out, would bring down with it the entire historical wall of Mapai [the dominant party in Israeli politics until its merger into the LP, author]..." (interview: Oron). Moreover, the decline of the Histadrut, whose legacy Rabin did not feel a part of (interview: Haber) and that lefthim in the "political wilderness" (interview: Zhulani), was also in line with Rabin's ambitions (interview: Maor). Ramon saw himself as the chosen future successor to Rabin, who had turned seventy years old in 1992 (interview: Gelman). That prospect further strengthened his resolve to weaken the Histadrut and its members, most of whom were not Rabin supporters. Furthermore, as he would later say in his famous "beached whales" speech in January 1994, Ramon saw the insistence of his party's members on preserving the status quo in the face of public opposition to the Histadrut as "political suicide" on the part of the LP (Barzilai, 1996, p. 314). This insistence earned the LP a negative image, both in the eyes of the Ashkenazi (Eastern European Jews) middle class and those of the more peripheral Mizrahi (Jews of Middle Eastern descent) public (Greenberg, 2007, p. 179). The reason that no one had previously taken any such strong action against the Histadrut was that "the Histadrut had enough power to say: Dear friends, we will not let this go by unmarked! And if anyone stands against us - we will bury him..." (interview: Oron).

This analysis illustrates how the creation of political coalitions between a small number of key players in politics, united around a common interest in implementing change, increases the chances of success for that change. This theoretical premise helps explain the action plan and conduct of a policy entrepreneur in the case of the NHIL. Aside from personal issues (the slogan: "the LP headed by Rabin") and the Likud's attack on the management of the Madrid Conference and relations with the United States (Barzilai, 1996, p. 249; Rabinowitz, 1998, p. 67), the LP's slogan in the 1992 elections was "A Change in Priorities." The party focused its attention on the transfer of resources from the settlements to an investment in education, healthcare and employment.

The election victory created the "determining trio" in the case of the NHIL: Ramon as Minister of Health, Shochat as Minister of Finance and Rabin as Prime Minister. The first two were also among those who formulated the healthcare clause in Labor's platform (interview: Bin- Nun). This trio also won the support of the Minister of Justice at the time, David Libai, who accelerated the legal framework for the Law (Barzilai, 1996, p. 270). The trio constituted one of the essential preconditions for this kind of reform - political support for the initiator of the reform. Without the political support of the Prime Minister, it is very hard to introduce reform into public administration in Israel (interviews: Ben-Shalom; Sneh). Ramon also explained: "Throughout, I had the absolute backing and support of the Prime Minister, and without Yitzhak Rabin's support it is doubtful whether the Law would have been passed..." (Ramon, unpublished). Thus, for instance, Rabin spoke openly to [Histadrut Secretary General] Haberfeld when the latter threatened to resign from the LP if Ramon did not cease his activities (Barzilai, 1996, p. 270). However, Rabin's support was not proffered only out of purely ideological considerations. Understanding that his lack of control of the Histadrut was a major reason for his fall as Prime Minister (1974-1977), Rabin was very interested in receiving assistance from the LP's young guard to free himself of his dependency on the Histadrut, which opposed him within the party, and in particular Ramon, who had declared that if he failed to pass the NHIL that would break the link between the Histadrut and Clalit, he would resign (Greenberg, 2007, p. 180).

Preparing for policy change: Political activity promoting the Law

Another main characteristic of a policy entrepreneur suggested in the theoretical section is the lack of the resources needed to influence policy outcomes. We explained that given the fact that entrepreneurs do not have access to all of the resources they need, they must negotiate, persuade, compromise and be flexible in a variety of areas. We also suggested that in order to succeed, policy entrepreneurs have to attract the support of key players in the policy arena, especially when factions opposing the change and favoring preservation of the status quo are powerful. Ramon's skills in promoting the NHIL proved to be crucial to the success of the policy change and are a classic example of this characteristic of the policy entrepreneur.

When he entered office, Ramon engaged in several simultaneous acts to promote the Law. He submitted the draftlaw to Rabin and all other ministers, and undertook a round of talks with them. The talks were effectively aimed at preparing the groundwork for the proposed change, identifying the principal points of dissent, and arriving at compromises with opponents of the change in the government, in the form of incremental amendments to the Law. At that stage the Histadrut already understood that enactment of the Law was a very real possibility (interviews: Gelman; Ziloni), and began trying to disrupt it or alter its format. Another step Ramon took was to form a coalition among opposition parties to formulate a bill very similar to his own, to be submitted by them in the event that the LP rejected his bill (Barzilai, 1996, p. 271).

To avoid complications and potential damage to his plans, Ramon set up a new committee called the Labor, Social Affairs and Healthcare Committee, which included representatives from other Knesset committees. He appointed Amir Peretz to head the new committee, while Haim Oron was appointed as Chairman of the sub-committee that addressed the size and scope of the healthcare basket of services (interview: Achdut). Others supporters of the Act were also placed in key positions (interview: Haber). Ramon's placement of those two figures, recruited to further the interests of the Law, in influential committee positions assured progress in that channel. He also called on powerful bureaucrats in the Israeli healthcare system, such as Mordechai Shani, who was Director General of the Ministry of Health in 1993-94. Shani contributed to formulating the Law and was perceived by many as a "bulldozer" wielding great influence in the matter (interview: Eldad). Thus, a policy entrepreneur's ability to manipulate the political agenda and the rules of the game in force at the time facilitates the implementation of change. The absence of any potential veto factors can also make the entrepreneur's work easier. The fact that Foreign Minister Shimon Peres - who could potentially have been the biggest hurdle to advancing the Law - was largely focused at that time on the Oslo Peace Accords (Peres & Naor, 1993) was a helpful element for Ramon in creating "industrial quiet."

Ramon was faced with two principal alternatives. The first was to try to carry out the recommendations of the Netanyahu Commission's majority opinion, which inclined towards far-reaching changes in every organizational aspect of the bureaucratic healthcare system. The second was to promote the recommendations of the more incremental minority opinion in all matters related to organizational and institutional change. Given that this analysis points towards Ramon's being motivated by his public perception as a powerful reformer, the question arises: why did he not choose the more deep-rooted change? One explanation might be a calculation (perhaps rightly so) that an institutional change so far-reaching as to destroy the existing structure of the healthcare funds would arouse very strong political opposition and make it too difficult for him to act (interview: Doron). Accordingly, Ramon did not insist on destroying the existing order, as recommended in the majority opinion (interview: Chernichovsky). As a result, in the eyes of many players in the arena at the time, the Law in fact proposed no significant organizational change (interview: Shani).

In addition, Ramon also prepared bureaucrats and interest groups connected with the healthcare system. Evidence of how much importance he attached to such bureaucrats is seen in his extensive activity to prepare the groundwork for change by holding meetings with the forum of hospital directors, the forum of regional heads and various workers' committees (interview: Gelman). His personal skill also helped him contain possible opposition from the leaders of the nurses' and administrators' organizations (interview: Haber). A confrontation with an alliance of those players could have ruined all of his maneuvers.

It is interesting to note that the Israel Medical Association (hereafter: IMA), as a powerful interest group, was a relatively minor element in Ramon's efforts to prepare for change. That being so, the question arises of why he did not act with the same intensity in the face of such an important interest group. Moreover, prior to 1995 the IMA was considered a purely professional union (interviews: Belsher; Wapner). The reason he was less active with this group is that the application of the Law in its existing format would have had no adverse effect on the IMA. "As soon as they [the doctors, author] were promised the same health insurance funds and the same salaries, they calmed down..." (interview: Doron). In those circumstances, Ramon was spared further potentially strong opposition that could have ruined the Law, as had happened with other proposals.

In the public arena Ramon tried to preserve and reinforce support for the Law (interview: Filc), which was very popular with the general public, in the government and the Knesset (Greenberg, 2007, p. 180). Ramon also had to contend with the ultra-Orthodox population and Israeli Arabs. The first did not, in general, support the Law, not just because "the public in question was largely Arab, for whom other solutions could have been found" (interview: Gafni), but primarily because their agreements with Clalit dictated significantly lower membership fees than the rest of the population (interview: Shvarts). Ramon encountered no special difficulties among the Arab public and its political representatives, mostly because that sector would benefit more than anyone else from the Law (interview: Bin-Nun).

The health funds were players - albeit not significant ones - in everything concerning the Law (interviews: Shani; Shemer). Their position on the Law derived to an extent from their financial status. While Leumit Health Fund's financial status allowed it to support the Law enthusiastically (interview: Elhayani), and Clalit also recognized the inherent financial advantages for it (interview: Doron), the better established funds, Maccabi and Meuhedet, feared that the Law would compromise their financial status (interview: Shani), and they joined forces to oppose it (interview: Gross). Maccabi even tried to recruit the Likud politicians to their side, but for Likud the Law represented a blow to the mechanism that had worked against them politically for many years, so they had no desire to assist Maccabi in contesting the Law. Moreover, for Likud it was a case of "let them get on with it..." (interview: Gelman). Accordingly, when Maccabi approached Likud to request their help in the political arena to block the initiative, the answer they received was: "We don't want the Law, but we do want to weaken the Histadrut..." (interview: Kaye). Ramon, aware that the initiative had many supporters among the opposition, tried to institute a dialog between his own party and opposition parties so that Knesset members from all parties would vote "at their discretion and according to their conscience" (Yedioth Ahronoth, January 6, 1994, p. 4).

Preparing for policy change: Neutralizing the Ministry of Finance

In the theoretical section we explained that when entrepreneurs recognize the activity itself as being in their interests, they deem it appropriate to compromise on the nature of the results of the change. This is true even if these results are not considered ideal. Given that the policy entrepreneur does not possess all of the resources needed to realize the outcomes of the entrepreneurial activity, it is clear that successful entrepreneurial activity must be based on persuasion, pragmatism and willingness to compromise. As we will demonstrate next, the compromise with the Israeli Finance Ministry's bureaucrats, the dominant player in the Israeli public policy arena (Cohen, 2011), was one of the critical junctures in Ramon's path to the policy change.

The compromises Ramon made were not only with the political echelons. He also identified the bureaucrats in the Finance Ministry as major players whose traditional opposition to the Law must be defused. It is widely assumed that the Finance Ministry was neutralized at that stage in a manner that was simple but quite rare in Israel - by the Minister of Finance (Shochat) dictating policy to his staff: "There will be obstacles to the Law, but there will be a NHIL! You will not stand in its way..." (interview: Rosen). Such an act on Shochat's part is not self-evident, as his bureaucrats could move to undermine his public image as a Minister who was not acting in his Ministry's favor. In fact, this was the only time (on such a large scale) when a Law was passed that appeared to contradict the wishes of the Israeli Ministry of Finance bureaucrats. Moreover, despite Ministry claims that Shochat was more attentive to other ministries' needs during his first term of office as Minister of Finance and took less care to preserve funds (interview: Lifshitz), in this matter he - a political ally of Ramon and Rabin - stood particularly firm in the face of his staff's obstinacy. He probably adopted this position because he understood that by helping Prime Minister Rabin and his probable future successor, Ramon, he would increase his chances of maintaining his political status. When Finance Ministry bureaucrats tried to appear before the government and the Ministerial Committee for Legislation and persuade them, in the early stages, not to pass the Law (interviews: Cogan; Freedman), Shochat prevented them from doing so and forced them to fall in line with him (interviews: Bin-Nun; Leventhal; Rosen; Sneh). Notwithstanding attempts by Finance Ministry bureaucrats, in March 1993 Ramon's bill passed the first stage of legislation - government approval - and was transferred for handling to a special committee headed by Peretz (Barzilai, 1996, p. 270).

Although the literature maintains that the Finance Ministry bureaucrats opposed the NHIL, not everyone feels that the Law was necessarily enacted against their wishes, because they were seriously afraid that Clalit would collapse and cause a major crisis (interview: Shvarts). Indeed, there seems to have been a turning point in the Finance Ministry's position towards the end of 1993 from its traditional opposition to support for the Law. This support came once the Ministry's staffunderstood that they would be allowed influence in areas important to them and that perpetuating the existing crisis would damage their interests too. Furthermore, tactical needs arising from their desire to maximize their influence in the matter made them try to hide the switch in their position from other players and the general public. A look at the printed press of the time shows that close to the time of passing the Law, the Ministry's opposition to it dwindled.

At the beginning of 1994, some recognized that the Finance Ministry was in fact supporting the Law (interview: Avital). The strongest basis for this claim comes from the person who was formerly Deputy Head of the Budget Department at the Ministry. He says that the Ministry's position in the matter did indeed turn around at the end of 1993, explaining that: "...at first the Ministry had reservations about the Law. In the beginning I opposed it. But the more I studied the material and familiarized myself with it, the more I supported it. I am telling you that I was not against the Law. And if I say that I was not against it - then the Ministry was not against it... Ramon might be surprised to hear me say so, because he believed that I was against it, but I was not..." (interview: Peltz).

Ramon appears to have understood that in order to obtain the Finance Ministry's cooperation, especially in light of its traditional opposition to the Law up to the end of 1993, he must include the powerful Ministry bureaucrats in the reform process. To that end, Ramon made many compromises vis-à-vis the Finance Ministry. It is therefore worth asking why Ramon accepted compromises on some matters while refusing to do so on others.

The answer to that question offers further insight into the policy entrepreneur's successful activity: focusing on key points of the change while compromising on the aspects that are less crucial to the faction (or individual) introducing the reform in order to advance the proposed change. In this case, Ramon made a large number of compromises as long as they did not affect his main goal - severing the link between the Histadrut and Clalit. For instance, he allowed the Ministry of Finance to freeze the existing budget so that additional sources of funds would not be added to those that already existed in the Law (interview: Bin-Nun).

However, Ramon's most important compromise was connected with the issue of updating the basket of healthcare services. One of the most significant compromises he made vis-à-vis the Finance Ministry was the agreement that the basket of healthcare services would be updated subject to Ministry approval (interviews: Shani; Sneh). For the Ministry, that compromise was one of the two greatest and most important impacts in formulating the healthcare policy. It was agreed that the basket would be updated once a year according to the healthcare cost index. All other updates would be made "according to need and within the framework of budget priorities, not according to an automatic formula" (Ministry of Finance, 2006, p. 58).

In effect, it was not financial considerations that were at the basis of this strategy on the part of the Ministry, but a political analysis of the existing players in the arena. Bureaucrats at the Ministry understood that as part of the structural change, the method of linkage to price indices would not fully compensate the healthcare funds (discounts on the cost of the healthcare basket) for the increase in the cost of a day's hospitalization. The motive of linking the update to healthcare fund costs (doctors' pay, price of a day's hospitalization and so forth) created a new reality whereby the healthcare funds themselves became a factor fighting against the rising cost of a day's hospitalization and an increase in doctors' pay. An increase in the wages in the healthcare system above the average pay in the economy would definitely damage the healthcare funds, which would have to pay more to their doctors and receive no compensation for doing so. Thus, "...when hospital directors wish to raise the cost of a day's hospitalization, no supervisor or healthcare coordinator should contend with that on his own, but the health insurance funds themselves should join in and oppose it. When there is a discussion on doctors' pay, the health insurance funds cooperate only with us [Ministry of Finance, author] and fight against prices rising..." (interview: Peltz). This insight demonstrates that when policy entrepreneurs want to effect a change, they may forfeit parts of the reform that they do not consider to be essential, thereby offering more conservative factors a compromise that they may consider critical. Finding areas of difference and being willing to compromise on them can be a good formula for successful policy change.

Another compromise was the agreement that no additional sources of funds would be added to the Clalit basket of healthcare services (interview: Ovadia), although it was perceived as less "wealthy" than the baskets of other funds (interview: Shemer). Further compromises were made in relatively close cooperation between the Ministries of Health and Finance such as leaving the matter of excess insurance payments open while determining a fixed premium, a uniform basket with competition at the level of service, and more. In fact, creative activity on the part of bureaucrats at those two ministries during the almost three-year period leading up to the enactment of the NHIL contributed significantly to its implementation (interviews: Bin-Nun; Haber). This creativity was mainly attributable to the good working relations that Ramon had developed with the Head of the Budget Department during the time he served as Minister of Health (interview: Haber). The Deputy Head of Budgets, who was in fact responsible for most of the Finance Ministry's approach, described the situation the best when he explained: "Ramon was wise enough to make sure that the Ministry of Finance would be included in the legislation process, that its voice would be heard and taken into account. In so doing he neutralized any possible opposition from the Ministry by offering it the possibility of making amendments where it [the Ministry] wished to do so... it became a struggle between Ramon and the Histadrut, with everyone sitting on the sidelines not believing that Ramon would succeed..." (interview: Peltz).

Trojan horse strategy and the resolve of the policy entrepreneur: The defining act in enacting NHIL

As suggested in the theoretical section of this article, a policy entrepreneur must often take calculated risks and act with resolve in order to bring about change. How necessary are that resolve and risk-taking if the entrepreneur's actions are to be effective? As we will show next, an examination of Ramon's acts illustrates the theoretical insight presented in this article regarding alternatives and strategies on the part of policy entrepreneurs in various decision-making scenarios. This section focuses on the Trojan horse strategy, describing the policy entrepreneur's entry into an institutional body comprised of powerful people in order to neutralize opposition from the inside. In other words, new forces enter into old institutions and break through the institutional framework to replace it from the inside. Such a strategy is needed mainly when key players view proposed changes as being deep-rooted and potentially damaging to them.

The Histadrut leadership, with Haim Haberfeld at its head, tried to frustrate Ramon's activity. Aside from raising initiatives to insure uninsured populations in order to dampen Ramon's ideological claims (interview: Ziloni), they obtained enough support from members of the LP center that in July 1993 Haberfeld was able to force a special conference of the party committee before the bill was submitted for the first of the three readings in the Knesset necessary to pass a bill (Barzilai, 1996, p. 272). Ramon did succeed in postponing the conference until after the first reading, but the understanding that without taking control of the Histadrut the Law would not be passed led him and Amir Peretz in his wake to propose the latter as a party candidate for Head of the Histadrut (ibid, p. 276). In January 1994, internal elections were held in the LP for Secretary General of the Histadrut. Against the sitting candidate, Haberfeld, Ramon and the socalled "octet" (eight dovish LP members) put forward Peretz, who pledged support for the NHIL (Greenberg, 2007, p. 181). It came as a surprise when the unpopular Haberfeld beat Peretz in the election (Barzilai, 1996, p. 288). Many at the Ministry of Health saw this as the blow that would put an end to the two-year-long efforts to formulate the Law (interviews: Bin-Nun; Rosen).

Another fear at that time was that Rabin would withdraw his strong support of Ramon because of concern that Histadrut opposition would jeopardize the Oslo Accords with the Palestinian leadership (Goldstein, 2006, p. 415). During that period, the Histadrut also intensified its efforts to recruit public opinion against the Law. Histadrut pressure leftits mark both on Rabin himself, who at that point was probably afraid of the wrath of senior Histadrut members (interview: Peltz), and on government ministers, including those who had hitherto supported Ramon. Thus, the Prime Minister's support (which is an essential precondition to passing reform in Israel) gradually dissipated to the point of utter lack of support, as evidenced by his refusal to support the Law in January 1994, when Ramon made his famous "beached whales" speech protesting the powers opposing change in the LP and the Histadrut (Kadmon, 2009). The Minister of Finance, Shochat, also explained that in the current constellation the chances of the Law being approved in its present format were slim (Maariv, February 1, 1994, p. 5). The "iron triangle" in the form of the Prime Minister, Minister of Finance and Minister of Health began to fall apart. In January 1994, the Chairman of the Knesset announced his intention to remove discussion of the bill from the government's agenda.

In situations where an entrepreneur encounters serious opposition from key players, a successful political initiative can employ original and unfamiliar tactics, coupled with a willingness to take risks. At this point, when Ramon lost Rabin's unreserved and uncritical support, he made a move that, more than any other, proved his perseverance and determination to pass the Law. On February 8, 1994, despite attempts to prevent him from doing so (Beilin, 1997, p. 277), he resigned his position as Minister of Health and returned to run for the post of head of the Histadrut, with a new party, together with Amir Peretz and probably with Rabin's blessing (interview: Ziloni).

Ramon's entry into the Histadrut was in effect that most important act leading to the enactment of the Law. In May 1994, Ramon's faction won the Histadrut elections, beating out the LP headed by Haberfeld, and winning 46% of the votes (Barzilai, 1996, p. 398). It is interesting to note that at that point Haberfeld had a chance of trying to form a coalition with Ramon's opponents (including those from Likud) and so continue to oppose the NHIL (interviews: Gelman; Oron). However, Rabin then imposed party discipline (interview: Sneh) and instructed Haberfeld that for ideological reasons "the party would not enter into a coalition with the Likud" (interview: Ziloni). For reasons that remain unclear - perhaps because of his health - Haberfeld accepted his fate. And so Ramon became the de facto and de jure ruling Chairman of the Histadrut, with the intention of severing the organization from Clalit.

On June 15, 1994, the NHIL passed its third reading in the Knesset and was finally approved. A dramatic policy change had taken place in Israel. Not a single Knesset member voted against it. Sixty-eight Knesset members voted in favor and 27 Likud members abstained (Yedioth Ahronoth, June 16, 1994, p. 5). The majority of the dissenters were the extreme religious parties, which opposed the NHIL (interview: Gafni), fearing that the preferential healthcare fees they had hitherto enjoyed would be adversely affected (interview: Shvarts). However, at that stage they were not major players in the policy arena and could not stand alone against the change. A sociodemocratic law had come into force in a neo-liberal era.

Summary and discussion

This article has discussed the influence of policy entrepreneurs on designing public policy while focusing on their characteristics, strategies and motivations. After defining the essence of what comprises a policy entrepreneur, the article specified the principal characteristics of entrepreneurial acts and described what constitutes successful and effective entrepreneurial activity. A policy entrepreneur is presented as a person who may emerge from among the general public, some interest group or another, or from among decision makers - politicians or bureaucrats who are active in the public policy arena. A combination of three characteristics in the creation of political entrepreneurs is suggested here: the existence of an opportunity to influence political outcomes; the total absence of the tools needed for the purpose; and the desire to maximize personal benefit through activity with the declared goal of influencing political outcomes. We tested this theoretical framework using the formulating of the NHIL in Israel in 1994 as a case study. While the focus is on the Israeli experience, the theoretical insights developed in this article could also provide some tentative lessons for other healthcare systems and reforms, including the US.

We highlighted self-interest as one of the primary motivating forces of policy entrepreneurs. In the same way as entrepreneurs in the business arena act in order to maximize their benefit, policy entrepreneurs never ignore their self-interests. The article illustrates how an entrepreneur's ability to create small alliances of powerful players, who join forces on the basis of common interests (in the Israeli case in particular, the support of the Prime Minister), increases the chances of success in effecting change. The article details the important strategies and structural conditions necessary to the policy entrepreneur's success and describes, by way of example, Haim Ramon's activity as a gifted policy entrepreneur in enacting the NHIL.

The combination of motivation and a window of opportunity proved to be the key to Ramon's success in effecting policy change. As a successful entrepreneur, he identified the needs of significant groups in society and the political potential inherent therein to fulfill their needs. We also maintained that identifying an opportunity for change could also take the form of identifying dynamics different than those of the entrepreneur (e.g., the conflict of interests between the members in his party) and exploiting these in effecting change. In addition, we demonstrated how the existence of an opportunity could affect the entrepreneur's willingness to take risks. Thus, entrepreneurs may adopt a Trojan horse strategy that may appear outwardly to entail greater risk than the entrepreneurs estimate because they can produce greater benefits due to the opportunity identified.

Some two years after the NHIL was passed, many incremental amendments were made to it that were in accordance with the neo-liberal approaches of privatization, competitiveness and the free market (Mizrahi & Cohen, in press). This trend is not unique to healthcare policy (Doron, 1999). However, these changes do promote informal payments for healthcare and other problematic activities by individuals and groups in Israeli society (Cohen, in press; Cohen & Mizrahi, 2012). In response to these developments, supporters of the welfare state try to recruit influential players to strengthen and influence the public policy arena. They are especially keen to attract people identified with an ideology that supports an expanding social state. The practical contribution that may be gleaned from this combination of those forces is the conclusion that that strategy in itself is not effective. In order to establish a social-democratic value-based social policy, it is necessary to refer to, seek and even create a system of incentives for influential politicians and bureaucrats based not only on ideologies but also on their personal self-interests. In the practical political test, the ideological dimension itself could be the very aspect that lets down those who rely on it and only on it.

Footnote

2 Acknowledgement: I am grateful for the comments and suggestions of Prof. Shlomo Mizrahi from Ben-Gurion University of the Negev, Israel, Prof. John Gal from the Hebrew University, Israel, Prof. Shifra Shvarts, from Ben-Gurion University of the Negev, Israel, and Prof. Roger D. Congleton from West Virginia University, West Virginia, USA and Ms. Naama Ende on the original paper. I remain responsible for any errors of fact or interpretation in my analysis.

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Appendix

Appendix 1: List of interviewees

(Names are listed in alphabetical order. Positions are accurate as at the time of the interview unless expressly stated otherwise).

1. Prof. Leah Achdut, former Deputy Director of Research and Planning, National Insurance Institute, April 10, 2008, Jerusalem

2. Mr. Eyal Avital, former Deputy Director, Budgets Department, Ministry of Health, October 15, 2008, Modi'in.

3. Dr. Yigal Ben Shalom, Director General, National Insurance Institute, January 11, 2007, Jerusalem.

4. Dr. Yoram Belsher, Chairman, Israel Medical Association, February 10, 2008, Ramat Gan.

5. Prof. Gabi Bin Nun, Deputy Director General, Budgets, Ministry of Health, December 4, 2007, Jerusalem.

6. Prof. Dov Chernichovsky, former member of Netanyahu Commission, November 12, 2007, Beer Sheva.

7. Dr. David Chinitz, researcher, Hebrew University of Jerusalem, August 17, 2008, Jerusalem.

8. Mr. Reuven Cogan, Health Affairs Coordinator, Budget Department, Ministry of Health, March 2, 2008, Jerusalem.

9. Prof. Avraham Doron, researcher, Hebrew University of Jerusalem, May 4, 2008, Jerusalem.

10. Prof. Gideon Doron, former member of Yitzhak Rabin's strategic team, February 13, 2008, Tel Aviv.

11. Prof. Haim Doron, former Director General, Clalit Health Services, February 17, 2008, Sheba Medical Center at Tel Hashomer.

12. Prof. Aryeh Eldad, member of Knesset Labor, Welfare and Health Committee, May 18, 2008, Jerusalem.

13. Dr. Asher Elhayani, Director of Central Region, Clalit Health Services, March 29, 2007, Tel Aviv.

14. Mr. Danny Elkayam, Director of Insurance and Health Department, National Health Institute, November 27, 2007, Jerusalem.

15. Dr. Danny Filc, researcher and board member of Physicians for Human Rights - Israel, June 5, 2008, Beer Sheva.

16. Rabbi Moshe Gafni, member of Knesset Lobby for Public Health, May 1, 2008, telephone interview.

17. Mr. Gershon Gelman, Chairman, Histadrut Tel Aviv and Jaffa region, January 13, 2008, Tel Aviv.

18. Prof. Revital Gross, senior researcher, Smokler Center for Health Policy Research, Myers- JDC-Brookdale Institute, December 28, 2008, Jerusalem.

19. Mr. Shraga Haber, former Assistant Director General and Head, Division for Planning, Budgeting and Health Economics, Ministry of Health, February 12, 2009, Jerusalem.

20. Dr. Tuvia Horev, Acting Director, Taub Center for Social Policy Studies in Israel, September 12, 2008, Jerusalem.

21. Prof. Avi Israeli, Director General, Ministry of Health, November 11, 2008, Jerusalem.

22. Dr. Rachelle Kaye, Deputy Director General, Planning and Economics, Maccabi Healthcare Services, November 22, 2007, Tel Aviv.

23. Dr. Dan Koren, former Labor Party Member of Knesset, March 20, 2008, Tel Aviv.

24. Dr. Alex Leventhal, Director, International Relations Department, Ministry of Health, September 3, 2008.

25. Dr. Yaakov Lifshitz, former Director General, Ministry of Finance, November 26, 2007.

26. Mr. Yoel Lifshitz, Adv., Deputy Director General for Supervision of Health Funds, Ministry of Health, October 12, 2008, Jerusalem.

27. Mr. Zvi Maor, Director, Sharon-Shomron Region, Clalit Health Services, Occtober 18, 2007, Netanya.

28. Mr. Haim Oron, Member of Knesset and member of Knesset Finance Committee, January 24, 2008, Tel Aviv.

29. Dr. Baruch Ovadia, former Director of Social Services, Clalit Health Services, March 16, 2008.

30. Mr. Haim Peltz, former Deputy Supervisor of Budgets and Healthcare Coordinator, Ministry of Finance, January 1, 2009, Ben Gurion International Airport.

31. Mr. Aryeh Pinchasi, Head of Human Resources Department, Ministry of Health, November 6, 2007, Jerusalem.

32. Mr. Haim Ramon, Deputy Prime Minister and member of Foreign Affairs and Defense Committee, March 2, 2008, interview by mail.

33. Dr. Baruce Rosen, Director, Smokler Center for Health Policy Research, Myers-JDCBrookdale Institute, February 5, 2008, Jerusalem.

34. Dr. Ran Saar, Director, Central Region, Maccabi Healthcare Services, October 11, 2007, Givataim.

35. Prof. Mordechai Shani, former Director General, Ministry of Health, and member of Netanyahu Commission, April 22, 2008, Sheba Medical Center at Tel Hashomer.

36. Prof. Joshua (Shuki) Shemer, former Director General, Ministry of Health and Maccabi Healthcare Services, June 13, 2008, Sheba Medical Center at Tel Hashomer.

37. Dr. Michael Sherf, Director, Soroka University Medical Center, June 5, 2008, Beer Sheva.

38. Prof. Aryeh Shirom, former member of Netanyahu Commission, December 21, 2007, interview by mail.

39. Prof. Shifra Shvarts, researcher, Ben-Gurion University of the Negev, July 21, 2008, Sheba Medical Center at Tel Hashomer.

40. Dr. Ephraim Sneh, former Minister of Health, February 26, 2008, Jerusalem.

41. Prof. Avia Spivak, former Deputy Governor, Bank of Israel, February 26, 2008, Jerusalem.

42. Ms. Leah Wapner, Adv., Secretary General, Israel Medical Association, February 10, 2008, Ramat Gan.

43. Efraim Ziloni, Adv., Chairman, Economic and Social Division, Histadrut Laborers Federation, February 27, 2008, Tel Aviv.