CONTENTS
Overview
1. Demographic Trend Of Japan
2. Birth Rate
3. Mortality
4. International Comparison
5. Administrative Structure Of Public Health
6. Training And Research Of Public Health
7. Financing Of Public Health Related Research
8. International Cooperation And Contribution
9. OECD Health Care Quality Indicator Project (OECD HCQI)

1
1
3
4
6
7
9
9
10
11

Chapter 1. Health Status
1. Health Status And Utilization Of Health Services
2. Health Promotion Campaigns
3. Health Promotion Act And National Health And Nutrition Survey
4. Health Related Problems

13
13
14
17
18

Chapter 2. Lifestyle Related Diseases And Metabolic Syndrome
1. A Paradigm Of "Lifestyle Related Diseases" And “Metabolic Syndrome”
2. Current Status Of Major Lifestyle Related Diseases
3. Metabolic Syndrome: A Waist Size Story

20
20
20
23

Chapter 3. Health Protection
1. Maternal And Child Health
2. Mental Health
3. Oral Health
4. Infectious Diseases
5. Research And Public Subsidies For Diseases Of Scientific Interest
6. Public Assistance For A-Bomb Victims
7. Renal Failure
8. Organ Transplantation

25
25
26
28
29
35
36
37
38

Chapter 4. Medical Care
1. General View Of Japan’s Health Policy And Planning
2. Health Planning
3. Health Manpower
4. Hospitals And Clinics
5. National Hospitals And National Centers
6. Accreditation Program Of Hospitals
7. Patient Safety And Medical Malpractice

40
40
40
41
41
43
44
45

Chapter 5. Health Economics
1. Health Insurance
2. Health Insurance For The Old-Old
3. Fee Schedule And Reimbursement System
4. Claims Processing And Computerization

48
48
49
51
52

5. National Health Care Expenditure
6. The Structural Reform 2008

54
56

Chapter 6. Pharmaceutical Affairs
1. Pharmacies And Separation Of Prescription And Dispensing
2. Pharmaceutical Reimbursement And Price Setting
3. Clinical Trials
4. Japan’s Pharmaceutical Industry
5. Pharmaceutical Monitoring And Surveillance
6. Blood Products
7. Substance And Drug Abuse

58
58
59
60
61
63
63
64

Chapter 7. Environmental Health
1. Air Pollution
2. Drinking Water Supply
3. Sewage System
4. History Of Pollution Related Diseases
5. Environmental Pollution Victims Compensation System
6. Measures Against The Global Warming Issues
7. Public Health In Environmental Disasters
8. Food Sanitation
9. Waste Disposal

65
65
67
68
68
69
70
71
72
74

Chapter 8. Industrial Health
1. Historical Background
2. Administrative Structure Of Occupational Safety And Health
3. Work-Related Accidents
4. Workers’ Compensation
5. Karo-Shi Controversy
6. Asbestosis

76
76
76
76
77
78
78

Chapter 9. Social Security And Welfare
1. Social Security And Financing
2. Welfare For The Indigent
3. Maternal And Child Welfare
4. Welfare For The Disabled
5. Welfare For Homeless
6. Pension System
7. International Treaty Of Social Security

80
80
82
83
84
85
85
87

Chapter 10. Long-Term Care
1. Administrative Structure
2. Beneficiaries
3. Financing
4. Need Assessment
5. Benefit
6. Need Assessment Tool
7. Care Management
8. Experience In Five Years And Reform In 2006

89
89
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91
92
92

Overview
1. Demographic Trend of Japan
According to the national census conducted on 1 st October 2007, Japan’s
population is estimated to be approximately 128 million or approximately 2.1% of theworld population (6.15 billion). As of 2003, Japan ranks as the 9 th country in termsof population but is soon expected to slip out of top 10 due to stagnant population
growth.

The year 2005 marked a mile stone in Japan’s population history: it showed thefirst natural decrease in population. The number of deaths in the year (1,083,796)
surpassed the number of births (1,062,530) for the first time, or 21,266 natural
decrease of the population. According to the future population forecast, Japan hasreached its peak population one year earlier than originally expected (2006) and will
decline thereafter. In 2100, the population will shrink to 64 million, roughly thehalf of the present population (level of 1930).
Due to the sharp decline of birth rate, Japan’s population pyramid does not appear
pyramid any longer; rather it appears as “mush room”. As the two protrusions
indicate, Japan has seen baby booms twice: one shortly after the Second World War(1947-50) and second in early 1970s. Japan will face an unprecedented aging
society when the first baby boomers (now over 50 years old) retire.
1

The stagnant population growth can be explained by sharp drop of birth rate. The
crude fertility rate hit the record low of 1.25 in 2005. Japan is one the countries
with the lowest crude fertility in the world following Italy (1.26) and Korea (1.17).
On the other hand, mortality has consistently improved over the years. The
improvement has been most prominent in infant mortality. Japan now boasts theworld’s lowest infant mortality with only 2.6 out of 1000 newborns die within thefirst year (2006). This figure was less than half of that of the U.S. (6.9 in 2005).

Improvement of mortality has prolonged life span to one of the longest in the world:
78.53 years for male and 85.49 years for female (2005 life table). Here again theyear 2005 marked a turnaround: the life span shrank slight from previous year
possibly due to the influenza epidemic.

Agin g Japan e se popu lation : Past an d Fu tu re[Prediction by Institute of Population & Social Security]

100%

elderly(65yo or over）

80%

60%
productive age(15～64yo）

40%

20%

young(0～14yo)

00
21

90
20

80
20

70
20

60
20

50
20

40
20

30
20

20

20

10
20

00
20

90
19

80
19

70
19

60
19

50
19

40
19

30
19

19

20

0%

Prolonged life span coupled with declining birth rate will inevitably make the entire
population structure aging. According to the estimate, the percent of the elderly2population, now 21%, will reach the peak of 35.7% in 2050.
Reflecting the world longest life span, Japan also boasts one of the highest
concentrations of centenarians. According to the estimate by MHLW, there are28,395 centenarians nationwide as of 15 August 2005, of whom 85.4% are women.
The elderly who reaches100 years old will be cerebrated with presents (silver goblet)from the Prime Minister pursuant to the Elderly Welfare Act since 1963. In 1963,
the number of awardees was 153, but the number has increased to 15,370, or 100 foldin 2005.

2. Birth Rate
Aging of Japan’s population is attributable not only to prolonged life span but also
to the sharp decline of birth rate. Japan once boasted of its high fertility rate.
During 1947 through 1949, the first baby boom, the annual live birth was around 2.6
million or the crude fertility rate of 4. However, the crude fertility rate has
consistently declined to the latest figure of 1.34 (2007), far below the replacementlevel. This figure is higher than Korea (1.13, in 2006) but far lower than the U.S.
(2.1 in 2006).

A sharp decline in birth rate seen in 1961 was due to a superstition concerning the“fire horse” year according to the lunar calendar coming by every 60 years.

3What are noteworthy about the trend of births are abortions. Japan has a liberalpolicy about abortions (cf. Maternal and Child Health). As vividly illustrated below,
the number of pregnancies has remained stable in the postwar era until 1973. The
decline of births was brought about artificial “culling” of pregnancies.

3. Mortality
Crude mortality rate of Japan in 2006 was 8.8 per thousand. Crude mortality rate
has been on a gradual increase since 1982 when the figure was 6.0 reflecting theaging of population.
However, when the rate is age-adjusted, the mortality has consistently declined to
the lowest of the developed countries. The decline was brought about first by the
sharp decline of tuberculosis in the post war era and second by the sharp decline of
cerebrovascular diseases.
4

400

400

A g e - a d j u s t e d m o r t a l i t y [ fe m a l e ]A ge - adj u ste d m o rtal i ty[ m al e ]350

age-adjusted mortality (per 100,000pop)

disease250
ma l i g n a n c y
200

150

hea rt d is ea s e

100

age-adjusted mortality (per 100,000pop)[so urc e:vital statistics, dise ase c lassification was change d in 19 95]
cerebrovascular

300[source :vital statistics, disease c lassific ation was c hanged in 19 95]

350

300
cerebrovascular250

disease200

150
ma l i g n a n c y

h e a r t d is e a s e

100

p n e u mo n i a50

p n e u mo n i a50suicidesuicide
0

'98

2001

'95

'92

'89

'86

'83

'80

'77

'74

'71

'68

'65

'62

'59

'56

50

'53

'98

2001

'95

'92

'89

'86

'83

'80

'77

'74

'71

'68

'65

'62

'59

'56

50

'53

0

(1) Suicide
While Japan enjoys the world-longest life span, suicide is alarmingly becoming apublic health threat. Japan has the highest suicide rate among industrializedcountries.

A total of 32,155 people or 24 per 100,000 populations end their lives bythemselves in 2006. Japan’s long economic plight no doubt must have played a rolein almost 50% increase of suicides since 1990 when Japan had “seen better days”(annual suicide then was around 20,000).

5

A sharp increase of suicide is a serious public health threat because suicideconsumes as much as 23.3% of potential years of life lost (PYLL). As the abovegraph shows, the absolute size of PYLL attributable to suicide has continued tooccupy a sizable share in the cause-specific PYLL, while the share of other causes
has declined dramatically in their size. In terms of PYLL, no public healthmeasures will match the effect of suicide prevention.
(2) Infant mortality
Japan’s infant mortality, a sensitive indicator of national health condition, was 2.6
per thousand live births in 2006, one of the lowest in the world. This great
achievement did not come at ease. Until as late as 1960s, Japan’s infant mortality
was considerably higher than that of the U.S. or U.K. It has been achieved throughconcerted efforts in effective maternal and child health activities. Congenital
anomaly accounts for 38% of infant mortality and constitutes by far the largest causeof death. Since congenital anomaly is hard to prevent in public health perspectives,
preventing SIDS or accidents will be a next challenge in the field of maternal andchild health.

4. International Comparison
Declining birth rate is not unique to Japan: it is a universal phenomenon observedin most countries. It is true that Japan belongs to the lowest group in terms offertility rate, but it is also noteworthy that other Asian countries, most notably Korea,
have seen a sharp decline of their birth rate. Korean fertility (1.13 in 2006) is evenlower than that of Japan.
Japan’s morbidity pattern is considerably different from other industrializedcountries. Take, for example, age-adjusted mortality by major causes of deathamong major OECD countries [Graph]. While no huge difference is observed for6

age-adjusted mortality of cancer, a considerable variation is seen for ischemic heartdisease and cerebrovascular disease. Japan has low mortality from ischemic heartdiseases together with Korea, while having a relatively high mortality due tocerebrovascular disease. These sharp differences may be explained by life style,diet and ethnic differences. However the gradual change in life styles and dietary
habit is changing its morbidity pattern closer to that of present industrial countries.
200
180

Australia

Comparison of cause of death (age-adjusted, both sexes)[source: OECD Health Data 2002]

Franceage-adjusted mortality per 100,000

160
140

Germany

120
100

Italy
80
60

Japan

40
20

Korea

0
IHD

CVA

cancerUnited5. Administrative structure of Public Health(1) Brief history
The first legislation on health care system, I-sei, was enacted in 1874. Thislegislation included a wide area ranging from administrative structure of publichealth to pharmaceutical affairs and medical education. At that time the most urgent
purpose of public health was infectious disease control.
To make effective
enforcement of control measures, the public health administration was incorporated
into police apparatus. In 1875, the Bureau of Public Health was established in the
Ministry of Internal Affairs, which had all-powerful authority over police, educationand ideology. In 1937, the first Public Health Center Act was implemented andMinistry of Health & Welfare (MHW) was spun off from the Ministry of Internal
Affairs in 1938.
Those dates signify the dark side of public health development of Japan: bothpublic health centers and MHW were not established by the demand from the people,
rather they were initiated as part of war-preparedness for the war which had juststarted in China.
In the post-war era, the Public Health Center Act was amended in 1947 to include
not only personal services but also regulatory function over pharmaceutical affairs,
food sanitation and environmental health. The law was further amended in 1994 tochange its name to the Regional Health Act to incorporate Municipal Health Centers
7

(MHCs). In response to the massive health hazard such as the subway saline
terrorism and the Great Osaka-Kobe earthquake, the new directive was set to make
PHCs as main bastions for massive health hazard control.
(2) Organization and staffing
Public health activities are provided predominantly by local governments under
supervision of Ministry of Health, Labor and Welfare (MHLW. MHW was mergedwith Ministry of Labor in 2001). The front line of public health activities is publichealth centers (PHCs), which number 535 as of April 2006. There used to be 848
PHCs as of March 1994, when the Regional Health Act was enacted. The act was
intended to delegate much of the personal services provided by PHCs to MHCs andthe ensuing radical restructuring process reduced the number to 571.
On the other hand, the number of MHCs has increased to 2,692 as of November
2005. The distinction between PHCs and MHCs may be confusing and warrant somefurther explanation. Both are the same in that both are part of local governmental
bodies but PHCs are endowed with law enforcement power while MHCs are not.
For example, when a mass food poisoning breaks out, it is PHC that assumes the
responsibility to investigate the cause and take necessary action against therestaurants. Also all health care facilities such as hospitals, clinics and pharmacies
are subject to periodic audit by PHC.
What is confusing about the two is that both provide personal services. PHC and
MHC share their responsibility by assigning more specialized and focused clients to
PHC and more general clients to MHC. For example, all doctors who diagnose
tuberculosis are required to report to PHC and the patient records will be put into
files maintained by PHC and the TB patients will be kept under surveillance by
public health nurses (PHNs) of PHC. On the other hand, MHC provides moregeneral and community oriented services such as well-baby clinic, immunization ormass health screening.
Public Health Center (PHC)

Municipal Health Center (MHC)

personal services specialized or focused (psychiatric, more general and community oriented

TB, intractable diseases, infectious (well baby clinic, immunization, healthscreening, disabled elderly)

disease such as HIV)Law

supervision and audit of health careenforcement

facilities, restaurants

Organizational prefecture(396),
structure (N)totaling 535

Director

Must

be

MD

none

major

cities(139) cities, towns, villages (2,692)

withcertainno requirement

qualification*)Staff

all kinds of health professionals

predominantly public health nurses anddieticians

8*) The director of PHC has been, by law, required to be a MD, although the work is moreadministrative than clinical.

The call for deregulation proposed that such requirement

should be abolished, to which public health doctors strongly opposed.

In April 2004, therequirement was partially loosened to allow non MDs to be directors of PHC when certain
conditions are met.

One must have health-related qualifications and have certain practicalexperience, and completed the one-year course of NIPH.

Local governments may appoint

non MDs who fulfill the above requirements when they cannot secure MDs to fill the
directorship of PHCs.

6. Training and research of public health
For the sake of providing recurrent training for professional staff working for
PHCs and MHCs, MHLW maintains National Institute of Public Health (NIPH).
NIPH expanded its size and scope after merging with National Institute of HospitalManagement in April 2002 and consolidated in a new campus in Wako city in thesuburb of Tokyo [new symbol and photo of the new building is shown]. The new
NIPH provides a variety of professional training and research activities in the field of
not only public health but also hospital management and social welfare.

NIPH is WHO-certified and started a new MPH (Master of Public Health) course
comparable to western schools of public health in 2004. The new course consists ofsix subspecialties: Health & welfare administration, Community health and welfare,
Environmental health, Biostatistics, Hospital administration and International health,
all of which will award MPH degrees.
Particularly, the International health course accepts international students as wellas Japanese students and all courses will be taught in English.
Being agovernmental institute, no tuition is required and availability of low-cost dormitory
will prove to be advantageous.
NIPH also provides e-learning courses in twelve fields to provide practical training
to public health professionals. NIPH also maintains a members-only website of“Health Crisis Management”.
http://www.niph.go.jp/English/announcement.pdf

7. Financing of Public Health related research
MHLW funds research grants in the field of public health.
9

The budget of healthand labor related research grant has more than tripled from 1996 to 2002 (12 to 40.7
billion yen) reflecting a strong interest of the government in life science and genome
research. In 2003, an average of 28.7 million yen ($26,000) was awarded to 1,454
projects involving more than 20,000
researchers.
Such research is likely to involve
privacy issues.
To facilitate
research activities in public healthfield while protecting privacy ofhuman subjects, MHLW enacted a
guideline
forepidemiologicalresearch, which took effect in July2002.

8. International Cooperation and Contribution
Japan is contributing a lot to the enhancement of public health in the world.
Since 2000, approximately 20% of WHO budget is contributed by Japan, second only
to the U.S., which contributes 22%.
In addition to assigned contribution,
22
Japan is voluntarily contributing 10.4
million dollars for the purpose oftropical disease prevention, primary
health care, children vaccination
program, emergency medical aid andWHO pays WHO?
research for chemical exposure on
WHO comprises of 192 countries
but 3 countries contributehealth.
more than half [2005]
19.468Being restricted in military power
49.8697%
by its peaceful constitution, Japan is
expected to play a larger role in termsof manpower in the field of public
8.6623health (only 38 Japanese staff out of
4,268 staff (including 1,681 experts) of WHO as of Sept 2005). The newly createdinternational health course in NIPH is expected to boost Japan’s role in theworldwide cooperation to achieve the common cause.
Dr. Nakajima, the first Japanese who serve the director general of an internationalorganization under UN, retired in July 1998 after serving 10 years of two terms.
During his tenure, Japan helped establish a WHO research center in Kobe (WHOKobe Center) in 1996 to further study on urbanization and health. Currently Dr. Omi
is serving as Director General of the Western Pacific Regional Office of WHO.
Apart from contribution to WHO, Japan promotes bilateral and multilateral
10

cooperation through JICA (Japan International Cooperation Agency) and othervarious NGOs.
Economic assistance through bilateral relationship is divided into three
categories, ODA (Oversea Development Assistance), OOF (Other Official Flows)
and PF (Private Flows). Japan’s annual budget for ODA is 760 billion yen(approximately 8 billion dollars), which is further subdivided into 1) gift and 2)
loans. Many of public health related ODA is given as gift such as construction of
hospitals and medical equipments. In FY 2002, 38 programs were provided as
gift economic assistance in public health.
Technological assistance consists of inviting technicians to Japan for training andsending Japanese experts to the receiving countries. As of FY 2004, 65 projects
were going on as shown below in the order of inception.
Mexico-women's health
China-PHC training cetner of Amhui province
Yemen-TB(III)Cambodia-TB
Tunisia-reporductive healthBangladesh-man power for reproductive healthDominica-medical education
Laos-innovation of Setatilat hospital
Khazafstan-Improvement of community care of Semiparatinsku
Thailand-Asia center against parasitosis
Honduras-regional reproductive health
Myanmar-basic health services against Hansen diseaseCambodia-MCH(II)
China-vaccination
China-Center for drug safety of China-Japan Friendship hospitalThailand-trauma center
Chili-rehabilitation for the disabled
Nepal-TB and lung diseases
Vietnam-reporductive health(II)Nicaragua-regional health services for Grenada
Vietnam-Bakmai hospital
Paraguay-continuous education of nursing and midwives
Zambia-AIDS and TB
Tanzania-PH administration of Morogoro province
Ethiopia-polio eradication
Kenya-international collaboration against parasitic diseases
Kenya-infectious disease research Central Medical Institute
Malaysia-food sanitation program
Bolivia-networking of regional health of SantaCruz county
Senegal-health manpower development
China-training for rehabilitation technicians
Philippine-pharmacopoeia
Zambia-PHC of Luthaca city (II)Guatemala-Chagus disease
Thailand-AsiaPacific disability center
Philippine-TB
Laos-public health services for children
Pakistan-information system for health administration
India-diarrhea diseases
Thailand-information system for public health insurance
Cambodia-medical technicians training
Honduras-Chagus disease
Elsalbador-Chagus disease
Brazil-healthy cities in the northeast district
Ghana-West African center against parasitosis
Bolivia-regional MCH network of Lapas city
SriLanca-health system planning
Thailand-skin diseases
Malaysia-food sanitation program-follow up
Uzbekistan-Improvement of nursing education
Cambodia-TB(II)
Afghanistan-TB
Afghanistan-Reproductive healthDominica-regional health services for Samana province
Mexico-cervical cancer in the south district
Morocco-maternal care in rural villages
Vietnam-public health service of Hoabin province
Philippine-regional health in Muslim Mindanao district
Almenia-Reproductive health
Myanmar-measures against infectious diseases
Fiji-vaccination program in the Pacific region
Myanmar-reproductive health regional health
Madacasgal-MCH through Majenga University hospital
Peru-comprehensive health care for the victims of human right
Kenya-improvement of regional health services in the West area

July-99

Japan's bilateral technical assistancein public health field as of 2004
[source: Kokumin Eisei no Doko 2005, p27]

June-00

June-01

June-02

June-03

June-04

June-05

June-06

June-07

June-08

June-09

9. OECD Health Care Quality Indicator Project (OECD HCQI)
Another important field in international cooperation is with OECD (Organizationof Economic Cooperation and Development). Although OECD is not primarily
intended for public health, it is an important venue for developed countries to shareand exchange experience and findings to solve the common problems in public healthand social security.
In May 2004, the first health minister meeting was held in Paris. OECD has
repeatedly held the ministerial meeting on social security but the meeting of healthministers was the first of its kind. There it was agreed to develop a common
indicator to objectively measure the quality of health care of individual countries.
The Health Care Quality Indicator (HCQI) is being collected and analyzed by experts
from many member countries. Japan is going to contribute indicators to enable11

objective comparison of its level of quality in the world ranking.
In March 2006, the first 17 indicators were published and the project is moving
into the second phase with more proposed indices in five major fields: cardiovasculardiseases, diabetes, mental health, primary care and patient safety.

12Chapter 1. Health Status
1. Health Status and Utilization of Health Services
To grasp the health status and utilization of health services, the government
conducts regular survey on the nation. One is a questionnaire survey on households[National Household Survey, NHS] and the other is a survey on hospitals and clinics[Patient Survey].
According to the NHS conductedin June 2004, 32.3% of the
population has at least one physicalcomplaint. The percent of those
who express at least one physicalcomplaints increases with age inboth sexes. The figure is a slightincrease from 3 years ago (30.5% in1998 survey), which may reflect the
aging of the population.
NHS also surveys the perceived
unknownbadhealth status of the population. Asked
good
not good
how they perceive their health status,
40.6% of the population aged 6 years orover answered that their health is good or
P e r c e i ve d h e al t h s t at u sfair while 11.5% answered “not good” or[ 2 0 0 1 N at i o n al H o u s e h o l d Su r ve y]“bad”.
International comparison of perceived
fairhealthstatusrevealssomewhataverageinteresting findings. The OECD Health
Data compares the percent of those who
perceive their health status “good”
as shown in the following graph.
In the comparison year of 1998,
44.5% of the Japanese perceived
their health as either “good” or“fair” almost on a par with thefigure of Koreans. On the other
Perceived Healthhand, the U.S. and Canada had a far
higher figure of nearly 90%. One
might be cautioned in interpretingthesefindings
becausesuch
CanadaUnitedStates

NewZealand(97)Ireland

Australia(97)Switzerland(97)Iceland

NorwayNetherlands

Belgium(97)Denmark(2000)
SwedenUnitedKingdom
Austria(99)Spain(97)
FinlandGermany% who believe they are well

Italy(99)[1998, unless otherwise specified.

Czech(99)source: OECD Health Data 2003]

Korea

Hungary(2000)
Japan

SlovakPortugal(99)

0

10

13

20

% who perceive they are in good health

30

40

50

60

70

80

90

subjective perception may involve methodology of survey and cultural attitudes.
Utilization of medical care is estimated by Patient Survey conducted every three
years.
Patient Survey is a nation-wide sampling survey on inpatients andoutpatients of hospitals and clinics and is conducted on one day in middle of Octoberevery three years, the latest of which was conducted in October 2002.
As of the survey date, 1.2% of the population is hospitalized and 5.4% of the
population visited outpatient clinics. Age and sex-specific utilization expressed as
the estimated number of patients per 100,000 populations is displayed in the graph.
The number of inpatient exceeds thatof outpatient in the age groups of 90 orover in both sexes.
One should be cautioned that theestimated number of patients given in
Patient Survey is a one-day sampling
survey and underestimate the number of
outpatients who regularly visit hospitals
or clinics.
The survey includes theinterval of regular outpatient visits, and then the number of patients who are underconstant medical treatment can be estimated by multiplying the number of patients on
the survey day with the average interval, plus the number of inpatients.
The estimated number of patients in
10 most common diseases is displayedin the graph. Hypertension is by far
the most common disease with an
Estimated number of patientsof 10 most common diseases
estimated number of patients under[source: 2002 Patient Survey ]medical treatment is seven million.
Over than 6% of the entire populationis under medical treatment withhypertension.
Hypertension

Diabetes Mellitus

Back problem

Heart disease(excluding

hyptertension)
CerebrovasculardiseaseCataract

ALL CANCER

AsthmaIschemic Heart
Diseases

Arthritis

0

1000

2000

3 0 0 0in thousand4 0 0 0

5000

6000

7000

2. Health promotion campaigns
After achieving the life span of 80 years in and around 1978, the focuses of publichealth activities gradually shifted from infectious diseases to chronic
noncommunicable diseases. Those diseases were “aging related disease” or “adultdiseases” or what was later to be called as “lifestyle related diseases”. To combat
these diseases, intervention into personal lifestyle is more important than medicalcare, and therefore it will inevitably involve national campaign to appeal to thegeneral public.
As a result, a series of public health campaigns have been employed. Looking
back, it turned out to be a history of a variety of national campaigns with mixed
14

results.
(1)1 st wave: National Movement for Health Promotion (1978)
The 1st National Movement for Health Promotion was launched in 1978. One of the
major measures taken in the 1st was establishing the Municipal Health Centers(MHC) in every municipality as the facility for health promotional activities in
addition to the existing Public Health Centers (PHC).
However, it is noteworthy to mention that this first wave might have committed a
mistake: relocation of public health nurses (PHNs) from the National Health
Insurance section to MHCs. Before 1978, many municipal governments, which
serve as insurers of their NHI programs, employed PHNs for health promotion andpreventive medical activities for the insured. Since not all residents are the insuredof the NHI (enrollment is approximately 40% of the residents), the clients of PHNs
were limited to those insured by the municipal governments.
To cater to all the eligible residents, PHNs were relocated to MHCs. Because ofthis change, the long tradition of PHNs working as part of health insurance operation
was lost. For example, PHNs of the NHI bureau were allowed to investigate thehealth insurance claims to capture the medical care utilization of the patients they
manage. After most PHNs were relocated to MHCs, they lost access to healthinsurance claims to use them for their public health activities.
This reform is now increasingly viewed as a policy mistake and the government is
now promoting cooperation between NHI section and MHCs in a municipal
government.
(2) 2 nd wave: Active 80 Health Plan (1988)
The 2nd wave was dubbed "Active 80 Health Plan" after its purposes to cater to theprolonged life span of 80 years. In it, an emphasis was placed in physical activities
and to promote physical fitness, qualification of "Health Trainers" was initiated in
1988. Health Trainers possess knowledge of both medical and physical science tomake prescription for recommended physical activities tailored to individual
conditions and medical needs. Also, fitness clubs satisfying certain requirements
such as having a certain number of qualified Health Trainers were given special
designation by government. Although such designation will not entitle them tohealth insurance benefit, the membership fee for patients with chronic diseases suchas hypertension, diabetes and hyperlipidemia will enjoy tax-exempt status if their
physical activities regimen is prescribed by attending doctors and supervised byqualified Health Trainers.
Such promotion, coupled with economic booms at that time, spurred mushroomingof fitness clubs and stimulated the growth of health and fitness industry. However,this campaign did not have explicit goals to be achieved and no appraisal was made toquantify its achievement. At least, not many authorities believe that the campaign
has made drastic results.
15

(3) 3 rd wave: Healthy Japan 21 (2000-2010)
The 3rd wave of national health promotion movement, the Healthy Japan 21 (HJ21)
is currently being actively promoted. The covered period is between the year 2000
and 2010 with defined set of goals. In this campaign, emphasis is placed in the
prolongation of "healthy life span" which means the life span without disability.
This emphasis reflects resentment over a considerable number of elderly withdisability in the face of the world longest life span.
The HJ21 campaign set the explicit goals against which its achievement isappraised. It set as many as 70 goals in nine fields (nutrition/diet, physicalactivities, mental health, tobacco, alcohol, dental health, diabetes, cardiovasculardisease and cancer). The HJ21 initiative set itemized goals to be achieved by 2010
and requires an interim appraisal in 2005. The interim appraisal was disclosed in
September 2005 with some disappointing results.
Not many goals showed
improvement since the baseline but showed even worsening. Overall, the outcomeof the campaign was far from being
Prevalence of obesity 20-60 men
satisfactory.
baselineinterim appraisal goal in 2010%
In the field of nutrition/diet, prevalence30
29.5
of obesity has increased particularly in men
24.3
25
in 30s and 60s. Salt intake and rate of20
energy intake from fat has declined
15.0
15
somewhat, but the proposed goal of eating
10
vegetable >350gr/day has not been achieved5
at all. In the field of physical activities, the0
H9 (1997)
H15 (2003)
H22(2010)
goal of 9200 steps for men and 8300 steps
for women was set but the result was rather declining. In the field of tobacco,smoking rate of men has declined but the rate of women did not show any sign ofdecline. In the field of diabetes, the number of possible diabetics is estimated to be
16.2 million and shows no sign of decline. The rate of continued treatment fordiabetes did not show any improvement. In the field of cardiovascular diseases, risk
factors such as hypertension and diabetes did not improve at all. In the field ofcancer, cancer screening rate did not increase and severe geographic maldistribution
still remains.
Overall, one must become pessimistic about the prospect of achieving 70 goals by2010 and these disappointing results constitute a backdrop of the radical andphilosophical turnabout in the health care reform plan in 2006.
(4) Health Frontier Strategy (2005-2015)
Health Frontier Strategy (HFS) may be confusing because some of its goals andtime frame overlap with the HJ21 campaign. After the enactment of the Long-term
Care Insurance, the insurance benefit disbursement has increased leading to thefinancial crunch. Since the increase was predominantly in “light” level of disability,
16

the need for “prevention” of disability was highlighted.
HFS does share the same goal with HJ21 in that both aim to prolong healthy life
span (life span without disability), however HFS has dual goals: one for prevention oflifestyle related diseases and another for prevention of disability. Also, HFS
proposes more simple and explicit quantifiable goals to be achieved by 2015 as
follows:●Prevention of lifestyle related diseases-increase 5 year survival of all cancers by 20%-decrease cardiovascular disease mortality by 25%-decrease cerebrovascular disease mortality by 25%-decrease incidence of diabetes by 20%●Reduction of disability-prevent worsening of the disabled elderly in borderline and level1 to level2 by 10%-prevent becoming disabled (borderline and level1) by 20%
HFS also serves as a backdrop for the health care reform proposed in 2006 with its
proposed goal of reducing the number of patients of metabolic syndrome by 25% by
2015.

3. Health Promotion Act and National Health and Nutrition Survey
As the legal basis of promoting the HJ21, a new law named Health Promotion Act
was enacted in 2003. This law is intended to promote healthy lifestyle, mandatory
segregation of smoking are and coordinate health screening conducted by different
providers under different schemes. So far, for example, employers are required toprovide health screenings to workers under the Industrial Safety and Hygiene Act,and schools provide health screenings to pupils under the School Health Act, andeach health insurers provide health screening to the insured with little coordination
with each other. The new law makes the formats of health screening records
uniform to assure consistent record keeping in every individual.
The law also stipulates the National Health and Nutritional Survey (NHNS).
NHNS is an equivalent of the U.S. NHANES and is a national sampling survey on
nutrition intake and health status. NHNS was originally the National Nutrition
Survey (NNS) conducted pursuant to the Nutrition Improvement Act since postwar
era. NNS was expanded to include blood exams and health related items. It took
on more importance because it provides evidence to evaluate the outcome of a seriesof health policy campaigns.
The new NHNS was started in November 2003 and will be conducted every year.
The results of the 2004 survey were recently published. It was conducted on the
randomly sampled 3,421 households from whom 9,345 people responded to thelifestyle questionnaire, 7,689 people underwent physical exams and 3,932 people
provided blood samples.
17

4. Health Related Problems

90

Somking rate of Japanese(1) Tobacco Control
2004, the smoking rate in Japanwas 43.3% for male and 12%
for female.
Although thesmoking rate for male has
steadily been declining, it is
stillhigher
than
most

70

60
% smoker

According to the NHNS in[source: Japan Tobacco, MHLW National Nutritional Survey]

80

50

40

male-JT
male-MHLW
female-JT
female-MHLW

30

20developed countries.
The
10
smoking rate for female islower than most developed
0
65 70 75 80 85 86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 99 2000 2001 2002 2003
countries and is somewhat
stable overall, but the smoking rate among young women in the 20s and 30s isincreasing alarmingly.
More alarming is the recent increase of the smoking rate among school children.
According to the survey on junior and senior high school students conducted bygovernment in 2000, the rate of "smoking in the last one month" increased in all
grades: 36.9% of male and 16.2% of female students in 12th grade replied yes to thequestion.
Moreover,
Russia(94)25, 9% of male and8.2% of female 12th
Japan(04)grade students say theyFrance(93)smoke every day.
femalemale
Despite health risk
Italy(94)
involving smoking, theGermany(94)government used to benotsoenthusiastic
Canada(94)about tobacco control
International Comparison of smoking rate
UK(94)
mainlybecausethe[source: Japan:MHLW, US:DHHS, others WHO]
tobacco industry was
US(00)
themonopolistic
0102030 smoking % 40
50
60
70
government enterpriseand hence a valuable source of tax revenue. Only after the government enterprise
was privatized to the present JT, the government started to tackle the problem
wholeheartedly.
The action plan for tobacco control was initiated in 1995. In cooperation to theplan, the tobacco industry voluntarily withheld nighttime operation of vending
machines in 1997 and refrained from TV ads in 1998.

18

The plan called for separation of smoking and nonsmoking space as part of the anti
smoking efforts. The separation is enforced according to the types of facilities andis mandatory for health facilities and public facilities.
The Health Promotion Act enacted in 2003 also endorsed the prevention of passive
smoking by way of separated smoking. The WHO convention in May 2003 adopted
the Tobacco Control Framework Convention, which Japan ratified in June 2004 andjoined the other 40 ratifying countries.
(2) Alcohol Problems
The number of heavy drinker defined as drinking 150ml pure alcohol is increasing
and is estimated to be approximately 2.4 million as of 1997.
According to the Patient Survey, a nationwide sampling survey on hospitals andclinics conducted in every three years, the number of alcoholism patients under
medical treatment increased from 14,720 in 1968 to 19,900 in 2002 (alcoholic
psychosis 2,800 plus alcohol dependency 17,100). Although the figures may appear
small in comparison to the estimated number of heavy drinkers (2.4 million), themajority of alcoholism patients are considered to be under treatment for alcohol
related conditions such as liver diseases.
Japan does have the "Prohibition against Drinking for Minors Act", but its
effectiveness is seriously hampered by ubiquitous vending machines of alcohol. In
1993, the governmental Public Health Committee urged the total ban of vending
machines and limiting the alcohol sales to over-the-counter.

19

Chapter 2. Lifestyle Related Diseases and Metabolic syndrome
1. A paradigm of "lifestyle related diseases" and “metabolic syndrome”
Chronic diseases such as cancer, cardiovascular diseases were once referred to as"aging related diseases" because the incidence increases with aging. However a newparadigm of "lifestyle related diseases" was proposed by a report by the Public HealthCommittee in 1996 to emphasize primary prevention over secondary prevention.
The rationale for creating the new paradigm of "lifestyle related diseases" in placefor "aging related diseases" is that the latter may give a false impression that suchdiseases are inevitable with aging and a sense of resignation that they are notpreventable and can only be countered with early detection at best.

2. Current status of major lifestyle related diseases(1) Diabetes
Majority of diabetic patients in Japan are of type II or NIIDM, which is heavily
dependent on lifestyle. Although its rank in the immediate cause of death is only
the 10th in vital statistics, it also contributes to other major causes of death such as
cardiovascular diseases or cerebrovascular diseases as major risk factors. Diabetes
also contributes to various forms of disability such as renal failure and blindness.
Diabetic nephropathy accounted for about 42% of newly initiated dialysis patients(2005) and the number is increasing still. Also, as many as 3,000 people lose vision
due to diabetic retinopathy making it the largest cause of blindness.
For the first time in November 1997, a nation-wide survey on prevalence ofdiabetes was conducted as part of the National Nutritional Survey. According to thesurvey result applied to the national population, the number of suspected cases ofdiabetes defined as "HbA1C 6.1% or over plus patients already under medical
treatment" is estimated to be 6.9 million and the number of potential cases defined as"HbA1C 5.6% or over" isestimated to be 13.7 million(total population is 125
million).
The survey was repeatedfive years later in November
2002. Applying the same
criteria with 5 years ago, thenumber of suspected cases
increased to 7.4 million and potential cases 16.2 million chiefly due to population
aging.
(2) Hypertension
According to the result of the 5th National Survey on Cardiovascular Diseases
20conducted in 2000, the prevalence of hypertension has increased slightly in the total
number except men aged 60 years or over and women over 40. On the other hand thepercent of people with hypertension who are currently under medical treatment has
increased possibly due to the effective mass-screening program rigorously conducted
for a last decade.
Japan used to have a high prevalence of cerebral apoplexy until as late as 1970s.
The health indices concerning apoplexies as measured by mortality and prevalence
have since then improved dramatically thanks to the great effort to control high bloodpressure.
A series of nation-wide sampling surveys to elucidate the secular trend of bloodpressure of the Japanese have been conducted at 10 years interval for 5 times
1961-2000. Each time BP was measured on subjects aged 30 years or older randomly
sampled from the entire population. Tracing the long-term trend of BP bears witness
to the yield of public health activities.
Trend of BP of the Japanese [60-69yo, Male]The
averagesystolic 180[source: cardiovascular disease survey]
159.8
pressure (SP) of men aged 60 160
152.9
148.1
145.4
143.1
to 69 was nearly 160 mmHg, 140
but it has consistently declined 120
SP
to 143 in 2000.
What is 100
DPnoteworthy about BP is that 80
88.1
86
85.7
85.7
84.4
diastolic pressure (DP), which 60
has not declined as drastically 40
as SP. In other words, the 20
difference or pulse pressure
0
1961
1971
1980
1990
2000
(PP) has shrunk.
Morerecently, PP is increasingly considered to reflect atherosclerosis or elasticity of bloodvessel, then this tend my suggest that the BP of male Japanese has declined while
suppressing atherosclerosis.
(3) Hyperlipidemia
According to the Patient Survey conducted in October 1996, the number of patients
under treatment for hyperlipidemia per age group is peaked in the age group of 70 to
74 at around 280 patients per 100,000. This figure severely underestimates theactual number of hyperlipidemia patients. Cautions should be taken because thesurvey is a cross sectional covering only three days and the number reflects only
patients with hyperlipidemia as their primary diagnoses. Majority of hyperlipidemia
patients are receiving treatment for the disease as secondary to other primary
diagnoses.
(4) Obesity
Japan Obesity Association defines the obesity as BMI 26.4 or higher. According
to this definition, the National Health & Nutritional Survey conducted in November
21

2004 revealed that 27% of men and 21.4% of women aged 15 years old or over wereobese. For men in their 40s, almost one out of three are obese.
When compared with 20 years ago, there is a marked increase of obesity among
men in all age groups but not in women. Since the prevalence of obesity will
increase in the later stage of life, obesity should be considered as a major publichealth concern in combating lifestyle related diseases.

(5) Cerebrovascular diseases
Cerebral vascular diseases used to occupy the most common cause of death until
1980. However it is now ranked in the 3rd place thanks to a sharp decline of themortality especially due to a dramatic decline of cerebral bleeding because of betterblood pressure control. Ironically enough, the improved survival of cerebral
vascular diseases increased the number of surviving patients under treatment and thesubsequent disabled people.
Primary prevention of cerebral vascular diseases and tertiary prevention fromdisability such as acute phase rehabilitation remains a major challenge for Japan's
public health.
(6) Heart diseases
Japan used to have a high prevalence of rheumatic heart diseases but ischemic
heart diseases are increasing even as the age-adjusted cause of death since 1993. As
the incidence of ischemic heart diseases increases, some questions were raised as tothe unsatisfactory rescue rate in the acute phase of onset. In addition to primaryprevention, improvement of rescue and survival of acute phase should be emphasized.
(7) Cancer
Cancer has been the leading cause of death since 1981. Age-adjusted mortality
shows a slight but gradual increase for male, while a slight decrease is observed forfemale. Site-specific cancer mortality shows that while mortality of stomach anduterine cancer are declining, lung and colon cancer mortality are on the risesuggesting effects of lifestyle changes.
Incidence of cancer cannot be known from vital statistics especially when the22

survival of cancer improves. According to some cancer registry such as the one
being conducted in Osaka suggests that stomach cancer is still by far the commonest
cancer for men and second for women. However stomach cancer slipped from the
top of the mortality for men thanks to improved survival. For women, stomach
cancer is still the largest killer.

3. Metabolic syndrome: a waist size story
Metabolic syndrome is a complex of medical disorders to predispose a person forlife style related diseases. It is broadly defined as a combination of visceral fat
accumulation plus two or more of hypertension, hyperglycemia and hyperlipidemia.
23

It is equivalent to the disease entity of syndrome X, deadly quartet, insulin-resistancesyndrome. Also its definition varies across different organizations: WHO (1999),
NCEP-ATPIII(2005), IDF(2005) and the recently proposed Japan’s criteria by eight
related academic societies. Some critics argue that metabolic syndrome should not
be viewed as a well-defined disease entity in strict medical terminology which needs
to be treated.
Until early 1980s, the three major symptoms of lifestyle related diseases (highblood pressure, hyperglycemia and hyperlipidemia) were considered as independent
to each other although their progression tends to be concurrent. However, there has
been a growing consensus among researchers that accumulation of visceral fat is areal culprit leading to the WHO’s publication of the term “Metabolic syndrome” aswell as its diagnostic criteria. The pathophysiology of the syndrome has also been
fully investigated and it is now widely believed that a certain adipocytokine(adiponectin, leptin, TNF-α, bisfatin) excreted from the accumulated visceral fat
causes metabolic disorder leading to atherosclerosis.
Japan’s diagnostic criteria include a simple and obvious measurement: waist size.
>=85cm for men and >=90cm for women. The term “metabolic syndrome” caught a
lot of public attention making people nervously aware of their waist sizes. The
criteria include the presence of at least two of three symptoms (hyperglycemia,
hypertension and hyperlipidemia).
Those with one symptom are regarded as“borderline”.
According to the 2004 NHNS, 23% of men fulfill the criteria and 22.6% of them
are classified as borderline. The figure for women is 8.9%, 7.8% respectively.
The metabolic syndrome took on importance as health policy agenda because theproposed health care reform emphasizes disease management by health insurers
targeting metabolic syndrome. The government set the goal to reduce the number ofpatients as well as those in borderline of metabolic syndrome by 25% from its start in2008 and the goal year 2015. To achieve the goal, all health insurers will be
required to provide annual health checkups to beneficiaries aged 40-74 and keep
individual health records in file as long as they remain insured.
Japan’s new health policy agenda will pose an ethical and philosophical challenge
on how much the government (or insurers) can intervene into the privacy of lifestyleof individuals and may provoke debates on a moral question: is health a right or an
obligation?

24

Chapter 3. Health Protection
1. Maternal and Child HealthJapan's infant mortality used to be as high as 150-160 per thousand births until
early 20th century but declined sharply to below 10 in 1975. Japan's current figureof 3.0 (2000) is one of the lowest even among developed countries. This may well
be regarded as a triumph of Japan's post war MCH policy.
According to the MCH Act, pregnant mothers are required to report to themunicipal governments and MCH notebooks will be issued. This entitles her topublic funded free health guidance and preventive medical activities as well as ahealth record for the child through the course of pregnancy and after birth.
Health guidance and consultation by public health nurses may continue after birthespecially when the new born babies are weighed 2500mg or less, in which caseparents are required to report to the local public health centers to prompt them forquick action.
All newborn babies are entitled for public funded mass screening to detectcongenital metabolic diseases such as phenylketonuria, and for the babies born to HB
positive mothers, immunoglobulin and vaccination will be provided as part of healthinsurance benefit. In 1994, nearly 2,500 newborns received immunoglobulin andvaccination for HB out of 1.127 million newborns.
To detect preventable causes of intellectual impairments such as phenylketouria,
mass screening program for neonates has been conducted since 1977. By 1998,
5,672 Cretinism, 2,330 neuroblastoma, 371 phenylketonuria have been detected toassureprompttreatment.
However, questions were raised
as to the effectiveness of mass
screening for neuroblastoma
andtheprogramwasdiscontinued in 2004.
In a
somewhat
odd
contrast,
intrauterine diagnoses of Down
syndrome and other detectableanomalies are not actively
performed.
For very low birth weight babies who require intensive care after birth, healthinsurance coverage starts on the first day of their births as dependent family status of
their parent's health insurance. The usually required 20-30% copayment will be
waived by public funding for the babies whose birth weight below 2000g.
All babies are entitled to free well-baby checkups twice at the age of 1.5 years and25

3 years, all of which are provided by municipal governments.
As for abortion, Japan is definitely a “pro-choice” country. The Maternity
Protection Act (MPA) authorizes certified doctors to perform artificial abortion on
women pregnant 21 weeks or less when the following conditions are met:
1) Pregnancy or delivery is likely to jeopardize the pregnant woman’s health in either
physically or economically (italic author’s)
2) The woman got pregnant because of rape
Whether the requesting woman meets the above conditions is up to the certified
doctors’ judgment. Doctors have to report the number of abortions performed
pursuant to the MPA. If the aborted fetus is 13 weeks or older, it will be treated as
still birth and doctors will have to issue certificates of still birth.
Japan’s Penal Codes penalize illegal abortions (The Penal Code section 212-216).
Abortions performed pursuant to the MPA are exempted from such penalty.
The number of reported abortions in 2001 was 341,588, of which only 192 were
because of rape. All others were performed for protection of maternal health either
physically or economically. Majority of abortions are performed in early stage (11weeks of gestation) of pregnancy, by which time no reporting of still births are
required.
The number of abortions has declined to a quarter since 1955, when the number hit
1.17 million. However the number of abortions of teenagers per age group 15-19 yo
has steadily increased perhaps because of younger sexual activities and non-use oforal contraceptive pills (OCP has not been approved until quite recently). Currently
approximately 11.9 per 1000 teenage girls undergo abortions annually (2003), morethan doubled since 1995 when the figure was 6. MHLW aims to reduce unwanted
pregnancies and abortions in teenagers by half for next 10 years.
>=50yo 0.0%45-49yo 0.6%
40-44yo
6.8%

unknown 0.0%

16-19 weeks 1.7%
12-15 weeks 3.1%

20-21 weeks 0.7%
unknown 0.0%

<20yo
13.6%

35-39yo15.0%

Abortions by age of mothers(2001 source : MHLW)
total=341,588
20-24yo8-11 weeks
37.8%

24.2%

30-34yo
18.5%

7 weeks or less 56.6%

Abortions by weeks of gestation(2001 source:MHLW)
total=341,588

25-29yo
21.3%

2. Mental HealthJapan’s mental health is notoriously characterized by its heavy reliance on
hospitalization: the highest per capita psychiatric hospital beds in the world (355,269
26

beds in 2003 or 277.5 beds per 100,000 population, occupancy 92.9%), the average
length of stay for psychiatric hospitals is 348.7 days in 2003, and the number ofpsychiatric patients in hospitals accounts for approximately 0.26 % of the entire
population.
This “institutionalism” may be partially explained by a historical accident in late
60s in which then U.S. ambassador had been stabbed by a psychiatric patient. This
accident provoked a public outcry against danger caused by letting potentially
dangerous psychiatric patients in community and called for construction of
psychiatric hospital beds to segregate the psychiatric patients from the rest of thesociety. Then the generally perceived “safety” of Japan’s society might partially bemade possible at the sacrifice of psychiatric patients’ right.
On the other hand, a series of scandals involving abuse in some psychiatrichospitals prompted arguments over potential violation of human rights of psychiatricpatients. In 1987, the Mental Health Act was amended to assure more emphasis on
human right protection of psychiatric patients by tightening the conditions ofinvoluntary hospitalization.
Under the Mental Health Act, five forms of hospitalization are stipulated as
involuntary hospitalization: detention hospitalization, emergency detention
hospitalization, custodial hospitalization, immediate therapeutic hospitalization andobservational hospitalization.
The most restrictive, detention hospitalization will be granted if the psychiatricpatient presents “clear and present” danger to self and/or public as agreed by morethan one qualified psychiatrist (to qualify, a doctor must have at least 5 years ofclinical experience and 3 years of psychiatric practice fulfilling a certain training
course and passing exams). Emergency detention hospitalization will be granted for
up to 72 hours on the same condition with detention hospitalization with thediagnosis by only one qualified psychiatrist. Custodial hospitalization may beordered by an attending psychiatrist if the legal custodians agreed without consent of
the patient. Immediate therapeutic hospitalization may be ordered by an attending
psychiatrist for prompt treatment of the disease. Observational hospitalization will
be granted for temporary
The number of psychiatric patientsobservation to allow time forthe psychiatrist to makeoutpatient
diagnoses.
inpatient
Detention hospitalizationaccounted for 36.1% to total
psychiatric hospitalization in1965 but declined sharply
ever
since.
Currently
nearly 70% of psychiatric
900000the number of outpatient is the number of those eligible for subsidy for copayment

800000700000600000500000400000300000200000100000

27

19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02

19
90

YEAR

19
85

19
80

19
75

19
70

0

inpatients are voluntary and custodial hospitalization 27.5%.
Detention
hospitalization accounts for only 0.8%.
To encourage discharge from psychiatric hospitals and “normalization” ofpsychiatric patients living in community, generous subsidy is awarded to the
copayment for outpatient treatment. The number of psychiatric patients who aretreated in outpatient has increased dramatically as shown.
Broken down by
diagnosis, depression and eating disorder have seen a sharp rise while the number ofschizophrenia
remainedThat sinking feelingconstant.
Regrettably, there havebeen sporadic criminal cases
behavioral disordereating disordercommitted by psychiatricschizophrenia
depression
neurosispatients living in community.
300[The number of mental patients under treatment, source: Patient Survey]

index (1996=100)

200

Pursuant to the Penal Code,crimescommitted
inunconsciousness are exempt
from criminal prosecutions
or may receive non-guilty
verdict. A new law titled “Medical Care and Observation Act for Those who
Commit Crimes under Unconsciousness” took effect in July 2003 to assure proper
medical treatment and observation for those who are acquitted due tounconsciousness.
100

0

1984

1987

1990

1993

1996

1999

2002

3. Oral HealthJapan’s oral health activities dates back to Taisho era (1912-25) when educational
activities to emphasize oral hygiene started. In the post war era, oral healthactivities were provided by public health centers as part of MCH.
In 1989, the epoch-making “8020 (eight zero, two zero)” campaign was started,which signifies that “maintaining 20 teeths at the age of 80”. Since it was deployedas part of elderly health, it aimed at bed-ridden elderly who carry the risk ofdeteriorating teeth resulting in malnutrition.
MHLW conducts a nation-wide sampling survey on oral health every six years.
The latest 1999 survey results show that 57.9% of men and 61.6% of women have atleast one missing permanent teeth. For those with at least one missing teeth, theaverage number of missing teeth was 5.6 for men and 6.1 for women.
The following graph shows a historical trend of missing teeth since the first survey
in 1957. Interestingly enough, while the number of missing teeth of younger
generations has steadily declined, the number of missing teeth of elderly increased
until 1987. The sharp decline afterward should have reflected the dramatic effect of“8020” campaign.
28

Overall, the oral health in Japan has improved dramatically particularly for theelderly. The goal set by the “8020” appears well within feasible.
25

A g e - s p e c if ic n u m b e r o f m is s in g t e e t h[ N a t io n a l D e n t a l H e a lt h S u r v e y , b o t h s e x e s ]N o t e t h a t t h e n u m b e r o f m i s s i n g t e e t h o n e l d e r l y a f t e r 8 0 2 0 c a m p a ig n s t a r t e d i n 1 9 8 9Number of missing teeth

20

1957
1963
1969
1975
1981
1987
1993
1999

15

10

5

0
20～ 24yo30～ 34yo

40～ 44yo50～ 54yo60～ 64yo

70～ 74yo

4. Infectious Diseases
Japan used to be plagued with epidemics of infectious disease, which also claimed
a high mortality. The number of reported cases of major traditional infectious
diseasehas
declined
drastically
since
late
1960s,but
so-called
emerging and reemerging
infectious diseases began
to pose renewed publichealth threats.
In
1999,
the
new
Infectious
Diseases
Control Act was enacted
incorporating
separate
laws against STD, AIDS. Under the new law, infectious diseases are classified into
four categories depending on their severity and societal risks.
(1) Hansen’s disease
Hansen’s disease is an infectious disease transmitted by Mycobacterium Leprae
affecting skin and peripheral nerves. It was once considered as an incurable deadly
disease but became curable by drugs (Diamino diphenyl sulfone, DDS andrefampicin). Since the infectiousness of the bacteria is not strong, the disease does
not necessarily warrant isolation. However, Japan chose a forced isolation policy
starting in 1907 and culminated in the enactment of the Leprosy Prevention Act in1953. Such forced isolation simply developed prejudice and suffering of thepatients but the isolation continued until the abolishment of the Act in 1996. The
patients filed a civil suit against the government claiming that they had been unduly
isolated and their entire lives had been sacrificed. The court upheld the plaintiffs’29claim in May 2001 and the government started a series of compensation as well as
rehabilitation of the victims’ honor. The forced isolation policy is now widely
viewed as a smear in Japan’s public health policy and a study group was organized toanalyze the history in 2002 through 2004. In February 2006, another law wasenacted to compensate the patients in the former Japan’s colonies.
(2) Viral Hepatitis
Viral hepatitis is certainly one of major public health threats in modern Japan.
There are estimated to be 1.2 to 1.4 million (more than 1% of population) carriers of
HBV and nearly 2 million (1.6% of population) HCV carriers. Hepatitis virus is aknown cause of liver cancer. According to a survey, 76% of 30,000 liver cancer
deaths in 1997 are attributed to HCV and 17% to HBV. More alarmingly, thenumber of liver cancer death per population has steadily increased from 14 per
100,000 in 1984 to 24 in 1995 and the increase is solely attributable to HCV.
One of the major transmission routes of HCV is iatrogenic. A considerable
geographic variance of HCV prevalence might support this hypothesis: some
hospitals and clinics used to provide IV treatment without much heed to sterilizationand mass immunization programs were occasionally conducted without changing
cylinders and needles in the past. Post transfusion hepatitis had been largely
eradicated thanks to the introduction of HCV screening introduced in November 1989.
Introduction of Interferon to treatment of HBV and HCV to health insurance benefit
also contributed to effective treatment of carriers.
(3) HIV/AIDS
WHO/UNAIDS estimates that there are 40 million patients of HIV infection or
AIDS worldwide at the end of 2004. The accumulated number of reported HIV
positive cases was 6,734 and the number of AIDS patients was 3,336 as of March
2005 with accumulated death toll reached 1,357. Breakdown by transmission routeis: homosexual contact 60%, heterosexual contact 25.6%, illicit IV drug use andlongitudinal infection from mothers less than 1% respectively.
800

800

The number of reported cases of HIV

The number of reported cases of AIDS

700

700

600

600

foreignersF

foreignersF
500

foreignersM

foreignersM

500

JapaneseF
400

JapaneseM

JapaneseF

300

300

200

200

100

100

0

JapaneseM

400

0
198 5 198 6 19 87 19 88 1 989 1 990 199 1 1 99 2 19 93 19 94 1 995 19 96 199 7 1 99 8 19 99 200 0 20 01 20 02 2 00 3 2 004

1 98 5 198 6 1 987 19 88 19 89 1 99 0 1 99 1 19 92 199 3 19 94 1 99 5 1 99 6 19 97 199 8 199 9 2 000 2 00 1 20 02 2 00 3 200 430

AIDS epidemic in Japan can be summed up as following points:
The number of reported cases of HIV is constantly growing among Japanese maleswith transmission routes of homo and heterosexual relationship.
The number of reported AIDS cases has declined for the first time since the start ofsurveillance system became fully operational.
The number of HIV and AIDS cases involving foreign nationals account for
approximately 30% of reported cases in the order of Southeast Asia, Latin America.
Sexual intercourse accounts for the largest share of transmission routes and IV
drug use and maternal infection account for less than 1%. However, the cases ofwhich transmission routes unknown account for nearly half of the foreign nationals
and increasing even among Japanese.
Majority of sexual transmission among Japanese took place inside the country forboth HIV and AIDS with concentration in and around Tokyo area. However forhomosexual intercourse, majority of transmission concentrates in Tokyo. As forgeographical distribution, the number of reports from Kinki block (area around Osaka,
Kyoto and Kobe) is alarmingly increasing.
Although the severity of AIDS epidemic in Japan may be less than other countries
in public health perspectives, it draws the regrettable past in which a nearly two
thousand of hemophiliac patients had been infected iatrogenically through imported
blood product. The dispute over the iatrogenic HIV infection culminated in 1996
when the then health minister officially apologized to the patients and the patientsgroup and the government and pharmaceutical companies had settled according to therecommendation by court.
Also in the same year, criminal charges were brought against a leading doctor and aformer Ministry of Health officer for professional negligence, but the district court
acquitted the doctor in March 2000 ruling that the tragic iatrogenic HIV infection byblood product had not been foreseeable in and around 1985 and therefore thedefendant could not be held professionally negligent.
(4) Tuberculosis (TB)
Japan is still suffering from ahighTBmortality
incomparison
with
major
developed countries with 2,328
deaths in 2004 or 2 per 100,000
population. TB used to be theleading cause of death until aslate as 1950 but has dropped toas low as the 25 n d rank in 2001.
In around 1950, the age
specific mortality of TB was
31highest among young population: nearly 300 per 100,000 population in the 20s
making the disease widely quoted in sad stories involving young men and women.
Under the TB Control Act, doctors who diagnosed TB patients are required toreport to the nearest public health centers to prompt them to keep track of the patient.
Public health centers have been serving as the forefront for TB control andprevention. 28,391 new patients were reported in 2005. This translates into 23.2
per 100,000 population. The year 1997 was remarkable because the hitherto
declining incidence rate turned upward for the first time in 43 years. Especially the
number of active TB patients who are capable of infecting others was 11,318 in 2005.
Once reported, public health centers keep track of the patients until they are
diagnosed as free of TB for three years. The cumulative number of patients kept
track by public health centers was 72,079 as of December 2004, of whom 26,945 wereactive TB patients.
The long lasting trend of declining incidence and prevalence of TB showed a signof resurgence in 1999 prompting MHLW to announce “TB Emergency Declaration”.
Because TB is concentrating in and around large cities, DOTS(Direct Observational
Therapy of Streptmycin) had been actively pursued. The effort bore fruit and thenumber of patients currently under surveillance by PHC declined to 68,508 in March
2006.
The TB Control Act require all babies aged 0 to 4 years old to be checked PPD skintest and receive immunization (BCG) for those who showed negative result (noimmunity), all of which are publicly funded. If successful, BCG will develop
immunity against TB evidenced by positive PPD test. This iatrogenically induced
positive PPD test of Japanese citizens is sometimes puzzling to western doctors whonaturally interpret the positive skin test as indication of TB infection. In Japan,
mildly positive PPD skin test results are interpreted as evidence of immunity
developed by BCG vaccination and is usually not interpreted as TB infection if otherfindings suggest otherwise.
Immunity endowed by BCG is not entirely everlasting nor does it provide full
protection against TB as evidenced by sporadic outbreaks among young people. The
PPD skin test will be repeated in elementary and junior high schools and BCG may berepeated for those students who failed to turn positive and hence no immunity.
In 1991, the Public Health Committee issued a recommendation with a targeted
eradication of TB in the 2030s. In November 1992, the mass chest X-ray exams
conducted on all school children in elementary and junior high schools wereabolished to reduce unnecessary radioactive exposure, and those with strongly
positive PPD skin test were asked to undergo thorough examination at hospitals or
clinics. Before, school children of the 1 st and 7 th graders were examined with PPD
skin test and were inoculated BCG booster shot but the practice was abolished in
2003. Babies were examined PPD skin test first and BCG was inoculated to those32with negative result, but the preceding PPD skin test was abolished and all babies arerecommended to be inoculated BCG by six months old.
(5) Infectious disease surveillance system
According to the Infectious Diseases Control Act, a surveillance system has been
operational since 1981. It consists of two components: mandatory reporting forserious infectious diseases and voluntary reporting for less serious ones such as
measles or influenza. For the latter, participating hospitals will report the numberof diagnosed case on a weekly basis. The result is published over the web by the
National Institute of Infectious Diseases in English.
(http://idsc.nih.go.jp/kanja/index-e.html). For example, epidemic of influenza isshown in a weekly report as the average number of new cases per “sentinel” hospital(approximately 5000 nationwide).

(6) Mass vaccination program
Japan has achieved a great public health success in infectious disease control in the past,
the most notable of which was the emergency import of polio live vaccine in 1961 when
Asia had been hit by a large polio epidemic.

Mass vaccination was also provided forschool children for influenza in 1962 and became mandatory in 1977.
The rationale behind the mass vaccination for school children was to strengthen herd
immunity to control influenza epidemic.

The effect of such mass vaccination is vividly

illustrated by Thomas A. Reichert et al as below.

The excess death of elderly was

suppressed when mass vaccination on school children was under way.

However the

mandatory vaccination was eased in 1985 and discontinued in 1994 in response to the public
outcry against adverse effects.
Possibly due to reduced herd immunity, Japan has seen a large resurgence of influenza in
1998-99 seasons resulting in estimated 20,000 deaths most of whom were the elderly.

In

2001, the Act was amended again to encourage FLU vaccination to the elderly on a
voluntary basis.

FLU vaccination rate for the elderly came to be viewed as a quality

indicator of an entire country and was included in the OECD Health Care Quality Indicator

33

(March 2006, OECD HCQI
Project working paper 22).
Japan’s rate was 43% in2003 and is ranked low inthe “world quality ranking”.
Forvaccine-preventable

infectious
hasdiseases,higherJapan

incidenceofmeasles than most developed
countries

despitewell-developed
program.

vaccination

The reason is probably its timing: Japan’s officially endorsed vaccination is for

one year or older, by which age most children contract the disease.

Given the world lowest

infant mortality, the delayed measles vaccination does not seem to jeopardize children’s
health.

The outline of Japan’smass vaccination programis below. As for measles,
mumps and rubella, acombined vaccine (MMR)
was introduced in 1989
but was plagued withaseptic meningitis due to
its mumps component andwas discontinued in May
1993.
Currently mumps
vaccinationisnotprovided.

34

(7) Quarantine
MHLW has 108 quarantine offices in 82 ports and 26 airports. They quarantinedover 30 million visitors by air and over 2 million visitors by sea as well as imported
food, animals and plants. The most imminent threat for quarantine is that of avian
influenza (H5N1). There have been sporadic outbreaks of avian FLU in paltry
factories including a case in Kyoto in 2004. The limitation of quarantine is that they
are unable to quarantine migrating birds.

5. Research and Public Subsidies for Diseases of Scientific Interest
Japan has disease specific research and public subsidies programs for certain diseases.
These diseases are called “diseases of scientific interest” and 45 diseases are listed as of2003.

Programs aimed at these diseases consist of two pillars: research grants and public

subsidies for patients.
Public subsidies for patients will effectively waive the copayment of 20 to 30% of healthcare cost under the national health insurance system for the treatment related with thediseases on the condition that the patients cooperate with the research programs.
program is a corner stone for the epidemiological survey for such diseases.
figure of the number of patients eligible for the subsidy is listed below.

35

This

The latest

6. Public Assistance for A-Bomb Victims

1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004

In recognition of the uniqueness of the A-bomb exposure in Hiroshima andNagasaki in August 1945, the A-bomb victims are entitled to special public assistance
not available for other war casualties. A-bomb victims include those who were
exposed intrauterine at the time of bomb blast and those who entered into the bombed
area within two weeks. The number of listed victims has declined somewhat due toaging and now 259,556 as of March 2006.
The benefit includes public
250000subsidies to waive copayment
Increaseof dialysis patientsinJapan[source: JapaneseSocietyof DialysisMedicine]for health insurance, and cash
benefit in the amount of 33,900
200000yen(approximately
300
dollars) per month for those
150000with chronic diseases notnecessarily related to A bomb
exposuresuch
as100000cardiovasculardiseases(approximately 80% of thoseeligible are receiving this cash
50000
benefit).
As for research activities tostudy the long-term effect of0radiation exposure, a research
36institute was established under cooperation between Japan and the U.S. in 1975 andits findings are contributing much to the development of radiation exposure standards
and protection.

7. Renal Failure
Japan has 108,570 dialysis units and 275,119 dialysis patients at the end of 2007,
which accounts for approximately 2% of the entire population and approximately one
fifth of the world dialysis patients. This reflects a small number of kidneytransplantation (only 1,136 in 2006, of which cadaver transplantation was only 182)
and the generous coverage of health insurance system (for renal dialysis the patients’
copayment is capped at 10,000 yen (approximately 80 dollars) per month.
6

5

4

3

Kidney transplants per 100,000 pop［2006, OECD Health Data］

2

1

00
Japan
TurkeyMexico
Korea
Greece(05)NewZealand
PolandSlovakRepublic
Italy
Hungary(05)Australia
Denmark
Germany
Unitedkingdom
Switzerland(05)
Ireland
Luxembourg
Portugal
CanadaBelgium(05)CzechRepublic
FinlandSwedenFranceIcelandSpain
Norway(05)Austria
UnitedStates

Japan
UnitedStates(05)Portugal(05)Germany
Korea(04)Italy(05)
CanadaBelgium(05)FranceCzechRepublicHungary(05)SlovakRepublic
Spain
NewZealand
Luxembourg
Austria
Denmark(05)Turkey(05)Australia
MexicoUnitedkingdom
IrelandNetherlands(05)Finland
Iceland

50

100

150

200

Dialysis patients per 100,000 pop［2006］［source, OECD Health Data 2008］

Renal failure used to be considered fatal until December 1962, when dialysis was
included in health insurance benefit. Still, health insurance subjected the patients to
20 to 30% copayment, which would accumulate to a considerable sum for long-term
treatment such as dialysis. In October 1972, public subsidy was introduced to help
ease the financial burden of dialysis patients and in October 1984, the Health
Insurance Act was amended to cap the monthly copayment for long-term treatment
such as dialysis and hemophiliacs to 10,000 yen (the copayment was raised to 20,000
yen per month now).
The above graphs illustrate clearly Japan’s peculiar position in OECD countries: it
is ranked top in terms of the number of dialysis and bottom in terms of kidneytransplants per population. Dialysis (costing five million yen annually) costs
approximately 1.4 trillion yen or 4% of total health care expenditure of Japan. Morealarmingly the increasing trend does not show signs of leveling off.
The increase is mainly attributable to diabetic nephropathy as shown in the graphbelow suggesting an urgent need for controlling diabetic complications.

37

8. Organ Transplantation
Kidneytransplantation
was included in healthinsurance benefit in 1978,
but cadaver transplantation
was not available in theabsence of the law that
authorizes removal of organs
from corpses. The Cornea
and Kidney Transplantation
Act was enacted in 1980 toauthorize removal of cornea
and kidney from corpses on certain conditions, but the dissemination of cadavertransplantation was still hampered by prohibition of organ removal from brain deadbodies.
Surgeons had to wait until the heart beat completely stops before they could
remove the donated organs, which compromised the success rate of transplantation,although cadaver transplantation was somewhat enhanced by establishing the organ
sharing information network in 1983. Also, removal of other organs such as heart,lungs and livers were not yet permitted.
Some frustrated patients resorted to traveling abroad to receive transplantations
provoking public outcry in some countries and commercial organ transactions in38

other countries. Even corneal transplantations rely as much as 40% of corneas on
import from abroad.
In October 1997, the long awaited Organ Transplantation Act was enacted toauthorize removal of donated organs from brain dead bodies. As a peculiar twist oflegal reasoning, the law authorizes brain death only for those who expressed theirwish to donate organs of their choice and consent to acknowledge brain death as theirtime of death. Moreover the declaration of brain death may only be made after
following a strict guideline set forth in the law. Also the law prohibits buying andselling of organs for commercial purposes.
In February 1999, the first organ transplant of heart, liver, kidney and cornea
removed from a brain dead body was performed under the new law. The number ofpatients on the waiting list as of May 2007 was, 11,778 for kidney, 94 for heart, 148
for liver and 125 for lungs.
As for bone marrow transplant, the bone marrow bank, a database of HLA typing ofpotential bone marrow donors, was established in December 1991 and maintains a
database of over 276,847 potential donors as of March 2007. The bank could matchthe cumulative number of 8,210 patients who underwent bone marrow transplants byMarch 2007. The bank could successfully match 78% of patients with potential
donors and is aiming at 300,000 potential donors to achieve 90% matching rate.

39

Chapter 4. Medical Care
1. General View of Japan’s Health Policy and Planning
Japan’s medical care is characterized by ready access, free choice of providers andequality of treatment opportunities.
These characteristics owe much to its
ubiquitous health insurance system that covers the entire population. Through thehealth insurance system, the price of every medical procedures as well as
pharmaceutical price are under strict government control. Japan’s great success inachieving one of the highest health standard in the world is no doubt the fruit of thesestrengths.
However these seemingly satisfactory achievements of Japan’s medical care havenot been without problems. Lack of quality assurance mechanism, amenity of
hospital wards and patients’ right such as access to their medical records have been
increasingly brought under criticism in recent years particularly after a series ofserious malpractice cases had been exposed.

2. Health Planning
Japan’s health policy used to be that of laissez faire until 1985, when the Medical
Service Act was amended for the first time in the postwar period to require
prefectural governments to set up the regional health planning by which theprefectural governments can control the growth of hospital beds in the area withexcess bed capacity. This was a bitter reflection over the traditional laissez fairepolicy that had resulted in a serious geographic maldistribution of medical carefacilities and personnel. It was also part of cost control measures against spiraling
health care cost.
As of March 2006, the country is divided into 365 regions that controls the numberof acute general hospital beds (psychiatric beds and TB beds are controlled at
prefectural level, which numbers 47). Of these, 217 regions have excessive hospitalbeds than the objectively assessed number of necessary beds and henceforth are
subject to restrictions on new hospital beds construction.
As the history suggests, Japan’s regional health planning developed as beds-control
measures. In the structural reform in 2008, the revised Medical Service Act
incorporated critical path and quality indicators into the regional health planning in
the field of four diseases (diabetes, cancer, stroke and heart diseases) and fivecategories of care (emergency medicine, rural health, disaster health, pediatrics andobstetric care).
The revision of the Medical Service Act was part of the “Structural Reform of
Health Care 2008” and the new regional health planning will be implemented as partof the “Health Care Cost Containment Plan (HCCCP)”, a five year plan set up by each40

prefecture. For the development of health planning, an effective information
technology such as electronic health record (EHR) will be necessary. A national
database of health insurance claims will also provide an infrastructure for such
purposes.

3. Health Manpower
Japan’s health care is staffed with 270,371 doctors (211.7 per 100,000 population),
95,197 dentists (74.6), 241,369 pharmacists (189.0) and 1.15 million nurses (89.5) asof the end of 2004.
Medical education in Japan is six years course enrolling high school graduates.
There are 80 medical schools including a Defense Medical College. The post
graduate training has been poorly developed in Japan. Beginning in April 2003, the2 year post graduate training became mandatory and a matching program to recruit
new medical graduates and clinical training hospitals was developed.
All health professionals are under guidance of MHLW, which licenses them. In
case of misconducts, the MHLW minister is authorized to discipline them withtemporary suspension of their license or revocation. In case of medical malpractices,such sanctions were imposed only in the cases which constitute criminal prosecution.
However, in reply to the growing outcry, MHLW took such a disciplinary action
against doctor who committed serious malpractices in 2004.
Another problem was that doctors who were sanctioned with temporary suspensionof licenses were allowed to practice simply after the suspension terminated without
any compensation or contribution. There has been a growing demand that someform of reeducation should be required before the suspended doctors are allowed toreturn to the practice. As part of the structural reform, the Doctors’ Act wasamended in 2006 to require the suspended doctors to receive certain reeducation
including ethics.

4. Hospitals and Clinics
The Medical Service Act delineates the medical care facilities as hospitals andclinics. Hospitals are further classified into acute general hospitals, psychiatrichospitals and tuberculosis hospitals and clinics are classified into medical clinics anddental clinics depending on the case mix of the patients they treat. It is noteworthy
that a considerable number of medical clinics (13,477 as of October 2005) own
inpatient beds up to 19. These clinics with beds effectively functioning as small
sized hospital and their inpatient beds constitute approximately 167,000 beds out of
1.8 million beds (approximately 10%).
The total number of inpatient beds in Japan as of October 2005 was approximately
1.8 million including 354,296 psychiatric beds. Acute general beds of hospitals areapproximately 1.37 million or just above 1% of the total population. These figures41

suggest that Japan has larger number of inpatient beds per population than mostcountries in the world by every means. Still, the number has somewhat declined
from the peak of 1.95 million beds in 1990 thanks chiefly to the hospital beds control
by the regional health planning enforced by the Medical Service Act.
As of October 2005, there
were 9,026 hospitals of all
categories, almost 10%
decline since its peak of
10,096 in 1990 reflecting
mergers and acquisitions
in recent years.
There
were
97,422
medical clinics, of which
13,477 were clinics with19 or less inpatient beds
and the rest were clinics
without beds. The number of clinics with beds has been constantly declining while
the number of clinics without beds has steadily increased.
The ownership of hospitals and clinics in Japan is predominantly in private sector.
However since the average size of national and public hospitals tend to be larger,
public sector accounts for approximately 46% in terms of hospital beds. Ownershipof private sector is either sole proprietorship or medical corporations (MC). MCs
are special professional corporations incorporated pursuant to the Medical ServiceAct.
MCs are similar to for-profit corporations in that they are established by direct
investment from private shareholders but differ from for-profit corporations in thatthey are prohibited from disbursing profit to shareholders as a form of dividends.
However the corporate asset of MCs is nonetheless the shareholders’ property andthey are entitled to claim refund at its market value anytime. MCs are also subject
to more regulations and supervision by the regulatory authority as to their businessand operations than ordinary
for-profit corporations.
In
general,for-profit
corporations are prohibited fromowning and operating hospitals
and clinics based on the so-called“not-for-profit”
principle
presumably dictated by the
Medical Service Act.
This
“not-for-profit” principle was42somewhat eased in the field of home care in the Long-Term Care Insurance systembut is strictly adhered in the field of medical care and institutional LTC despite
strong call for deregulation mainly from industry side.
Japanese hospitals are in general well equipped: two out of three hospitals
including psychiatric and tuberculosis hospitals have whole body CT scan. The
percent of hospitals that own high-tech medical equipment is: NMR-CT (MRI) 23%,
angiography 27% and UGI fiber scopes 72% (Health Care Facilities Survey as of
October 1999). This dissemination of high-tech equipment may be beneficial topatients but may not be favorable in health economics viewpoint. Disseminatingthese high-tech equipment in a cost-effective manner while securing easy access topatients will be difficult but important health policy issues.
Japan’s inpatient care is characterized by prolonged length of stay: 36.3 days for
all hospital beds (including psychiatric beds) in 2004, longer than any other OECD
countries.
The ALOS has
steadily been declining due toincreasing number of nursing
homes of the LTC insurance: thelatest figure is 20.2 days for acutegeneral beds and 338 days forpsychiatric beds.
Increasing attention is being
focused on geriatric long-term
hospital beds, which number
approximately 383,911 as of 2005.
As part of the 2006 structural reform, the government announced a plan to reduce thegeriatric long-term beds to 150,000 by 2012 with an aim to reduce the already long
ALOS. To understand the situation, one must understand the peculiar status ofgeriatric long-term beds.
Since the inception of the LTCI in 2000, the geriatric long-term beds wereseparated into two types: one paid from health insurance and another type paid fromthe LTCI. Ironically enough, the case mix of the patients occupying these beds does
not differ much and simply they cost far more than the same patients institutionalized
in nursing homes and skilled nursing facilities.
The reduction is expected to be achieved through restructuring the hospital beds
into nursing homes or skilled nursing facilities.

5. National Hospitals and National Centers
By far the largest hospital chain in Japan was, ironically, MHLW itself.
Succeeding military hospitals and tuberculosis sanatoriums in the prewar period, thechain consisted of 239 hospitals and sanatoriums scattered nationwide in 1986. The
43

financial conditions of these hospitals were such that the government had to pump in
exorbitant sum of subsidies.
In 1984, the Committee for Administrative Reform called for consolidation andprivatization of national hospitals. In 1987, the Special Act for Reforming National
Hospitals was enacted and many hospitals were either abolished or privatized.
Eventually the remaining 146 hospitals were separated from the government as a
newly formed NGO called “National Hospital Organization (NHO)” in April 2004.
The new NHO consists of 146 hospitals with approximately 60,000 beds and 47,423
employees including approximately 5,000 doctors (The chain also includes 13
sanatoriums for Hansen diseases).
The new hospital chain will focus on“policy-oriented health care” in 19 fields such as AIDS, disaster medicine andinternational collaboration in health. It is also expected to serve as a coordination
center for clinical research such as clinical trials and clinical indicators.
National centers were established as flag ships of national hospitals with specificpurposes. Currently there are six national centers including the National Cancer
Institute (Tokyo, 1962), the National Cardiovascular Center (Osaka, 1977), theNational Mental & Neurological Institute, the International Medical Center (Tokyo,
1993), the National Pediatrics Center (Tokyo, 2002) and the National Longevity
Center (Aichi, 2004).

6. Accreditation Program of Hospitals
There has been no formal accreditation program to evaluate and certify hospitals
and clinics in Japan until 1997, when Japan Council for Quality Health Care(jcqhc.or.jp) started its official accreditation program. Accreditation is voluntaryand hospitals that would like to undergo accreditation must apply and pay theaccreditation fee (1.2-2.7 million yen or approximately 10 to 20 thousand
US$ including five year period). As of March 2007, 2333 hospitals were accredited
as satisfying the standards set by the organization (30% of 8978 hospitals
nationwide).
Unlike the US JCAHO,
whose
accreditationisaprecondition for participationin Medicare/Medicaid, Japan’s
JCQHC
accreditationisvoluntary and has no legal
grounds and the number ofhospitals seeking accreditation
appears to have peaked out asshown in the graph. As an
incentiveforgetting44

accreditation, the accredited items are exempt from restrictions of advertisement andaccredited hospitals are allowed to advertise the items to the public.

7. Patient safety and medical malpractice
Safety in medical care isincreasingly drawing publicattention almost in parallelwith patients’ awareness of
their right.
Japan has longbeen
consideredasnon-litigious society but an
alarming
increaseofthenumber of medical malpracticerelated litigations filed every
yearsuggestsa
rapidlyoccurring transformation of both societal atmosphere and patients’ attitude. MHLW
has long taken a “hands-off” stance about medical malpractice and negligence on thebasis that they are basically civil disputes, which should be settled among concerned
parties. However a series of serious accidents disclosed at major medical centers
have prompted the government to intervene as a precautious measure.
(1) Reporting system of medical errors/adverse events
Effective in October 2002, the Medical Service Act was revised to require that all
hospitals as well as clinics with inpatient beds to take necessary precautionary
measures including a guideline to secure safety, reporting system from employees
about any potentially dangerous “near miss” cases in daily operation and training andmonitoring about safety. Particularly, academic medical centers will be required toappoint a full-time “risk manager” both for prevention of accidents and taking
appropriate actions in case any claims arebrought up patients.
The Physicians’ Act mandate that the doctor
shall report to police when the patient dies of
unexpected causes, but there is no mandatory
reporting of incidences that fall short of death.
In 2004, the Medical Service Act was again
revised to require a certain designatedhospitals (including all university medical
centers. There are 273 hospitals in 2006)
reporting of any medical accidents to the
JCQHC effective in October 2004.
.
45

The reporting is performed with strict confidentiality: for example, only the day of
the week and time zone is reported. The purpose of reporting is for prevention ofsuch errors or accidents, not for punishing the responsible persons. In 2005, 1,114
accidents were reported, of which 143 cases had resulted in patients’ death. In 2006,
the data were 1,296 accidents of which 152 were fatal.
JCQHC publishes the analysis of the reported cases every quarter. The following
is an example of precautionary warning derived from reporting that inexperienced
nurses misjudged the dosage of insulin through confusion of unit and ml. The
warning is expressed in a visual and impressive manner and posted over the website.

(2) Controversy over criminal prosecution
Japan’s penal code includes “accidental death or injuries resulting fromprofessional negligence (the Penal Code, section 211). This criminal charge isunique to Japan because not many other countries have the same incrimination. Thischarge is applied when anybody causes death or brings bodily harm to others for
failure to pay due attention required for professional activities. Here, professional
activities refer to any
activities which needlicense or qualification,
the most typical ofwhich is car driving.
Drivers who killed or
injured somebody else
while driving a car for
failure to pay due
attentionwill
becharged for this crimeand doctors and any
46health professionals are no exception.
However, medical malpractices have seldom been prosecuted as criminal cases
mainly due to the lack of prompt alerts to the police. Such good old days wereradically altered in and around 1999, when a serious medical error in which surgeons
had operated on a wrong patient at a prestigious university hospital and alerted theentire society. Since then, the number of criminal charges brought against doctors
for medical accidents or errors resulting in death or bodily harm of patients increased
radically as shown in the above graph.
The alarming increase of criminal prosecutions culminated in early 2006, when a
OBGY doctor was arrested after he had performed a C-section on a pregnant woman
with rare and difficult obstetrical complications (placenta praevia AND accreta) who
had eventually died of excessive bleeding. Police charged him with “accidental
death resulting from professional negligence” for not taking required attention suchas transferring her to the tertiary hospitals. The incident came to be called “Onohospital incident” after the name of the hospital in Fukushima prefecture andprovoked a nationwide debate.
Medical community including OBGY association defended him that the patient’s
condition had been rare and difficult ones and that he should not be held responsible
simply for not being able to rescue her. The impact of the incidence was such thatthe number of medical graduates who sought OBGY had declined due todiscouragement.
On 20 th August 2008, the district court ruled that the doctor was not guilty. This
incident not only provoked debate but also sent a strong caution to the police andprosecutors that they should be rather cautious in pursuing criminal charges against
medical accidents.
(3) The proposed Medical Accidents Investigation Committee
Medical community resents police involvement on medical accidents but thesection 21 of the Physicians’ Act require doctors to report to police within 24 hours
when patients die of “unnatural causes”. The supreme court ruling in April 2004
held that deaths due to medical accidents are also unnatural causes and failure toreport to police would constitute the violation of the section 21.
After the ruling, there has been a growing outcry among medical communities
calling for revision of the Physicians’ Act to preclude police involvement. MHLW
proposed a bill “Medical Accidents Investigation Committee (MAIC) Act” in 2007.
The bill intends to set up MAIC and require medical providers to report any medical
accidents. If a provider report to MAIC, their obligation to report to police would
be waived thereby effectively precluding initial involvement by police.
However the medical communities once again disliked the clause that “MAIC may
notify the police if they found that the accidents are caused by gross negligence”. In
April 2008, the third draft was published and an endless debate is still going on.
47

Chapter 5. Health Economics
Japan’s Health Insurance Act was enacted in 1922 but it did not take effect until
1927 due mainly to the large earthquake hitting Tokyo area in September 1923. The
enactment was motivated by German social insurance model created by Bismark andwas intended to cover industrial workers. Non-employed population such as farmers
and fishermen were left uninsured. In 1938, the National Health Insurance Act wasenacted and non-employed population was insured through mutual aid associations.
It is noteworthy that the NHI act was enacted in 1938 simultaneously with thenotorious National Mobilization Act. This historical fact suggests the dark side of
the NHI system, which was intended as part of the war efforts (Sino-Japanese war
broke out in July 1937 and the war procrastinated eventually developing into theWWII).
In the postwar era, the NHI act was revised to expand the coverage for the entire
nation. It was 1961 when the national coverage was achieved.

1. Health Insurance
The health insurance system not only finances the health care but also serves as a“defacto” policy implementation tool to enable the government to macro-manage thebehavior of hospitals and clinics in the entire nation through the uniform feeschedule.
Although the health insurance system covers the entire population, it is by nomeans a single unified system. Instead,
it is a fragmented system consisting ofdifferent insurers covering different
segments of the population.
The system consists of two major
pillars: The Employees’ Health Insurance(EHI) that covers employed working
population and their dependent family
members and The National Health
Insurance
(NHI)
that
coversnon-employed population. The EHI isfurther divided into Health InsuranceSocieties (HIS) that are established in
major corporations and the Social
Insurance Agency (SIA) that covers employees and medium to small sizedcorporations. For civil servants, Mutual Aid Association (MAA) provides coverage
equivalent to HISs. The NHI is further divided into municipal governments and
NHI societies that are established by some occupational association such as doctors,
48

dentists, lawyers and self-employed construction workers.
Currently the ratio between EHI and NHI is 3:2. The rest 1% are indigent people
who are covered by the means-tested welfare system.
The distribution of enrollment to different insurance system is heavily affected byeconomic situation. When the job market is bad, there is a migration from EHI to NHI.
Due to the long-lasting economic slump, the number of HIS has shrunk from over1800 to 1584 (as of March 2005) while the enrollment of NHI is increasing. Nearly
two million people migrated from EHI to NHI during one year ended in May 2002.
With no improvement in the job market in sight for the foreseeable future, themigration toward NHI will continue.
(1) Premium
Since Japan’s health insurance is social insurance, premium is metered to one’s
income. In case of the EHI, the premium rate is simply a certain % of monthly
salary plus bonus (the number of dependent family members does not matter) with acap (620,000 yen or approximately $5000 for monthly salary and 2 million yen or 17
thousand dollars for annual bonuses). The rate of SIA (the largest insurer) is 8.2%
plus 1.23% for the LTCI for beneficiaries over 40 years old. Employers are required
to contribute at least half of the premium for their employees. The rates of HISs
vary between 4 and 10%.
Premium schedule of municipal NHI varies considerably. It consists of threeparts: annual basic premium per household, annual percapita premium for eachbeneficiary and income-related part subject to the annual per household cap of530000 yen (approximately $5000).
(2) Governmental subsidy
For some insurers, premium contribution is supplemented by the governmental
subsidies. Subsidies are most for municipal NHI, in which the 43% of benefit
disbursement is subsidized. For SIA, 13% of the benefit disbursement is subsidized.
HISs covering large corporations receives not subsidies.

2. Health Insurance for the Old-Old
In 2008, the health insurance system was radically restructured. The elderly
population aged 75 years or older was separated and covered by the newly created the
Health Insurance System for the Old-old.

49

(1) Brief history of the elderly health care system
Since Japan’s population has been ageing considerably, the health care system had
inevitably to cope with financing problem.
The Elderly Welfare Act was
implemented in 1963. It was later revised to subsidize the copayment of healthinsurance to guarantee easy access to health care starting in 1973.
However the elimination of copayment drastically inflated the health care cost for
the elderly and financially distressed the National Health Insurance system run bymunicipal governments because of uneven distribution of elderly enrollment among
different insurance systems. There was a strong call for total unification offragmented health insurance system for better risk sharing of the elderly health carecost, but such solutions were not likely to come by because of strong opposition fromindustry side.
As an alternative, the Elderly Health Act was implemented to introduce a financial
redistribution mechanism among different health insurance systems to equalize thedisparity of elderly enrollment, which took effect in 1983. After the implementationof the EHS, health care cost for the elderly 70 years old or over was financed in asomewhat different manner than ordinary population. While the elderly population
are also enrolled to health insurance system and pay the same premium with theyounger population, their health care cost are paid by municipal governments where
the elderly resides.
All the health insurers contribute to a newly created financial pool managed by apublic corporation and the amount of contribution of individual insurers arecalculated to adjust the disparity of the elderly enrollment, i.e., the insurers with less50than national average elderly enrollment will have to contribute more than they areotherwise responsible, while the insurers with higher than national average elderly
enrollment will contribute less than they are otherwise responsible.
It is still noteworthy that although the EHS ameliorate the financial plight of themunicipal National Health Insurance system, it eventually proved to be only apatchwork remedy without a total unification of health insurance system leading to
the radical reform in the field of long term care as a form of the Long Term Care
Insurance system which effectively unifies the insurers to municipal governments.
(2) Policy debate over the reform
When Japan turned the new century, it has radically restructured the bureaucraticsystem of the government. The leadership of the prime minister was vastly
strengthened enabling the strong initiative by the PM Koizumi who took power in
April 2001. The newly created Advisory Committee on Economics and Financing
advocated streamlining health care system including the EHS.
Through the policy debates that ensued, policy options were actively debated but
eventually the Congress enacted the reform law which would change the EHS Act
into the “Elderly Health Care Security Act (EHCSA)” in June 2006. The EHCSA
separates the elderly 75 years or older (old-old) from the rest of the population as anindependent health insurance system.
(3) Organizational and financing structure
What distinguishes the EHCSA from the previous EHS (as well as the LTCI) is that
the EHCSA is administered by the organizations established in each 47 prefectures.
Therefore premium schedules also differ from prefecture to prefecture. Since
majority of the old-old elderly are pensioners, premium will be withheld frompension payment. Actually, the largest aim of creating a new independent system
was to make the ever-growing pension fund as yet another source of health carefinancing.
However the premium from the entire old-old population (approximately ten
million or 7.8% of the population) constitutes only 10% of the revenue. About halfof the revenue is from tax and 40% is from contributions from all health insurers ofyounger population.
(4) Fee schedule and benefit structure
The fee schedule does not essentially differ from the ordinary health insurance.
However, some modifications are made. One example is the family doctor fee forthe old-old. This is intended to be a forerunner of capitation and gate keeper model.

3. Fee schedule and Reimbursement system
The benefit of Japan’s health insurance system is comprehensive and uniform: one
can safely assume that all medical services including dental care and outpatient
medication are covered to all nation regardless of the insurance system.
51

The reimbursement is basically fee-for-service and the government sets thenational uniform fee schedule as well as the price list of all drugs covered byinsurance (unfortunately Viagra is not covered). There is no capitation payment like
British NHS nor manage-care arrangement as seen in the U.S..
The fee schedule is revised every two years through the negotiation between thegovernment and the provider sides (Japan Medical Association etc). The feeschedule revision is important in health policy making because not only it changes
the price but also it implements certain health policy. For example, the government
may be able to encourage doctors over the country to provide more house calls
through economic incentives by raising the price for house calls.
The year 2008 coincided with the fee schedule revision year and charges of typicalcases are presented below.

Reimbursement is not 100%. Patients are required to pay a certain specified
copayment whenever they receive treatment. The copayment is 30% (10-20% for
elderly over 75) with monthly cap, beyond which the overpayment will be refunded
by insurers upon request.

4. Claims processing and computerization
Hospitals and clinics submit claims for direct reimbursement to the insurers.
Practically, insurers do not handle the claims, instead they maintain clearinghouses
for claims processing. All hospitals and clinics will submit all the claims to theclearing houses established in each of 47 prefectural level. Clearinghouses areauthorized to audit the claims to verify the content of the claims, after then the52reimbursement will be paid to each hospital or clinic.

Claims are submitted in every calendar month. The total number of such claims iswell over one billion per year (!). Most claims are still submitted in paper form andare reviewed and processed manually.
In 2001, the IT Strategy Act was enacted under the Mori administration
proclaiming that Japan would be the world most advanced IT technology country by
2005. Subsequently the MHLW published its first “Health Care Information Grand
Design” in December 2001 and set the goal of computerization of insurance claims of
hospitals more than 50% by the end of FY2004 and more than 70% by the end of FY
2006. Moreover, the revision of the Health Insurance Act in 2002 included a
provision requiring the government to “develop a system to collect, analyze, evaluate
and disseminate data on health care and health care cost (the supplementaryprovisions Sec.2, 6(2))”. Unfortunately, despite this Grand Design and a newprovision, the computerization of claims did not advance as scheduled. In 2005, it
became apparent that health care field was most underdeveloped in terms of IT.
This time, the IT Strategic HQ of the cabinet took an initiative and set a time limitof 2011 for the full computerization of claims expressed in a document titled “The
Platform for the Health Care Reform” published on 1 December 2005. It also statedthat “efforts shall be made to analyze the online claims information”.
The
subsequent “The New Strategy for IT Reform” published by the IT Strategic HQ in
January 2006, for the first time, proposed establishing a “national database of healthinsurance claims” to be used for epidemiological research. This landmark decision
was much influenced by the Korean development of the data warehouse by their53

Health Insurance Review Agency(HIRA).
In response to the New Strategy for
IT Reform, MHLW compiled the 2 ndGrand Design in March 2007, an action
plan for the next five years.
It
reconfirmed the stated goal of fullcomputerization of insurance claimsby the end of FY 2010 (March 2011)
and set a schedule for the “national
database of health insurance claims”.
The system shall be constructed by theend of FY 2008 (March 2009) and startcollection of computerized claims data
in 2009 and will start publication of the results of analysis in 2011. The “committee
for utilization of health insurance claims for betterment of the quality of health care”
was launched in July 2007 and will compile the final report by the end of the year.
Fortunately, computerization of claims is rapidly developing. According to thelatest figure released by Social Insurance Payment Fund, the percent ofcomputerization of claims submitted electronically was 43.7% for hospitals, 15.8%
for clinics and 78.6% for pharmacies). In 2006, online submission also started andhospitals show higher rate of online submission than pharmacies (6.3% vs. 1.7%).
Once Japan’s claims are computerized. They are expected to be a powerful toolfor not only health economics research but also epidemiological research.

5. National Health Care
Expenditure
The government estimates thetotal disbursement of health carecost paid to hospitals, clinics andother related health care providers
such as pharmacies and independent
visiting nursing stations, which iscalled the National Health Care
Expenditure (NHCE).
The estimated total of NHCE in
FY2006 was 33.1 trillion yen or
approximately 288 billion dollars or
260,000 yen (2,260 dollars) per
capita, which constitutes 9% of54Japan’s National Income (NI, 367.6 trillion yen in 2005) or 7.6% of Gross Domestic
Product (GDP, 500 trillion yen). The NHCE in 2002 has, for the first time, declined
by 0.5% from previous year, thanks mainly to the increased copayment for salaried
workers (20% -> 30%) and price cut of the fee schedule (-2.7%).
Although this figure may seem reasonable particularly in comparison with the U.S.,
one should be reminded that the scope of NHCE is much more narrowly defined than
the national health expenditure of the U.S.. Japan’s NHCE is strictly limited to thecost paid by public financing system to health care providers and does not include
private payment such as glasses and contact lens, OTC drugs, add-on payment foramenity. According to the estimate made by the Institute of Health Economics andPolicy (IHEP), the NHCE is underestimated by at least 10% from the more broadly
defined health care expenditure of other countries.
The government has set a policy goal of controlling the growth of NHCE in parallelto the growth of the National Income so as not to strain the household. The percentof the NHCE per NI was 6% in 1990, when the bubble economy raised the national
income, but has increased steadily since then to 9% in 2006 (NI was 573 trillion yen
or approximately 5.5 trillion dollars). Given the long lasting economic slump
coupled with the rapidly aging population, the burden of health care cost will
inevitably continue to grow in the foreseeable future.

As for the financial source, the NHCE is broken down to insurance premium 49.2%,
general tax revenue 36.4% and patients’ out-of-pocket 14.4%. The share of patients’
out-of-pocket is growing due to the increased copayment of the health insurance
system.
As measured by %GDP, Japan ranks low of the middle of OECD countries withregard to personal health expenditure.

55

6. The Structural Reform 2008
In April 2001, the Koizumi administration took power and a “neo-conservative”
reform plan was adopted. There are two important “brains” behind the Koizumi
reform:theCouncilon
EconomicandFiscalPolicy(CEFP)(http://www.keizai-shimon.go.jp/english/index.html)
andtheCouncilon
Deregulation and Privatization (CDP). Members of the “brains” are dominated byeconomists and business leaders excluding medical societies. Therefore, the debate
over the reform is the battle between the neo-conservative reformers (CEFP, CDP) vs.
opponents (Japan Medical Association).
The stance of MHLW fluctuated in between. Shortly after Koizumi took power,
the CEFP issued the first policy statement “The basic fiscal policy and socioeconomic
structural reform” dubbed “Honebuto Houshin (audacious policy)” in June 2001.
The statement included two radical proposals: health care rationalization programand global budget on elderly health care cost. The CDP proposed a variety ofderegulation measures such as allowing for-profit companies to own and manage
hospitals, direct negotiation and contact between providers and insurers (Japanesemanage-care) and on-line processing of health insurance claims.
Their proposals were welcomed by Ministry of Economics & Industry and Ministryof Finance but were, imaginably, unpopular among medical communities and MHLW
also appeared reluctant, although it did issue a working plan to realize the Honebuto
Houshin in September 2001. In fact, not much of the proposals were realized as of2005. In 2002, as a political compromise of revising the health insurance laws toincrease patients’ copayment, the revision included a mandate that a structural reform
plan should be completed in two years.
The mandates also included a
recommendation that the government set up an information system to keep track ofhealth care cost, quality and utilization, which has not been realized yet.
The general election in September 2005 turned out to be the fanfare of the Koizumi
administration. The overwhelming victory of the ruling party (excluding therenegades who had opposed privatization of the postal services) brought with it the
boost for what became called the “structural reform of the health care system”. The
reform plan, which passed the Congress in June 2006, involves radical measures
which few would have anticipated.
In 2008, the following agenda took effect:● Establishment of the new independent elderly health insurance system covering theelderly aged 75 or over. The new insurer will be cooperatives of municipal
governments in prefectural level.
● Consolidating health insurers at prefectural level. The Social Insurance Agency
which has been managing the governmental health insurance will be separated into 47
prefectural levels as independent organization.
As a precursor, a committee
involving all health insurers is already established in every prefecture.
56

● Introduction of primary prevention programs against metabolic syndrome. All
health insurers will be required to provide annual health checkups as well as post
screening health guidance to all beneficiaries including dependent family members.
● Development of IT. These include the full electronic transfer of insurance claims
on provider side, and record keeping of individualized records of health checkups
between age 40 thru 74 years old. Also computerized insurance claims will be
actively used to facilitate the disease management.
● Reduction of geriatric LTC hospital beds through development of “community
path” to enhance effective coordination among various care providers encouraging
early discharge.
The prevention program against metabolic syndromes and reduction of geriatriclong-term care hospital beds are two pillars of the newly created “Health Care Cost
Containment Plan (HCCCP)” developed by each prefectures. In early 2006, MHLW
produced a forecast of NHCE in the long future. According to the forecast, thebenefit (=NHCE-patients’ copayment, 85% of NHCE) was projected to be 34 trillion
yen in 2011, the last year of the five year plan. MHLW hoped that the benefit will
be reduced to 32 trillion yen through prevention of metabolic syndromes andreduction of geriatric LTC hospital beds. It would eventually amount to 8 trillion
yen savings in 2025.
The forecast turned out to be doomed from the very beginning. MHLW officiallyacknowledged that no cost saving would be anticipated from primary prevention
program in its public announcement. Prefectures did presented the prospect ofhealth care cost by reduction of geriatric LTC hospital beds. Unfortunately, thereduction only added up to 0.7 trillion yen in 2011. This was a far cry from theexpected reduction of 2 trillion yen benefit (or 2.35 trillion yen of NHCE).
This gloomy aspects painfully remind everyone the difficulty of cost containmentof health care.

57

Chapter 6. Pharmaceutical Affairs
As part of the tradition of oriental medicine, poor separation of prescription anddispensing of drugs have long characterized Japan’s medical care, in which doctors
directly dispense drugs to the patients. This tradition has been considerably
modified thanks to the government efforts through economic incentives by way of
manipulating the uniform fee schedule.
Japan’s pharmaceutical regulation, on the other hand, has sometimes been smearedby iatrogenic disasters involving pharmaceutical adverse effects (ADR), the recent
cases of which involve Sorivudine scandals in 1993 and iatrogenic HIV infection
through imported blood products in the 1980s.

1. Pharmacies and Separation of Prescription and Dispensing
Traditionally Japanese doctors commonly dispense drugs directly to patients.
This is welcomed by both doctors and patients because doctors can raise profit
through markups between whole sale prices and reimbursement prices set by thegovernment and patients can save time for receiving all necessary care at a time.
This non-separation prescription and dispensing may explain the high share ofpharmaceuticals in the National Health Care Expenditure. The government andpharmacist association have long endeavored to enhance the separation by rewarding
higher prescription fee to doctors who choose issuing prescriptions rather thandirectly dispensing since middle of 1970s.
However initial efforts to enhance separation between prescription and dispensing
were hampered by physicians’ conflicts of interest. Many doctors and hospitals
established their affiliated pharmacies in their neighborhood and pocketed both
higher prescription fee and pharmaceutical markups.
To encourage “pure”
independence of pharmacies, “carrots and sticks” measures have been taken:
penalizing doctors who develop collusive arrangement with pharmacies andrewarding pharmacies that have fewer ties with particular hospitals or doctors.
From the health insurance policy, the official reimbursement price has been
repeatedly reduced to discourage doctors from direct dispensing by reducing thepharmaceutical markups. Also, generic substitution has been promoted by way oflisting the drug with generic names rather than brand names in the official
reimbursement list for the products whose patents had expired. For inpatient care,
all inclusive per diem reimbursement system is increasingly suppressing the share ofpharmaceutical cost in the inpatient health care cost.
According to Japan Pharmacists Association, 55.8% of outpatient prescriptions are
dispensed by pharmacies in 2006 (the rest are dispensed by prescribing doctors
directly bringing some pharmaceutical markups to doctors). The separation ratevaries considerably from prefecture to prefecture ranging from 24.3% to 73.5%.
58

Ideally, each patient should have an attending pharmacy which checks against
potential duplicate dispensing. However some pharmacies depend on hospitals or
clinics located nearby and it is still common to see patients get dispensed frommultiple pharmacies affiliated with hospitals and clinics making the advantage ofseparation of dispensing hard to achieve.
Pharmacies advanced well in computerization of health insurance claims: 88.2% ofpharmaceutical claims are submitted electronically in June 2008.
Sincecomputerized claims contain detailed pharmaceutical data including therapeuticclasses, the computerization enables detailed analysis of claims data. In March
2008, MHLW started to provide monthly data from pharmaceutical claims submitted
electronically. The system is called Pharmaceutical MEDIAS available over the
MHLW
websitePharmaceutical expendinture of prescription drugsby therapeutic class[http://www.mhlw.go.jp/topics/[source : computerized health insurance claims from pharmacies, FY2007]
nutrition drugs
medias/month/index.html].
1.4%
oriental medicine
Since
Pharmaceutical
OTHERS
2.0%
vitamine
2.4%
MEDIAS is a population survey
6.2%
antibiotics
3.4%
on administrative data, not a
chemotherapy drugs
3.8%
sampling survey like Social
Cardiovascular drugs
anticancer
drugs
29.7%
Insurance
ClaimsSurvey5.1%
conducted in every June, it candrugs
analyze
drug-specific hematopoietic
5.7%
utilization
data.
The
CNS drugs
antiallergic drugs
12.2%
following is a result of
7.1%
pharmaceuticalexpenditure
GI tract drugs
other metabolic drugs
10.7%
broken down by therapeutic
10.3%
class.
As part of cost control efforts, prescription only drugs are increasingly switched to
OTC, the recent example of which includes H2 blocker. Further, deregulation toallow retail stores to sell nonprescription drugs is being discussed.

2. Pharmaceutical Reimbursement and Price Setting
The government sets prices of all drugs reimbursed by the health insurance system.
The list of reimbursable drugs includes nearly 14,000 items for both oral, IV andointment.
To calculate the price, the government is authorized by the
Pharmaceutical Affairs Act to conduct a market survey every year.
This survey is conducted with close cooperation with wholesalers who submit theirtransaction records with health care providers. The official reimbursement pricewill set at the weighted average of the transaction price plus the reasonable margin
that is usually set at 2%. For newly approved drugs, the price will be set bycomparison with other drugs of the same therapeutic effect. For a limited number of59

innovative drugs, some bonus prices may be awarded on a case-by-case basis.
Because Japan imports pharmaceutical products heavily from the U.S., thetransparency of price setting has occasionally become centers of the tradenegotiations between two countries. In 2001, President Bush and PM Koizumi
reached an accord named “The U.S.-Japan Economics Partnership for Growth”, inwhich both sides agreed on enhancing transparency of drug price setting throughensuring the American industries the access to the raw data on which the price setting
was based as well as streamlining the new drug approval process.
The share of generic products of Japan is lower than most other developed countries.
According to IMS, the share of generic products as measured by dosage in 2006 of majorcountries was: US(63%), UK(59%) and Germany (56%).

Japan’s figure was only 16.9%

according to Japan Generic Manufacturers Association (5.2% on monetary values).

As partof health care cost containment measures, MHLW declared a policy to increase the share ofgeneric products to 30% from present 16.9%.

To encourage generic substitution, thepracticing rules of doctors was revised in April 2008 and doctors were asked to check on
their prescription when they do NOT permit generic substitutions (before doctors wereasked to check when they DO permit so).

3. Clinical Trials
Pharmaceutical products, cosmetics and medical equipment are subject toregulation by the Pharmaceutical Affairs Act. The Act was amended in April 1993
to allow public subsidies for research and development of orphan drugs as well as
accelerated review.
New drug applications will be subject to preliminary review by a special agency
named “Pharmaceuticals and Medical Equipment Evaluation Center” and then final
review by the Pharmaceutical Affairs Committee. Final decision is left to thediscretion by the Minister of Health, Labor and Welfare.
Regulations on clinical trials were tightened by the amendment of thePharmaceutical Affairs Act in June 1996 in response to a series of misconducts
exposed in the preceding years.
This led to “hollowing of clinical trials”. Tightened regulation coupled with low
interest of doctors in clinical research discouraged doctors from clinical trials.
Deregulation to accept foreign research data added to this trend: multinational
pharmaceutical companies prefer to conduct clinical trials outside of Japan and later
get a new drug approval by “importing” data to Japan. As a result, a considerable
number of new drugs remain unavailable for Japanese patients even after they areapproved somewhere else in the world. It is also feared that this “hollowing” ofclinical trials will deprive Japan of its scientific competency.
Furthermore, deregulation to allow foreign research data may not always
appropriate because the same drug may affect differently among different races.
60One example is Omeprazole (proton pump inhibitor). Higher prevalence of poor
metabolizer due to genetic type CYP 2C19 makes the drug more effective at lower
dosage.
To revitalize clinical trials, the Pharmaceutical Affairs Act was revised to initiate“doctors-sponsoring” clinical trials, which took effect in July 2003. Until then, only
pharmaceutical companies could apply clinical trials. Even if doctors wish thatcertain indications should be added to existing drugs, they are not authorized to
conduct clinical trials by themselves (prescribing drugs to patients for unapproved
indications is prohibited as off-label prescription).
On the other hand,
pharmaceutical companies are not interested in conducting expensive clinical trials
without much commercial promise.
Another measure taken by government was to develop a large-scale network ofclinical trials to enable participating hospitals and doctors to share resources such asdata centers and IRBs. A supporting organization, Japan Clinical Research Assist
Center (JCRAC) was established together with its data management center (DMC) in2001. JCRAC is currently assisting seven clinical trials through data management,

data analysis, IRB and training of Clinical Research Coordinators (CRC).
In April 2003, MHLW published a “3 year plan for vitalizing clinical trials” tofacilitate clinical trials in medical school affiliated hospitals and reached anagreement with Japan Medical Association in promoting doctors-sponsoring clinical
trials in community hospitals in August 2003.

4. Japan’s Pharmaceutical Industry
The output of Japan’s pharmaceutical industry was 6.4 trillion yen or
approximately 60 billion dollars in 2006, of which only 133 billion yen or61approximately 1.2 billion dollars was exported. Japan also imported 1.56 trillion
yen or approximately 14 billion dollars worth pharmaceuticals from abroad in 2006.
The output of Japan’s pharmaceutical industry has been quit stagnant for last ten
years. This long stagnation has reduced Japan’s share in the world pharmaceuticalmarket considerably. According to GlaxoSmithKline Annual Report 2000, Japan
constitutes 14.9% of the world pharmaceutical marketplace (32 billion Euro in 215
billion Euro worldwide) in 2000 but Japan’s share declined to 11% in 2004 according
to IMS. Of Japan pharmaceutical imports (1.56 trillion yen or approximately 14
billion dollars in 2006), top three countries namely UK, Switzerland and Germany
constituted roughly half. What is noteworthy is that while Japan’s pharmaceuticalproduction has been stagnant, the amount of pharmaceutical import has grown 58% in,
Countries of Japan s pharmaceutical imports
five years (2001-2006).
(2006, total 1.56 trillion yen)
[ source : MHLW Pharmaceutical Manufacturing Survey ]Pharmaceutical industry is one of theothers 8.3%

Denmark“weakest” industries of Japan as shown
3.7%
Italy
in the graph below (source: Japan
3.7%
Pharmaceutical
Manufacturers
Ireland
4.7%
Association) with constant negative tradeimbalance.
The weakness of Japan’s PuertoRico
4.9%
pharmaceuticalindustrymaybeFranceexplained by its smaller size of the
5.1%
companies: Japan has 463 pharmaceutical
Belgium
6.2%
companies whereas the U.S. has 483.
Even the largest Japanese company(Takeda) is ranked 16 th in the world

UK
21.3%

Switherland
16.6%

US
12.2%

Germany
13.3%

ranking and all others are below 20 th .
This fragmented industry structure may be the result of non-competitive environmentof Japan’s national health insurance system, in which government dictates drug prices,
and reimbursement is guaranteed.
Japan s pharmaceutical production by therapeutic class(2005, total 6.4 trillion yen)
Unlikeauto
industry,
Japanese[ source : MHLW Pharmaceutical Production Survey ]pharmaceutical industry grew to be
domestic-oriented industry.
cardiovascular
In the era of consolidation of the
20.4%
otherspharmaceuticalindustry,
Japanese
28.2%
pharmaceuticalcompanies
face
other metabolic
challenges to stay competitive in the9.9%
world market.
biologicals
alimentary tract
As
for
the
pharmaceutical 3.7%
9.2%
allergyproduction broken down by therapeutic
3.7%
CNSclass, cardiovascular drugs were
8.9%
antibiotics
hematopoietic
skin
5.4%
5.2%
produced in the ex-factory value of
5.5%62

one trillion yen or approximately 20.4% of the total Japan’s pharmaceutical output in2005 (6.4 trillion yen) according to the Pharmaceutical Manufacturing Survey by
MHLW.

5. Pharmaceutical Monitoring and Surveillance
The history of Japan’s pharmaceutical affairs has been tainted by repeatedtragedies concerning drug side effects and MHLW vowed to prevent it by establishinga monument of “No more drug tragedies” in front of its office building in 1998.
Therefore pharmaceutical monitoring surveillance is of utmost importance. Adverse
drug reactions (ADR) reporting has been mandatory for pharmaceutical companies
but reporting from health care providers was initiated in 1967 in the wake of the
WHO resolution in 1963. Monitors were expanded to include pharmacies in 1973
and the then MHW started periodic newsletter to inform health care providers of
ADRs in 1974.
A new standard for PMS (Post Marketing Surveillance) for pharmaceuticalcompanies was established in 1993. However it failed to prevent the Sorivudin
tragedy, in which 16 patients had died within a month after the new drug had been put
into market. Originally the ADR reporting was limited to certain monitoring
hospitals and the number of reporting has somewhat been stagnant until 1997, when
ADR reporting was broadened to all doctors and pharmacists. Although thereporting was voluntary, the number of ADR reporting from doctors and pharmacists
has increased. In July 2003, ADR reporting became mandatory for all doctors andpharmacists.
All reported cases are evaluatedby a subcommittee of the Central
Pharmaceutical Affairs Committee.
MHLW
periodicallypublishes“Pharmaceutical
SafetyInformation” every other month andissues“Emergency
SafetyInformation” in an ad hoc manner.

6. Blood Products
Japan’s per capita consumption of blood products are higher than most developed
countries. Basically all blood products consumed domestically should be suppliedby donated blood. However the donated blood alone is not sufficient to fulfill thedomestic demand and majority of the blood necessary for production of plasma
fraction products such as albumin and globulin is imported. As of 2002, only 36.4%
of albumin and 83.3% of globulin are supplied by domestic blood donation.

63

Japan has seen a sharp
increase of blood products
consumption in the late1970s, boosted by huge
pharmaceuticalmarkups.
This excessive use of blood
products may be partially toblame for the spread of theiatrogenic HIV infection inthemiddleof
1980s.
Controlling of excessive useof blood products has been attempted through practice guidelines and utilization
reviews. Still, a large geographic variance is observed in the per capita use of fresh
frozen plasma (FFP) and albumin product.
Much effort has been directed at controlling iatrogenic infection through blood
products. After the outbreak of BSE in Europe, people who ever lived in any of 10
European countries for longer than 6 months after 1980 are banned from donating
blood since 2001. Also, anybody who comes back from abroad became banned fromblood donation for 3 weeks in the wake of WestNile outbreak in the U.S. sinceNovember 2002.
Further, the Pharmaceutical Affairs Act was amended to require all healthprofessionals to report infections suspected of transmitting through blood products asof July 2003.

7. Substance and drug abuse
Historically, Japan’s drug abuse became a social problem in early post-war period.
Around late 1940s, more than 50,000 people were arrested for amphetamine abuse.

In

1950s, heroin addition became a problem but successfully controlled by strict law
enforcement.

However,the

1980s saw the second wave ofamphetamine abuse with morethan

20,000arrests.

Nowadays,

newer

types

abusive

substanceofarecirculated thanks to internet.
In 2005, MDMA was added tothe control drug list. Thanks toa strict law enforcement as wellas campaign, the number ofabusers shows a decline.

64Chapter 7. Environmental HealthAncient Japan was believed to be a country relatively free of environmental
problems. Although, Edo, an ancient name of Tokyo, was a metropolis whose
population exceeded one million at that time, foreign visitors then were marveled at
the cleanness of the city. Actually outbreaks of infectious diseases such as plagueor cholera were seldom seen in most cities at that time, although fires hazards were
rampant due to the “wood and paper” structure of houses.
Japan sequestrated itself from the rest of the world for as long as 260 years
beginning in early 17 th century till the middle of the 19 th century, which might haveprotected the country from intrusion of any foreign-born infectious diseases, but welldeveloped sewage system might also have been a contributing factor.
Japan threw away the antique feudalism and aggressively modernized the country
with industrialization, and then a series of environmental problems emerged. The
first law aimed at environmental protection was the Smoke Control Act in 1962. As
a series of massive environmental disasters unfolded, the public concern on
environmental issues inevitably intensified. In 1967, the Anti Pollution Act wasenacted and by 1970, the Air Pollution Control Act, the Noise Control Act and theEnvironmental Pollution Victims Compensation Act were enacted. Symbolizing thegovernment resolution to tackle the problem, the Environment Protection Agency was
instituted in 1971. In 1993, the Environmental Protection Policy Act (EPPA) was
enacted. It has three basic principles:
1. Succession and reception of the benefit of environment
2. Structuring a sustainable society which poses less burden on environment
3. Promoting environmental protection through international cooperation
Pursuant to this law, the government sets criteria for environment andenvironmental assessment as necessary.
The section 16 of the law requires
environmental standards for air, water, soil and noise.

1. Air Pollution
For air pollutants, environmental standards are set for the following ninepollutants.
Sulfur dioxide (SO 2 )Sulfur dioxide is generated by combustion of fossil fuel such as oil or coal, andcauses harm on respiratory tracts and is believed to be a cause of acid rain. Current
environmental standards hold that an hourly average of 0.1 ppm and daily average of0.04 ppm.
Carbon monoxide (CO)Most of CO in the ambient air is emitted by cars due to incomplete combustion.
Current environmental standards are eight hours average of 20 ppm and daily average65

of 10 ppm.
Suspended particular matter (SPM)
SPM refers to particular matters floating in the air whose diameter is 10
micrometer or less. Environmental standards for SPM are hourly average 0.2 mg/m 3
and daily average 0.1 mg/m 3 .
Nitrogen dioxide (NO 2 )NOx is emitted by combustion of fossil fuel mainly from factories and automobiles.
With high concentration, NOx damages respiratory tract and, on global level, is
responsible for acid rain and photochemical smog. Its ambient concentration has
been under constant monitoring.
Photochemical oxidant
Oxidant is generated from NOx through interaction with sunlight.
effect on mucosa and respiratory tract.

It has irritable

Above pollutants are “veterans” whose environmental standards were set in 1973.
The following pollutants are “new comers” whose standards were newly introduced in
1997 and after. Worthy of note is Dioxin. With growing public concern on thissubstance, the special law “Anti Dioxin Measure Act” was enacted in 2000 andstandards were set for both ambient air and food intake. A survey conducted in 2001
revealed that average daily intake of Dioxin by Japanese was found to be
1.63pgTEQ/Kg/day.
(1) Benzene(2) Trichloroethylene(3) Tetrachloroethylene(4) Dichloromethane(5) Dioxin
SORA (Study On Respiratory disease and Automobile exhaust)
Thanks to the aggressive efforts for air pollution control, the ambient air quality
has improved considerably. Nonetheless, there are concerns that air pollution might
have been simply “localized” to the roadside areas particularly in view of theincreasing prevalence of asthma and respiratory symptoms among school children.
The Ministry of Environment launched a large-scale epidemiological survey onschool children and infants living in the roadside of busy streets starting in 2005.
The project is acronymed as SORA, meaning sky in Japanese and consists of twoparts: a cohort study on school children and a case-control study on infants.
Already approximately 16,000 school children were recruited for the cohort study
and the baseline survey was completed in 2005. They will be followed up to theyear 2009 to evaluate relationship among individual exposure to automobile exhaust(estimated by modeling), confounding factors such as domestic allergen as well as
ambient air pollution levels and subsequent health effects.
As for the case-control study, volunteers were selected from 100,000 infants who
66

received health checkups at the age of 1.5 (July 2006-March 2008) and 3 (February
2008-March 2010). Cases will be those who developed asthma in the intervals of
health checkups and controls will be selected from those who did not.
Environmental Health Surveillance System (EHSS)EHSS is a national version of air pollution monitoring system started in 1996.
Questionnaire is distributed to mothers of three-year old children as part of thethree-year old health checkup.
Area-specific health data are linked withgeographical environmental monitoring system to enable epidemiological study on
environmental cause of human diseases. Six-years old children survey was added in
2004 and linked with those who responded to the survey at three years old. The firstfindings were published in December 2006 and reported the “incidence” of asthma
and other onsets of respiratory symptoms for the first time (Only “prevalence” wasavailable because of the cross-sectional nature of the EHSS).
Such cohort study was possible because the EHSS collects personal identifiabledata such as name, date of birth and address and the survey is conducted inpredetermined 44 areas. Of 52 thousand six-year old respondents in the 2004 survey,
23,110 respondents were matched with three-year old respondents in the 2000 and2001 surveys allowing for estimation of “incidence” of asthma in three years period.
The result was somewhat unexpected: incidence of asthma was higher in areas withhigher SO2 concentration. The finding illustrated the individual’s history of allergy
is far more important factor in asthma onset than any environmental factors (Odds
ratio of history of allergy was 2.13-2.14 while that of SO2 was 0.46, both p<0.05).

2. Drinking water supply
In 1787, 1.2 million residents out of 2 million residents in Edo (ancient name ofTokyo) were served with water supply. The Edo water supply was arguably thelargest in the world, compared to 0.9 million in London and 0.8 million in Paris.
This is partially the reason why Edo, one of the largest metropolises in the world then,was relatively free from outbreaks of water-borne diseases such as cholera, whichhaunted London at that time.
However, in national level, the % of population served with water supply remained
32.2% in 1955. The water supply was rapidly developed after that and 90% in 1980
and currently serves 96.8% of the total population in 2002.
The long-term trend suggests the health indices show marked improvement as thecoverage of water supply exceeds 50% and the prevalence of water-borne disease
reduces to minimal when the coverage is above 80%.
Although Japan has relatively heavy rain fall, most of Japan’s rivers are short andflows like “cascade”. Therefore Japan relies heavily on dams to store water.
Approximately 71.4% of water comes from dammed pool.
The Drinking Water Supply Act assigns the responsibility of supplying clean water67

to municipal governments. Approximately 3,000 municipal governments operate
approximately 11,000 water supply programs, the largest of which is Tokyo
metropolitan government serving as many as 12 million residents.
A Jewish critic (Izaya Bendathan) once blamed Japanese for them to presume that
“Water and safety is free” most vividly evidenced by an idiom “spending like water”.
Of course drinking water is not free. Monthly water bill for 20 cubic meters, anaverage household consumption, costs 3,083 yen (2001) ranging from as low as 700
yen to as high as 6,190 yen. Each municipal government operates its water supply
business independently to make both ends meet. Some advocate “privatization” ofwater supply, but it is questionable for private enterprises to operate in areas wherewater is hard to come by.

3. Sewage system
In the middle age, as people lived in an increasingly crowded environment, lack of
sewage system brought about epidemics of water-borne infectious diseases. WhenJohn Snow made a monumental work on cholera epidemics in 1855, the first sewage
system was constructed in London. Other industrialized countries followed suite
and, in 1884, Tokyo (Edo was renamed Tokyo after the Meiji Restoration in 1868)
also had the first sewage system.
As of 2002, 65.2% of population is served with sewage system, but the rate is only
31.8% for small towns and villages whose population is less than 50,000. Japan’s
sewage system processes 13 billion cubic meters of sewage water and the 75 million
tons of sludge constitute 19% of industrial waste. 60% of them are recycled as
fertilizer or construction materials.
As for urine and feces disposal, 57.9% of the total population is served withsewage system and 26.8% is served with septic tanks. However 16.6% of populationis still not served with proper disposal.

4. History of Pollution Related Diseases
In the course of rapid modernization and industrialization, Japan witnessed tragic
cases of pollution related diseases, some of which are well-known to the world with alingering distress of the victims. The following are some of them.
68(1)Minamata disease
Minamata disease, immortalized by photographer Eugene Smith with his picture book
“Minamata”, is arguably the world worst tragedy of organic mercury poisoning. It occurredin Minamata bay of Kyushu (see the map) early in the 1950s due to the bioaccumulation oforganic (methyl) mercury emitted into the sea from a nearby chemical plant.

Medically,

minamata disease is Hunter-Russel syndrome characterized by neurological disturbancesuch as motor disturbance, central narrowing of visual field.

However, it was only in 1968

when the government officially acknowledged the cause and effect of the disease.

A seriesof civil suits followed since 1967 and the disease became an icon for the civil movement
against the pollutions.

(2)Itai-itai disease
Itai-itai disease is chronic poisoning of cadmium first found along the Jintsu river inToyama prefecture.

It affected farmers who ate rice contaminated by cadmium emitted

from a mine upstream.

Medically it is osteomalacia caused by calcium draining from boneminerals due to impaired proximal renal tubules (detected by increased urinary secretion ofbeta2microglobulin).

By the same token with osteoporosis, women are more susceptible tothe disease than men.

Because of weakened bone, victims suffered from multiple bone

fractures complaining pain (itai means pain in Japanese).

(3)Chronic arsenic poisoning
Arsenic is a poison deadly enough to kill people in acute poisoning. Historicallyit has been notorious for its use in assassinations (victims include Napoleon!?) or
crimes (Wakayama curry poison
incident in 1998) and also killedmanyinindustrial
accidents(Morinaga arsenic milk tragedy in1955 killed at least 130 babies
affecting12,344 according to areportby
thegovernment).
However, only chronic poisoning isclassified as a pollution-relateddisease.
Clinically its symptoms
are manifested in nasal cavity as aform of perforation or ulceration as
well as multiple neuropathy.

5. Environmental Pollution Victims Compensation System
One of the unique features of Japan’s environmental protection is its “Environmental
Pollution Victims Compensation System (EPVCS)”.

This is a collective out-of-court

arbitration between polluters and victims whose health had been compromised by thepollution.

Under this system, victims do not have to resort to lengthy court procedures to69

win damages.

The system was developed in a bitter lesson learned from lengthy court

battles involving environmental diseases.
The EPVCS compensates two major pollution related diseases: respiratory diseases
derived from air pollution and chronic intoxication by toxic substances.

The respiratory

diseases include chronic bronchitis, emphysema, asthma and the chronic intoxication
includes some world-famous pollution disasters that took place in Japan in the past:
Minamata disease (Organic mercury poisoning), Itai-itai disease (Cadmium poisoning) andchronic arsenic poisoning.

To be eligible for compensation, a person must apply for

diagnosis to determine if an applicant meets the diagnostic criteria (such as central
narrowing of visual field for Minamata disease) but disputes arose in ambiguous cases
which fail to present typical symptoms.
A total of 2,958 victims have been diagnosed as Minamata disease by EPVCS to date, of
which 895 are still alive.

As for the disputed cases, a political compromise was reached in

1995 that the government set up an additional measure to provide subsidies for medical carefor the plaintiffs.

A total of 12,374 patients became eligible for the additional measure by

July 1996.
According to the Polluter Pay Principle (PPP), the EPVCS system is wholly financed bycompensatory damage paid by polluters and the government pays only its administrativecost.

As for air pollution, the compensatory damage is levied by the government frommajor air pollutants, namely automobiles and smoking factories in proportion to the amountof SOx emitted from each polluter.

For automobiles, the damage is levied from their car

tax in proportion to the size of their engine.

For factories, the damage is levied inproportion to the amount of smoke emission.

As for chronic intoxication, the damage islevied from the responsible corporations.

6. Measures against the Global Warming issues
According to the 4 th report by IPCC (International Panel for Climate Change) in
2007, the average temperature will rise by 1.1-6.4 centigrade by the end of the 21 s t
century and the sea level will rise by 18-59 cm due to the global warming.
The Kyoto conference on the global warming (COP3) held in December 1997 was alandmark event in the field of global environmental protection.

As a host country, Japan

enacted the “Anti Global Warming Act” in October 1998 and expressed its determination toachieve the goal set by the Kyoto protocol.

Still, the amount of “green house” effect gas

emitted in Japan in 2005 was estimated to be 1.36 billion tons or 7.8% more than 1990 level,a far cry from the reduction of 6% targeted by the Kyoto protocol.

To enforce thereduction, the government is looking to “environment tax” levied on emitted gas, to which
the industry is vehemently opposing.

The IPCC report also predicts a dismal forecast: the global warming will be
suppressed to 2-2.4 centigrade hike from 2000 to 2050 if the greenhouse effect gas
emission is reduced by 50-85%. But that will also reduce the world GDP by as much70

as 5.5%.

7. Public Health in Environmental Disasters
Japan has been hit by environmental disasters that involved potential public healthhazards.

Here are some descriptions how public health dealt with those disasters.

(1) The Great Kobe Earthquake
At 5:46 AM on 17 t h January 1995, Kobe City was hit by an earthquake of magnitude 8,
resulting in 5,488 casualties.

According to the vital statistics, 5,175 (94.3%) died on thefirst day of the disaster, of whom 4,059 died of crashing, 488 died of burning, 256 died of
injury.
The first few days were spent in chaotic conditions.

Many casualties flooded thehospitals and clinics with very limited resources for treatment.

The road was soon jammedwith cars and vehicles making it impossible for fire engines and ambulances to pass.

The

fires broke out afterward ran rampant because fire fighters could not secure water supply.
In a matter of hours, the entire city was a mass of debris and excavated bodies.
Kobe city government set up the disaster HQ one hour after the jolt.

A few city officials

who could manage to reach the office found themselves inundated with screaming requests
from hospitals, many of which had been severely damaged and left without power and watersupply.

The initial efforts of Kobe health officers were aimed at securing lifelines to thesefacilities and transporting inpatients to hospitals in unaffected areas.

Fortunately, as

media reported the severity of the disaster, many offers for help came from all parts of thecountry as well as from abroad.

More difficult task was how to bring the stuff to the needy

area because most roads were too jammed to allow smooth traffic.
Shortly after the earthquake, temporary refuges were set up in a variety of locations suchas schools, citizen halls and public facilities.
major concerns.
living spaces.

Make shift toilets were set up at such refuges.

Offensive odor filled theWater in the swimming pool and leakage from pipe was stored and used forwashing the human excrement.
toilets.

Sanitation and public health soon became

Public health centers distributed disinfectant to such

Disinfectant for hand and finger distributed by public health centers were believed

to be effective in keeping hygienic conditions of food.
It was rather fortunate that the disaster hit in the winter season in terms of preventing
infectious diseases.

Actually no complaints about pests were reported in most refuges.

Although a great number of victims were lost in the initial phase of the disaster, it may
well be regarded as a triumph of public health activities in that it could prevent secondary
casualties due to disease or unhygienic conditions, which almost always accompany suchlarge scale disasters.
[reference: Osaka University Medical School Department of Public Health “Public Health
Activities under the Great Earthquake[in Japanese]” June 1995](2)Outbreaks of Massive Pathogenic E.coli Food Poisoning
The year 1996 proved to be annus horribilis with massive outbreaks of pathogenic
71

E.coli food poisoning, in which 17,877 had developed symptoms and 12 deaths.
However, by far the largest outbreak took place in Sakai city in July of that year.
On Saturday, the 13th of July 1996, at about 10 am, Department of the Public
Health of the Sakai City Office received a report from the Sakai City Hospital about
10 patients from local elementary schools whose chief complaints were diarrhea andbloody stool during the night of July 12.
Similar reports were received at the municipal public health centers from othermedical institutions. Immediately, a massive food poisoning case was suspected andan investigation was started. On 13 th , a total of 255 children from 33 local
elementary schools received medical care for diarrhea or bloody stool. At 3 p.m., atask force was set up at the city office.
A rapidly growing number of school children started to complain of strong
abdominal cramps, diarrhea and bloody stool. By 14 th , over 2000 people werereceiving medical care at many hospitals and clinics.
The case was later confirmed as E. coli
O157:H7 infection. This strain of bacteria
proved to be deadly because it secretes
toxin
calledBello
toxin
causing
hemolytic-uremic syndrome (HUS).
From the onset of the outbreak, school
lunch was the most suspected cause of
poisoning.
Thoroughinvestigation
eventually concluded that radish sprouts
grown and harvested by a nearby producer
were the most probable cause.
[source: Sakai City “Report on the Outbreak of E.coli 157 Infection in Sakai City”
December 1997, p.9]

8. Food Sanitation
Japan imports much ofits food.
According to
the estimate by Ministryof Agriculture, 61% offood on caloric basis isimported.
Japan’s
domestic food supply has
consistently declined andis now one of the lowest
domestic supply rate evenamong
developed72

countries.
(1) BSE problem
The high reliance on foreign import makes Japan susceptible to food-relateddiseases. Outbreak of BSE (Bovine Spongiform Encephalopathy) in Europe in 2000
and a subsequent case reported in Japan in September 2001 sent an alarm to thegovernment and the general public alike. After that, all cows were examined for
BSE and approximately 8.18 million cows were examined by May 2008, from which
35 cows were found positive. Since August 2005, examinations were done for cows
21 months or older. Further, spinal cord, distal end of jejunum are mandated to be
removed.
In response to the BSE threat, the Food Safety Act was enacted, which introduced aseries of new approaches such as risk assessment, risk management and risk
communication. Also the new act established the Food Safety Committee in the
Cabinet Office, which takes charge ofrisk assessment of food safety.
(2) Food poisoning
Doctors
who
diagnosefoodpoisoning are required to report to thenearest PHC and 30,000 to 40,000
cases are reported in average year. In
1996 when Japan was hit by O157, thenumber climbed to 46,179 but the
number has been stabilized to 32,182
in 2007. The pathogens identified inreported cases (number of patients) in2007 (N=32,182) are shown in thegraph.
As the graph vividly illustrates,
Noro virus accounts for by far the largest share of pathogens. Actually Noro virus isa new comer: it first appeared in 1998 and increased since. Noro virus is likely tooutbreak in winter through sea food like oyster.
(3)Safety of imported foodJapan used to ban import of rice chiefly for the purpose of protecting domestic
farmers. It became part of the international trade conflict with the U.S. in the 1980s.
The government excused that the restriction on food import was due to safetyconcerns. However, when rice became in severe shortage in 1993 due to bad climate,
the government was forced to import rice from Thailand. Japan’s food import has
actually consistently increased and it has become the largest food importing country
in the world in terms of monetary value. Consequently, Japan became vulnerable tothe safety threats of imported food.
73

Concerns were particularly intensified about foods imported from China thanks torepeated cases of food contaminated with chemicals or pesticides. In January 2008,
ten people in Chiba and Hyogo prefectures who ate frozen dumpling imported from
China got poisoned. Police later identified the cause as organic phosphate pesticide,methamidophos.
The importer, JT Foods, voluntarily recalled the sold food.
Police suspected a criminal act behind the contamination and requested Chinese
authority for investigation. However, Chinese authority dismissed the claim and thecause is still at large.
Inspection on imported food is the responsibility of quarantine offices. Foodinspectors located in 31 quarantine offices examine importing applications andconduct sampling and laboratory examinations pursuant to the Food Sanitation Act.
Laboratory examinations are consolidated in two Imported Food Quarantine
Laboratories in Yokohama and Kobe quarantine offices. Laboratory examinations
were conducted on 10.7% of 1.86 million importing applications in 2006.
(4) HACCP
HACCP is an acronym of Hazard Analysis and Critical Control Point and was
adopted in May 1996 for dairy product. A manufacturer of dairy product may obtainapproval of MHLW if it manufactures the product based on HACCP.

9. Waste disposal
The Waste Disposal and Cleaning Act classifies domestic wastes and industrial
wastes and assign the responsibility of collection and disposal of the former tomunicipal governments while the responsibility for the latter to each industrial
generators. In 1997, the manifest system to keep track industrial wastes to ensure
proper disposal was introduced, in which each waste generators are required to issue
a manifest to the disposers.
Japan is generally viewed in the world as a successful country in achieving
effective recycling of resources. To make it possible, the following recycling laws
set goals to ensure recycling of resources.
Package recycling
Package and containers account for approximately of 56% of volume and 23% ofweight of domestic wastes according to the survey conducted by then Ministry of
Health & Welfare in 1995. In 1995, the Package and Container Recycling Act wasenacted requiring households to put out their garbage in a separated manner tofacilitate recycling.
Electric appliance recycling
The Electric Appliance Recycling Act in 1998 requires both consumers andmanufacturers to recycle four types of appliances namely television, air conditioner,
refrigerator and laundry machines.

74

Construction waste recycling
The Construction Waste Recycling Act in 2000 requires construction companies toseparate construction wastes such as concrete, metal and timber on site to facilitate
recycling at construction sites exceeding certain scales.
Food recycling
The Food Recycling Act in 2000 requires food manufacturers and processors toreuse uneaten food or wastes for fertilizer or compost.
Automobile recycling
The latest legislation, the Automobile Recycling Act in 2002 requires automobile
manufacturers to recycle properly the used cars and prevent any illegal dumping.
Domestic wastes
Japan’s 127 million people generate 1,124 grams of domestic wastes per person perday, 142,732 tons daily, of which 78.2% are incinerated by municipal governments
and only 5.3% are dumped directly into disposal site. Eventually the dumped
weight is reduced to 19% of the original weight.
As the following graph indicates, as much as 15% of domestic wastes were directly
dumped into disposal sites in 1992. Nearly 30% of the original weight was
eventually dumped in that year. Thanks to the recycling efforts and strengthened
incinerators, the weight of the final dumping has constantly been reduced. Japanhas 1680 incinerating facilities whose capacity is 202,733 tons daily, enough toincinerate the daily amount of domestic wastes. Also Japan has 1022 recycling
facilities whose capacity is approximately 20,000 tons daily.
As for final disposal sites, there are 2059 sites whose capacity equals 12.5 years
volume of domestic wastes. Japan even creates artificial islands by reclaiming thesea with wastes. A project named “Phoenix project” has created four islands inOsaka bay, with acreage totaling 500 ha.

75

Chapter 8. Industrial Health
1. Historical background
The origin of Japan’s occupational safety and health can be traced back to the
Factory Act in 1911 (became effective in 1916) with an intention to protect young or
female workers from exhaustive and dangerous working conditions mostly in the thenbourgeoning textile industry. The scope of the act had been gradually expanded, but
the all-encompassing act to protect workers of all industries was not enacted until thepost war era. The Labor Standard Act was enacted in 1947.
In later years, the increasing number of work-related accidents, most prominent of
which were large scaled gas explosions in mines, prompted a series of enactments ofworking condition safe guards.
Also, chronic work-related diseases such as pneumoconiosis among mine workers
and Reynaud disease among forest workers using chain saws alerted industries theimportance of preventive measures and health maintenance for the workers. In 1955,
special acts for silicosis and traumatic spinal injuries were enacted to promote suchmeasures.
In 1972, the Occupational Safety and Health Act (OSHA) was separated from theLabor Standard Act and established the industrial doctors as a medical specialty.

2. Administrative Structure of Occupational Safety and Health
Under the OSHA, employers who employ 50 or more workers will be required tocontract an industrial doctor. Also, employers who employ 1000 or more workers(including employers of certain industry who employ 500 or more workers) must
employ an industrial doctor on a full time basis.
Industrial doctors are responsible for health maintenance of all workers and must
conduct an on-site inspection of the working conditions to make sure the conditions
are safe and healthy. Industrial doctors are charged with suggesting professional
opinions to employers and managers with regard to safety and health maintenance of
the workers although these opinions are not legally binding.
All employers, regardless of industries, are required to conduct health check-ups
once a year. For workers working under special conditions, additional exams areincluded in the regular health check-ups.

3. Work-related Accidents
The number of victims of work-related accidents has been declining steadily since
its peak in 1961. This is a sharp contrast to the steady increase of the number oftraffic accidents victims. When one compares the number of new recipients of theWorkers’ Compensation Insurance to the number of traffic accidents victims, they76

were almost similar at around 800,000 in 1990. The number of new recipients of theWorkers’ Compensation Insurance has since declined to around 600,000 a year, while
the number of traffic accidents victims continued to climb to over one million in
1999.
The number of death caused by work-related accidents was 1,992 in the year 1999.
The construction industry accounts for 40% of the death toll. However, whenmeasured by incidence per working hours, the traffic industry has the highest
incidence: 3.67 per million working hours (the numerator includes both death andinjuries).

4. Workers’ Compensation
According to the Labor Standard Act, employers are held responsible for any
financial damage caused by work-related accidents. To guarantee the financial
liability, the MHLW operates the Workers’ Compensation Insurance (WCI).
The WCI covers not only medical cost for treatment of diseases and injuries but
also pay monetary damages to lost wages, disabilities and annuity for bereaved
family members. Also the WCI covers not only injuries caused by accidents but
also work-related diseases. To have the
WCI applied, one must apply to the local
labor offices, a branch of MHLW and thedeterminationofadiseaseaswork-related is not always easy task.
Sometimes disputes arise between theapplying workers (or bereaved family
members) and MHLW leading tolitigations.
In 2005 a big scandal broke out after an epidemiological survey revealed elevatedincidence of mesothelioma, a type of lung cancer caused by inhalation of asbestos.
The survey revealed that the asbestos emitted from some factories affected not only
the exposed workers but also
residents
livingintheneighborhood. Boosted bymedia coverage, there was asurge of asbestos-related
WCI application in 2006
(1006 mesothelioma patientswere determined to becausedbyasbestos).
However, the WCI does not
apply to the affected local
77

residents. large scale class litigations are under way against corporations which
operated the responsible factories.

5. Karo-shi controversy
Some workers die or get disabled by cerebral vascular diseases and ischemic heartdiseases. These deaths and disabilities may qualify for the WCI benefit if theunderlying conditions were worsened by excessive working stresses. However,establishing the cause and effect relationships is often difficult. Although, thegovernment does have its own arbitration process, disputes infrequently lead tolitigations. Bereaved family members who attribute the death of their family to
excessive working conditions and fatigue claim the causality by calling the deathKaro-shi, or death due to excessive work in Japanese.
To facilitate the determinationof causality and avoid disputes,
the government presets somecriteria for common work-relateddiseases, such as noise deafness,asbestosis
andneck-shoulder
disorders.
For cerebral andischemic heart diseases, thecriteria were first introduced in
1987 and were later revised in
1995.
Also controversial are those related with cardiovascular diseases and psychiatricdiseases. In September 1999, the criteria for determining work-related causality for
psychiatric disorders were published.
In view of the importance of prevention of Karo-shi, the WCI act was amended to
expand health check-ups to include secondary through examinations for workers who
showed some abnormalities in regular health check-ups in 2000.
The effect of the introductionof the new criteria is dramatic.
The number of approved cases
jumped up shortly after therevision. Likewise, approval ofmental diseases as work-related
became also easier particularly
for suicide cases.

6. Asbestosis
Asbestos had been widely used for industrial purposes until it was banned in78

middle of the 1970s for its carcinogenicity. The carcinogenicity of asbestos has along latent period (20-40 years) and its fatal effects emerged the world entered into
this century.
In 2005, media reported increased deaths due to mesothelioma (lung cancer
specifically caused by asbestos) around former factory sites handling asbestos.
Asbestos had been regarded as a major industrial hazard and workers who developed
asbestos-specific diseases such as mesothelioma and pneumoconiosis were entitledfor compensation by the WCI. However, little was known that it also affect local
residents living around the factory sites and they had no compensation.
In response to the public outcry, the government enacted the Act for Health Hazard
by Asbestos in February 2006 entitling non-workers for monetary compensation.
Compensation of victims is essentially the civil liability of responsible polluters.
However, it is always difficult for victims and their survived family members todemonstrate the cause and effect relationship in the court. Because asbestos was insuch a wide use, it is even impossible for them to know who is to be sued. Hence
there was a need for enactment of a new collective compensation system.
The asbestos compensation system set up a monetary fund with the initialendowment of 38.8 billion yen and would be financed by compulsory contribution
from all corporations. Corporations which used asbestos would be required tocontribute more.
People who claim that they had developed mesothelioma or lung cancer due toasbestos may apply to the Environmental Preservation and Revitalization Corporation(NGO affiliated with Ministry of Environment) for compensation.
Since
mesothelioma is considered to be specifically caused by asbestos, the applicants need
only to demonstrate the accuracy of diagnosis with pathological evidence. The
process is more complicated for applicants with non-specific lung cancer: they not
only need to demonstrate the accuracy of diagnosis but also need to demonstrate thelevel of environmental exposure to asbestos.
According to the criteria set by the government in March 2006, the applicants must
demonstrate that their exposure to asbestos had been equivalent to more than double
the risk of developing lung cancer than general population. This is tantamount to
the exposure to 25 fibers/ml/year. Clinically, either 1) evidence of pneumoconiosis
on chest X ray or CT, 2) amount of asbestos fibers or particles in lung exceeds acertain level (>5000 particles or >two million asbestos fibers in 1 gram of dry lungtissue or >five asbestos fibers in 1ml of alveolar lavage).

79

Chapter 9. Social Security and Welfare
1. Social Security and financing
The article 25 of the Constitution states that “All nationals shall have thefundamental human right to live healthy and cultural livelihood in the minimum” andthe statement issued by the Social Security Committee in 1950 defines the social
security as “economic assurance against potential causes of poverty either by way of
insurance or public subsidy but for those who fall below poverty level, the public
subsidy shall guarantee the minimum livelihood as declared in the Constitution”.
(1) Financing aspects of social security
Social security is undeniably the most important priority in Japan and is also very
expensive. Its sheer economic size can easily be illustrated by the share in thenational economy. The expenditure related to social security in 2003 was 83.6
trillion yen or about 23% of National Income (363 trillion yen). Forty years ago, in
1964, it was only 5%, meaning that social security used to be of far less concern for
most people.
25

Social security expenditure as % of National Income[source: National Institute of Population and Social Security]

20% of National Income

Welfare etc

15
Pension10

5
Health

64

66

68

70

72

74

76

78

80

82

84

86

88

90

92

94

96

98

00

02

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

19

20

20

0

Social security relies its financial source largely to premium and government
subsidy (tax). Japanese people pay social insurance premium of 56 trillion yen outof their 353 trillion yen annual income in 2003, more than the national tax (income
tax, corporate tax and consumption tax, etc), 42 trillion yen. From both central andlocal government, social security receives 26.7 trillion yen subsidy.
Another important source of income is interest, derived from accumulated social
security fund. Unfortunately, due to historically low interest rate, the interest
income dwindled: it now brings in only 1.6 trillion yen or 4.8% of total social
security revenue.

80

100

F i na nci a l s ources of J a pa n's s oci a l s ecuri ty[source: National Institute of Population & Social Security]

90

interest

80

local government

in trillion yen

70

central g overnment

60
50
40
30

pre m i u m

20
10

99
20
00
20
01
20
02

98

97

95

96

94

93

91

92

89

90

87

88

85

86

84

83

81

82

80

78

79

77

75

76

74

72

73

70

71

68

69

66

67

64

65

62

63

60

61

0

(2) National Burden
The % of social insurance premium plus tax in National Income is called “National
Burden”, a measure of disposable income. For the first time, it exceeded 40% in
2007. However the composition of the burden has changed dramatically. Burdenof social insurance premium has consistently increased while that of national tax has
declined from 18% in 1990 to 14.3% in 2008.
The
National
Burden of Japan is
still
low
in
comparison
with
other
developed
countries
despiteher
aging
population:
Japanese pay 15%of their income forsocialinsurance
premium
and25.1% for tax for
both central and local governments, due largely to the very low tax rate (FY2008).
However these figures should be interpreted with caution. Japan has heavier debt
than any other countries, for which the government will eventually have to pay back.
Japan’s loan spree started in around 1990, when Japan’s “bubble” economy burst
dragging the country into the deep and prolonged recession. Japanese government
responded to the declining tax revenue with loan as a form of governmental bonds.
As a result, Japan quickly ran up to the top of “debt” countries. As of 2005, Japan’s
debt reached 1.7 times the GDP. Such an accumulating debt burden may not be
solved without a huge inflation.
81

2. Welfare for the Indigent
Poverty has always been at
the center of social welfare.
Under
the
Livelihood
Protection Act, anybody who
fell below the preset level ofpoverty will be entitled tothe means-tested welfare
benefits.
To administer the system,
all cities have social welfare
offices
staffedbycaseworkers. Anybody who wishes to receive the welfare benefit for the indigent
must apply and undergo means tests. There are eight kinds of benefits: living
expenses, education, housing, long term care, delivery, occupational assistance,
funeral and medical care.
The system is heavily affected by the economics of the country. In 1965, 1.63% of
the total population was on the roster of the indigent. The percent has consistently
declined to hit therecord low of 0.7%
in 1995. However,Japan’slonglasting
economic
slumps are casting
dark shadows overthe system: thepercentoftheroster is on the riseagain. The figure
in 2005 was 1.15%.
(1) Livelihood assistance
After all available resources such as savings or financial support by relatives,
livelihood assistance may be afforded after means-test. The benefit is rendered tofill the “gap” between the minimum living standards and available financial resourcesof the recipients.
The minimum living standards are minutely set by government. For example, ahousehold of three (33 year old man and 29 year old woman and 4 year old child)living in Tokyo is supposed to need 162,170 yen (approximately $1500) to assure82

minimal living standards. Households whose income below this standards areentitled to living assistance benefit to fill the gap.
(2) Medical assistance
As for medical care, recipients of the Livelihood Protection Act are mostly exempt
from compulsory national health insurance system and their medical bills will be paid
from general tax. Diseases remain as the main cause of falling into poverty and asmuch as 80% of the recipients are receiving medical care. In financial terms,
medical cost accounts for approximately 56% of the entire budget of the system.

3. Maternal and Child Welfare
Social security for mother andchildren families is twofold: forthose whose father died, survivors’
benefit of the pension system will
apply, but those who divorced withfather will not qualify for thesurvivors’ benefit.
However, therecent sharp increase of divorce hasbrought the mother and children
family issue on top of the social
problem list.
Japan’s divorce was approximately 283,906 in 2003 or 2.25 per 1000 population.
This figure is far smaller than the U.S. with 4.34 divorce rate. However, Japan’s
figure has more than doubled since the 1960s.
Divorced spouses still owe legal liability to support the children, but theirfulfillment of their obligation is generally not satisfactory. To provide financial
support, the government provides the “Children Support Subsidy” to mother andchildren families. Benefits are available not only to divorced families but also tounmarried mothers.
Monthly benefit is 42,370 yen ($350) for families with one child and 822,958
households are on the roster in 2002. The government disbursement exceeds 300
billion yen and is increasing. The financing of the “Children Support Subsidy” isbecoming a heavy financial burden for the government.

83

Allowance for fatherless children

Number of beneficiaries (inthousand)800[source: MHLW]
Number of beneficiaries
annual budget

700
600
500
400
300
200
100

20

01

99

97

95

93

91

89

87

85

83

81

79

77

75

-

5,000
4,500
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
-

Budget in hundred million
yen

900

4. Welfare for the disabled
There are estimated to be 459,000 (3.6 per thousand population) people withintellectual impairment as of 2000, approximately 3.5 million (27.7 per thousand
population) people with physical disability as of 2001, and 2.04 million (16 per
thousand population) patients with mental disorder as of 1999.
(1) Financial support for the disabled 3500

Trend of the number of people with disability[ source : Survey on the disabled by MHLW ]

3000

2500

in thousand

Livelihood of those disabled ismainly supported by disability benefitof National Pension (plus Employees’
Pension for salaried workers). The
annual amount of NP benefit isinternal organ

2000

extremities
1500
approximately
one
millionyen($8,300) for severe disability and
1000
800,000 yen ($6,700) for moderate
auditory impairment
500
disability. For the disabled younger
visual impairment
0
than 20 years old, the “Subsidy for
51
55
60
65
70
80
87
91
96
200
Disabled Children” will be paid totheir parents or custodians. The monthly amount is 51,550 yen ($430) for severe
disability and 34,330 yen ($286) for moderate disability.
The number of physical disability has consistently increasing reflecting the
population ageing. The number of internal organ impairment includes renal failure
patients on dialysis and accounts for most of the recent increase of the number ofpeople with disability.
(2) Social services and the Structural Reform of Social Welfare

Social services such as domestic help services or group homes have been provided
by municipal governments funded exclusively by general revenue. Such services
84are provided by contractual agreements between municipal governments andproviders. However the Structural Reform of Social Welfare called for a structuralchange of contractual relationship between recipients and providers. The Welfare
for the Disabled Act was revised and authorized each recipients to choose andcontract with providers of their choice. Municipal governments pay the fee to thecontracted providers within some restrictions.
Some observers view this structural reform as a step toward a unification of theLong-Term Care Insurance (LTCI) system and social services for the disabled.
Expansion of the eligibility of the LTCI from 40 years or older to the entire
population aged 20 or over has been an agenda since its inception in 2000. This will
be an important policy issue of the LTCI, which is slated for revision in 2005.

5. Welfare for Homeless
Reflecting Japan’s long economic recession, homelessness is increasingly
becoming a top agenda for public health policy. For the first time, MHLW
conducted a nationwide survey for homelessness in January 2003. The survey
identified 25,296 homeless people nationwide, with the largest population in Osaka(7,757) followed by Tokyo (6,361). Their average age is 55.9 years old and 48.9%
are living in public parks. 64.7% of them are working, mostly of garbage collection.

6. Pension system
In 2003, pension became a most hotly debated political issue after it was disclosedthat the premium contribution for the compulsory National Pension (NP) had declined
dramatically. Until 2002, premium collection for the National Pension was largely
done by municipal governments, but the job was delegated to the Social Insurance
Agency (SIA). SIA, with its 312 branch offices nationwide was unable to match theeffort of municipal governments (3,200 nationwide) and the premium collection rate
quickly dropped to 62.8% from 70.9% in previous year, bringing the very existence ofthe pension system into question. Recently the Government Accounting Officereported that approximately 10 million people out of 22 million NP enrollees failed to
pay compulsory monthly premium (13,300 yen) at least one month in last two years.
What was worse, some politicians who blamed the cabinet members for failure topay premium in certain periods, were themselves found to have delinquent periods.
These exposes, coupled with a series of scandals such as leakage of personal
information and bribery cases undermined the public trust in the SIA as well as thepension system itself.
The government decided to recruit a civilian professional from private insurancecompanies as the director of SIA replacing the career bureaucrat of MHLW, with ahope that such experience professional of insurance business will be able to revive
the plagued NP system. Also SIA launched a series of confiscation of private
85

properties on those who willfully refuse to pay premium.
(1) Structure of pension system
Japan’s pension system consists of two pillars: NP and Employees’ Pension (EP),just like health insurance system consisting of National Health Insurance (NHI) and
Employees’ Health Insurance (EHI) system, with the following two differences.
● Health insurance is operated by a variety of insurers while pension system isoperated uniformly by SIA.
● Health insurance is pluralistic: each individual enroll to only one insures, i.e.
salaried workers do not enroll to NHI. Pension system, on the other hand, NP enroll
the entire population aged 20 to 59. Salaried workers enroll to both NP and EP
dually.
(2) Eligibility and premium
NP has three categories of its enrollees.
● Category I: Non employed population aged 20-59, such as self-employed,
students or jobless workers (22.4 million as of March 2003).
● Category II: Salaried workers who dually enroll to EP (36.9 million).
● Category III: Dependent spouses of salaried workers aged 20 to 59 (11.2 million).
Compulsory monthly premium for category I enrollees are a flat 13,300 yen.
Premium for category II is 14% of monthly salary (most workers receive bonuses in
addition to monthly salaries on average of 3 months worth, which also subject to thesame premium rate). For category III, no additional premium is required (premiumis paid by all salaried workers collectively).
Premium for category II is withheld from paychecks and therefore the collection
rate is nearly 100%, as well as for category III. However, for category I, themonthly premium of 13,300 yen must be paid voluntarily and therefore end up in sucha low collection rate of 62.8%.
(3) Benefits
Pension benefit is classified into three kinds. Here, only NP benefit is described,
omitting EP benefits. A third of NP benefit is financed by governmental subsidy.
● survivors’ benefit
Dependent family members such as spouses or children whose bread winners are
deceased can receive survivors’ benefit. NP survivors’ with one child can receive
monthly benefit of 86,300 yen. This benefit does not apply to divorced families,
which may be eligible for Child Support Allowances discussed in the other section.
● disability benefit
Disability benefit of NP constitutes an important part of disabled people. Monthly
benefit is 83,775 yen for severely disabled and 67,017 yen for moderately disabled.
Those who become disabled before age 20, i.e. disabled before they become eligible
for NP, will be entitled for the benefit after they become even if they have no
premium contribution (such benefit is financed by government subsidy). However
86

for those unfortunate who become disabled while they are defaulting their premium
contribution will have no benefit. Such “pension less” disabled people are one ofthe difficult policy debate.
● retirement benefit
By far the largest portion of NP benefit. Benefit becomes available at the age of
65 for enrollees who paid premium 25 years (300 months) or longer. Monthly
benefit is 67,017 yen for those who paid premium in full 40 years (age 20 thru 59) but
will be reduced if the period for which premium has been paid less than 40 years.
Given the average life span of 65 years old Japanese women is 23 years, the future NP
burden will inevitably grow, making many Japanese wonder if the system is reallysustainable for the future.
(4) 2004 revision of pension system
Actuarial basis of pension system is revised every 5 years reviewing the latest
demographic trend and economic indices. The year 2004 was the year. After
lengthy, and occasionally violent, parliamentary debates, the following decisions
were made.
● Make both ends meet by the year 2100.
● Increase the premium, which had been frozen since 1996, to up to 16,900 yen for
NP and 18.3% for EP gradually by 2017.
● Increase the government subsidy for NP from current 1/3 to 1/2 by 2009.
The ultimate goal of the 2004 revision is to secure the income of the retired elderly
at 50% level of their income during working age.

7. International treaty of social security
Internationalization called for mutual coordination of pension contribution.
When salaried workers are sent to another countries, in many times both employers
and workers find themselves responsible for dual premium payment to bothgovernments. This increases financial burden of corporations and without prospectof receiving retirement benefits. This is particularly true for Japan, which requires
much longer period of enrollment than other countries: it requires at least 25 years ofenrollment before he or she becomes eligible for receiving retirement pension.
International treaties are bilateral treaties between two countries and include thefollowing provisions.
1) Exemption of pension enrollment for nationals who work in the host country for ashort time to avoid duplicate premium contribution.
2) Tantalization of enrollment period for a person who has enrollment periods inmore than one countries to determine his or her eligibility for retirement benefit.
3) In some cases, exemption from compulsory health insurance may also apply.
The first of such treaty was ratified with Germany in 2000, followed by UK in
2001. In 2004, Japan ratified the treaty with US and Korea. The negotiation is87currently underway with Canada, France and Belgium.
The provisions of the treaty vary. The Japan-US treaty is most comprehensive
including the above all three. The German treaty includes 1) and 2). The UK and
Korean treaties include only 1).
The Japan-US treaty is worthy of particular comments not only because it affects
the largest number of nationals (over 50,000 Japanese are employed in the U.S.) but
also it includes a provision of health insurance. In a sense, Japan’s long-held policyof requiring all residents in the country to enroll to its health insurance system was
modified and allows Americans in Japan for a short time (<5 years) to be excluded
from the health insurance programs.

88Chapter 10. Long-Term CareIn April 2000, the much-awaited Long-Term Care Insurance (LTCI) took effect.
The new system will not only expand the long-term care services but also include
some innovative aspects not seen in traditional health insurance system.

1. Administrative structure
In contrast to the health insurance system, which has a fragmented structure withdifferent insurers covering different segments of population, the LTCI system has auniform structure: it is administered by municipal governments (there are three
categories of municipal governments, namely cities, towns and villages depending on
the population size). Municipal governments insure all residents aged 40 years orolder where he or she resides.
For example a 45-year-old male worker of Sony Corporation will be insured by
SONY health insurance society for health insurance but will be insured by themunicipal government where he resides for the LTCI. He will have to switch todifferent insurer for health insurance coverage if he switches the company but willcontinue to be insured by the same municipal government for the LTCI as long as hedoes not move somewhere else.
Because all beneficiaries are consolidated to municipal governments, it became
possible for municipal governments to draw a long-range plan to cope with the LTC.
All municipal governments are required by the LTCI law to develop a strategic planwith 5-year time frame to make a sound actuarial prospect.
Municipal governments also administer their own health insurance (NHI). However
it is difficult for municipal governments to draw a long range plan because only afragment of residents are insured by the municipal governments and the number of
insured residents varies depending on the economic situation (for example, a huge lay
off will deprive workers of health insurance coverage and they will migrate to the
NHI system which are administered by municipal governments).

2. Beneficiaries
As mentioned earlier, the LTCI does not cover the entire population. The
beneficiaries are limited to people aged 40 years or over, or roughly half the
population. This reflects the purpose of the LTCI law, which clarifies that the law isintended for disability caused by aging.
Further the beneficiaries are divided into two categories: beneficiary I for elderly
aged 65 or over and beneficiary II for people whose age is 40 to 64 years old.
The distinction between the two categories is the difference of premium collection
as discussed below.

89

3. Financing
Although Japan's LTCI may be classified as social insurance, it is an amalgam ofboth German and British models in terms of financing, i.e. half of the finance comesfrom tax and the half comes from premium contribution. Insurance premium is leviedon all beneficiaries but the method of levying varies between the two categories ofbeneficiaries.
For the beneficiary I, most of whom are pensioners, the premium is withheld fromtheir pension payment. For the beneficiary II, most of whom are working class, healthinsurers levy the premium by adding on the health insurance premium. There are asmall number of beneficiary I who do not receive pension. They are required to pay
voluntarily to the municipal government.
Since more than 3200 municipal governments administer the LTCI system, thepremium level also varies from municipality to municipality. The average monthly
premium is approximately 3000 yen and ranges from 1500 to 5000 yen. In eachmunicipality, the premium is scaled to the beneficiaries' income with 3 times
difference between the lowest and the highest income bracket.

4. Need Assessment
Unlike health insurance, the benefit of the LTCI will not automatically be granted
just by showing the insurance card. To be eligible for the benefit, the beneficiarymust apply to the municipal government for need assessment. Only after the person isassessed as disabled, he or she will be entitled to the benefit.
A beneficiary must apply to the municipal government and the municipal
government dispatches a surveyor to the applicant. The surveyors must be qualifiedcare managers and on-site survey will be conducted using the uniform assessment
tool, which consists of 73 survey items to measure ADLs, IADLs and behaviors. The
surveyors may record any particular findings to be considered for final assessment
but they have no authority to make any judgment.
The recorded assessment tools will be evaluated by computer to give preliminary
assessment [dismiss, borderline, level 1,2,3,4,5]. The municipal governments will
also ask attending doctors who are designated in the application forms to submit theirprofessional opinion.
The need assessment review committees [NARC] consisting of around five healthand welfare professionals will review the surveyors' findings and doctors'
professional opinion to decide whether the preliminary assessment should be altered.
What is important about the assessment process is that although NARCs haveauthority to make final assessment, they do not start their review from scratch. They
decide WHETHER THE PRELIMINARY ASSESSMENT SHOULD BE ALTERED OR
NOT by reviewing the surveyors' findings and doctors' opinion. In 80% of the cases,
the preliminary assessment will be final.
90

The need assessment is valid only for the specified period, usually 6 months.
Beneficiaries must apply for renewals to stay eligible for the benefit.

5. Benefit
Benefit of the LTCI system is divided into institutional care and home care. The
home care is characterized by integration of medical and non-medical care within thesame individually assessed budgetary cap.
Medical and non-medical services were not in a competitive relationship before
the LTCI system was implemented: medical services were reimbursed by the Elderly
Health Care system and non-medical services were financed by welfare system.
However the LTCI system brought both sectors into a competitive relationship in
which one's gain is another's loss, because they have to compete over the fixed "pie"of budgetary cap.
MedicalNon-medical

visiting nursing
home help
visiting rehabilitation
catering bathing
ambulatory rehabilitation[day care] ambulatory service[day service]
The monetary terms of benefit is metered to the level of care need. The level ofcare need will determine the per diem cost for institutional care and the monthly
budget cap for home care as shown below:

6. Need Assessment Tool
Objective evaluation of the individual's eligibility for benefit was a premeditatedpolicy throughout the design of the LTCI system. This reflects a bitter reflection oversome of the drawbacks of the health insurance system, most prominent of which is the"medically unjustifiable" prolonged hospitalization.
Because of chronic shortage of nursing home beds, many elderly who lack adequate
care at home are institutionalized at geriatric hospitals without firm medical necessity.
Although all health insurance claims are subject to rigorous review, such "medicallyunjustifiable" prolonged hospitalization is seldom denied payment chiefly because it91

is difficult to challenge the physicians' judgment without an objective evaluation tool.
The German LTCI also has an assessment tool but Japan's tool is far more complex
and sophisticated.
An evidence-based approach was adopted to develop theassessment tool: a radical departure from traditional negotiation oriented
policymaking. A field survey was conducted on a sample of residents of selectednursing homes to quantify the care need by means of one-minute time study andcorrelate it with ADL measurement. The methodology was in many ways similar tothat of the U.S. with its development of MDS, RUGs.
The product was the assessment tool consisting of 73 items that will predict theindividual care need with certain accuracy. The tool is fully computerized to facilitate
the assessment process and is now used nationwide to determine the eligibility for the
benefit.

7. Care Management
Another key policy of Japan's LTCI is care management. Care management is a
professional service to coordinate different services provided by different providers
to accommodate geographically dispersed home settings within a limit of allocatedbudget.
The U.K. in its Community Care Act 1990 first implemented care management.
This was part of the welfare reform promoted by Thatcher administration. Caremanagement was expected to be important for Japan's LTCI system because thebenefit includes not only non-medical services such as home help but also medical
services such as visiting nursing services. This is a sharp difference from German
LTCI, which provides purely non-medical services and therefore lacks official caremanagement system.
To cater to the need for need assessment and care management, a considerable
number of skilled experts were needed. A new professional called "Care manager"
was created and the first qualification exam was started in September 1998. Alreadythree exams were held and the number grew to over 200,000. Qualification will begiven professionals who already possess health or welfare related licenses and haveat least five years of clinical experience.

8. Experience in five years and Reform in 2006
As more and more beneficiaries become familiar with the new system, the numberof beneficiaries who applied for need assessment and qualifies for the benefit also
increased gradually. As of October 2006, approximately 4.4 million beneficiaries
were assessed as eligible for the benefit. This figure is approximately 17% of thetotal beneficiaries I (26 million). Trend and distribution of level of care need forlast five years is shown in the graph below. The number of eligible beneficiaries
increased at a faster rate than the increase of the elderly population. This does not92mean that an increasing
numberofJapaneseelderly are in need of care.
The graph shows that thegrowth is more evident inlower level of care need.
The share of borderline
and level1 was 40% of thetotal eligible beneficiaries
but almost 50% now,
suggesting the so-called“wood work” effects: more
people were prompted to apply

1,400

Users vs Nonusers in eligible benef iciaries

for need assessment as theynonusers
gain more knowledge of thesystem.
Notalleligiblebeneficiaries actually utilize
nonusers
nonusers
users
nonusers
nonusers
nonusers
services. Approximately 76%
users
of those eligible actually utilize
users
users
users
users
services.
Not surprisingly,
borderline
level1level2level3level4level5beneficiaries in lower level ofcare need are less likely to actually use services as shown in the graph.
As the LTCI became more familiar in daily life and people became more willing toutilize the services, cases of fraud and abuse also increased. The much feared
unfavorable effects of care managers serving as a sales representatives became
increasingly evident. Care managers approach beneficiaries who have not beenmuch interested in the LTCI and made their applications on behalf with a hope that anadditional eligible beneficiary will bring in additional clients. Under improper caremanagement, the level of care need of recipients is more likely to deteriorate than
improve.
In view of these unfavorable consequences, the reform 2006 emphasized“preventive care” rather than just catering to the need of beneficiaries. Following is
the major points of revision.
(1)Change of application process
1,200

Number of beneficiaries (in thousand)[May 2 004.source: administrative rep ort of National Health Insu rnace Federation]

1,000

800

600

400

200

0

To be eligible for benefit, beneficiaries must apply to municipal governments forneed assessment. Originally the LTCI act authorized service providers to apply forthe beneficiaries. Such was the main cause of the “wood work” effects. After
April 2006, such authority will be severely restricted for service providers.
(2)Change of need assessment process
On-site survey for need assessment is primarily the responsibility of municipal

93

governments.

However, it has been common for municipal governments to contract service

providers to send their care managers to the applicants’ home.

After the revision, such

relegation will be prohibited for initial assessment and discouraged for renewal assessment.
Further, NARC will be authorized to change the level of care need to the newly createdcategory “borderline2” for the beneficiaries assessed as level1 after evaluating the prospectof recovery or improvement.

(3)Community support center and preventive care management
Unlike British care management system where care managers are neutral agents
employed by municipal governments, majority of Japan’s care managers are
employees of service providers, and hence will inevitably serve as sales
representatives of the providers. Japan’s reform 2006 was an atavism to the British
model. For beneficiaries assessed as borderline (1 and 2), care management will be
provided by newly created Community Support Center (CSC) under direct contract
with municipal governments.
Such “preventive care management” intends toprevent the elderly at risk of disability from deteriorating further by improvement of
nutrition and enhancement of exercise.

94

Japan Public Health Association (JPHA) is a non-profit professionalorganization representing health departments of prefectural and municipal
governments as well as health professionals working in the field of public health.
In close cooperation with the Japanese Society of Public Health, an academic
association for public health research, JPHA promotes a wide range ofeducational and publication activities.

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http://www.jpha.or.jp
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