Towards an Anthropology of Resilience:
Educational, Welfare and Medical Institutions inJapan
Roger Goodman
St Antony’s College, University of Oxford
Tokyo College, University of TokyoMay 2024

Research background: (1) Comparative education and welfare

Research background (2): Anthropology of institutions

Key researchvariables since
1980s (1):Japan’schanging
population
structure
Population over 65: 1980 – 9%; 2020 – 29%

Key researchvariables since
1980s (1):Japan’schanging
population
structure
Japanese population shrunk by 800,000 in 2022 (=population of Yamanashi prefecture)

Key research variables since 1980s (2): Neo-liberalpolitical rhetoric• Strong theme developed in 1980s with Reagan, Thatcher andNakasone• Privatisation of national assets (railways, telecommunications,steel, coal etc)
• The economic ‘market’ should be allowed to decide which
institutions survive and which disappear.
• The government should not intervene in markets; competition will
drive quality.

Earlier puzzles and theses related to these themes

Puzzle: Why were so many high schools willing to be identified as special institutions(ukeirekō) to receive ‘problematic’ kikokushjijo in 1980s (40% drop in schoolchildren1982-2000)?
Thesis: Kikokushijo came from elite families who managed to maintain andreproduce their cultural capital under guise of ‘internationalism’; many private highschools (600 ukeirekō) marketed this cultural capital as part of their kokusaika(internationalisation) rhetoric to attract and retain other students when numbers falling.

Puzzle: Why was number of yōgoshisetsu exactly the same in 1995 as 1975 despite 37%
drop in live births over that period?
Thesis: 90% of yōgoshisetsu were private of which 70% were flagship institutionsof large family-owned-and-managed dōzoku keiei shakai fukushi hōjin; they ‘created’ newmarkets to survive, including ‘discovering’ child abuse and providing support for victims.
Puzzle: Why did the huge reduction in the number of private universities predicted inearly 2000s never happen despite 40% decrease in 18-year-olds 1992-2008?
Thesis: 80% of private universities were private of which 40% were flagshipinstitutions in family-owned and managed dōzoku keiei gakkō hōjin; they radically
restructured in order to survive and maintain the existence of the hōjin.

Key explanation: Family business as a source of resilience• Globally, Japanese family businesses have longest average life-spans,double that of US; 45% of companies in world which have been in businessmore than 200 years are Japanese.
• Linked to the idea of the ie and the dōzoku system and primacy ofcontinuity; includes great use of adoption, especially adult adoptions, ofwhich up to 80,000 cases/year.
• Can see not only in commercial world but also public fields such aswelfare, education and medicine.
• Hence, very few ‘less-competitive’ private senior high schools,
yōgoshisetsu, universities have closed over past 40 years despite
demographic, economic, political pressures. What about private medicalinstitutions?

Family-run private hospitals & clinics (dōzoku keiei iryō hōjin)Historical development very similar to welfare and education; stateencouraged private medical sector to expand to reduce need for state
expenditure, especially in post WW2 era; offered very generous tax incentives.
Grew very rapidly in size and number from beginning of 1960s when cameunder universal health insurance schemes; technically not-for-profit, butbetter thought of as for-profit institutions that do not pay dividends toshareholders.
Health costs grew rapidly in postwar period, but not as fast as GDP.
Today, 70% of all 8,000+ hospitals and 90% of all 100,000+ clinics in Japan are
private, of which combined around 80% might be defined as ‘familybusinesses’.

Puzzle: Why is there so little research on family-run
educational and welfare institutions in Japan?
• Perceived as ‘feudal’, ‘old fashioned’ anachronisms in the world of‘professional management’, ‘stakeholder/shareholder capitalism’and ‘independent boards’; hence rarely talked about even if widelyrecognised (‘taboo’)• Danger of ‘socio-emotional capital’ leading to scandals(untransparent finances; appointment of underqualified family
members; involvement in ‘political’ worlds; family feuds….)• Lack of research is also true in area of medical institutions…..

Family-run private hospitals and clinics (dōzoku keiei iryō hōjin)Research questions: Given so many medical institutions are family-owned
and managed what are the:• - implications for health outcomes and health costs?
• - implications for employment practices and institutional stability?
• - lessons for systems elsewhere?

Research methods:
Interviews with:
politicians; policy makers; academics
medical associations; equipment providers, pharmaceuticalcompanies
private hospital owners, hospital directors, doctors
public sector hospital directors, doctors
nurses; support staff
Secondary literature on hospital management- Also, participant observation: Not medically qualified, but patient
experienceJapanese healthcare from a global perspective
Japan has world-class health and a world-class healthcare system (notnecessarily connected):
Excellent population health (life expectancy; infant mortality; workdays
lost through ill health)Regular, low-cost health checks
Universal health insurance, premiums linked to income
Egalitarian, direct access to health providers and treatments, nowaiting lists
Strong cost control mechanisms; OECD figure is 81% of UK ageadjusted spend per capita OECD 2022 figures (but government shareof costs 35% and increasing, which belies ‘Bismarckian’ model label.)Family-run private hospitals & clinics (dōzoku keiei iryō hōjin)Two main types: (a) solo practitioner clinics and hospitals (b) large multihospital corporations ‘medical-social industrial complexes’ withintegrated care institutions and 1000s of employees
Examples of case studies of family-run hospitals and clinics:• 5th generation (one adoption) single-doctor clinic practice in Saitama
started in Meiji period (7 employees, part-time public sector doctor, 2nurses, 1 radiologist, 1 lab technician, 2 receptionists plus
occasionally mother )• 11th generation (3 adoptions) family-run hospital corporation, with
HQ in Chiba started 350 years ago (5000 employees offering life-time
employment, company union, seniority promotion; company‘culture’)
Governance and finance: Hospital/clinic owner generally serves aschair of board (so has management control); income come throughhealth insurance programmes and patient co-payments‘Fieldwork’ as a patient (1)Compare two personal experiences with what might happen in UK.
Trapped sciatic nerve• Japan: Go to internal medicine 内科 clinic for pain relief who says needorthopaedic clinic 整形外科. At nearest clinic, it takes in total one hour
for: registration, doctor consultation, 4 x-rays, steroid injection, electrictreatment, lumber belt fitting. Total cost (30%): ¥4200; generic medicines¥600; follow-ups ¥600; daily electric therapy ¥330; after 6 weeks sent for
MRI (¥7680) to check if need further treatment.
• UK: 3 days to get GP appointment for pain killers; return one week later;
book x-ray appointment at main hospital in one week; one week for x-rays
to return to GP; GP refers to consultant for appointment which currently
has 10-12 week waiting time; if still needed, consultant would give sametreatment as Japanese clinic.

‘Fieldwork’ as a patient (2)BPPV (Benign paroxysmal positional vertigo)
Japan: Feeling dizzy; go to employer medical centre¥400; arrange same day MRI on brain ¥7680; clear, so
sent to neck specialist at national university hospital, Xray and consultation ¥2190, sent for second MRI ¥4000;
see different neck specialist for consultation, all clear¥400; referred to ENT consultant, does hearing andother tests and confirms BBPV due to stones moving ininner ear which says will clear up by itself ¥7400.
UK: All GPs see BPPV regularly and will reassure patienton first visit that will clear up by itself (NB. UK MRI, longwaiting list; private charge would be ¥155,000.)

Examples demonstrate some key characteristics of Japanese healthcare system

World’s highest use of medical equipment (MRIs, CTs 5 x OECD average)
Visits to physician 2 x OECD average; number of doctors 0.7 x OECD average(female 50% OECD average);
Physician consultations 3 x OECD average; clinics on average sees 40
patients a day
Fees-for-services ‘directs’ medical interventions: more therapy, more tests,
more prescriptions, less surgery (big changes expected in June 2024)
No specialist certification; self-accreditation; medical licences for life
Big differences between public/private healthcare systems in terms of
medical school fees/pay/status/challenge/career independence (ikyokusei)

What is distinctive about family-run institutions canbe seen in topics covered in popular Q and A books!
• 『4つの経営資源を活かす―クリニックの黒字化メソッド』 (How toturn around your clinic: Making the most of four managementresources)• 『医師の独立・開業を成功に導く―家庭医療・専門医のススメ』(How to lead to success in opening your clinic: Suggestions for family
medicine/specialised medicine)• 『医師の妻がノウハウ0から人気クリニックを作り上げた―業界の常識にとらわれない経営』(How a doctor’s wife created a popularclinic from 0 expertise/experience: Management beyond industry-widecommon sense)• 『がんばらない小さなクリニックの経営戦略』(Easy management
strategies for small clinics)• 『決定版 クリニック開業ガイダンス』(Definitive guidance on
opening your clinic)

How to turnaround your clinic: Making the most of four management resources• In an era where loss-making management is commonplace, nearly 10% of clinics areoperating at a loss.

• Advantages of doctors opening independently• Why you should hurry, if you are thinking about opening a business• Is it advantageous to open a business through succession? 承継による開業は有利なのか？
• Can luxury cars be included in expenses? 高級車は経費に計上できるか？
• Advantages of having your spouse work 配偶者に働いてもらうメリット• Reducing the tax burden through medical incorporation 医療法人化による税負担の軽減• Incorporation is essential for business succession 事業承継には法人化が必須• To avoid future inheritance "disputes"• The more medical equipment you have, the more you can meet the needs of patients?
• His father's clinic, which he was taking over, was controlled by problematic staff.
Can problem staff be fired? 問題スタッフを解雇できるか• Why is your advertising not attracting new patients?
• How to deal with monster patients

Some initial ‘thoughts’ on potential impact of family-run medical
institutions compared to Beveridge models (e.g. NHS in UK)• Japan is often criticised for having a highly fragmented system: 4000+
insurance programmes, huge number of hospitals (8000+) and evenmore one-person clinics (100,000+), practice of doctor-hopping.
• This can lead to differences in health provision and outcomes but:
• In order to ensure continuity of (often family) business, private hospitals
and clinics need to compete to attract and keep patients; competition
can drive improvement in quality/efficiency of service.
• In huge centralised NHS system, individuals (and individualdepartments) focus only on their own role, little personal sense of cost
incentives.
• Japanese medical system may contain stronger incentives and control
structures to help improvements than NHS.