Provisional Translation

Japan 2035
Leading the Worldthrough Health

The Japan Vision: Health Care 2035
Final Report

June, 2015
Health Care 2035 Advisory PanelJapan 2035
Leading the Worldthrough Health
A health care system built for the next 20 years and designed for all
lifestyles and people – from children to older people, from patients toproviders – where individuals feel secure and supported to make thelife and work choices that are right for them.
Amidst rapid population ageing, advances in medical technology, andmajor shifts in health care, a health care system that contributes tofinancial stability while engaging each sector of society to support anation of health and well-being, where each person is empowered torealize their full wellness potential.

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Executive Summary

Background2035 Japan brings growing health care needs, shifting social environments and values, increasing
inequity, and globalization that require a health care system reformed to reflect shared vision andvalues. Relying on financial adjustments to maintain the current system will no longer suffice.
Based on the recommendations presented here, the Ministry of Health, Labour and Welfare should
construct implementation means, engage the public in discussion, and take steadfast action on
immediately feasible measures.
Goals
Health care in 2035 should strive to deliver unmatched health outcomes through care that is secureand responsive to each member of society. This system should not only fit the public’s image ofwhat a health system should be, but be both sustainable and actively contribute to prosperity inJapan and around the world.
Paradigm shift
The principles underlying today’s health care system restrict its ability to intersect with and fully
support social components that are critical to health, such as access to housing, community building,and employment. The health care system of the next 20 years requires a paradigm shift that allows
it to transform into a multidisciplinary health network capable of safeguarding Japan’s health in a
new era. These changes will shift the spotlight from:・ Quantity to quality
・ Inputs to Value
・ Government regulation to autonomy
・ Cure to care・ Fragmentation to integration
Key principles
1. Fairness
We envision a health care system built for and with the support of all generations; a system that
does not create or support health disparities due to differences in age, employment status, or family
situation; and a system that evaluates health care on the value it provides to patients and society, noton the inputs it demands.
2. Solidarity built on autonomy
We envision a health care system that supports individuals to actively participate in theircommunity; and a system that, rather than asking people to face challenges alone, provides anadequate safety net, and encourages proactive approaches in health care to ensure that each person
has access to the benefits of wellness.

53. Shared prosperity for Japan and the world
We envision a health care system that fosters investment-based economic and social stability forJapan and the world; a system that leverages health care, a pillar of Japanese ingenuity, to resolve
global health issues; and a system that builds a world that coexists in peace and prosperity throughglobal cooperation.
A health care system for the next 20 years: Vision and actions
1. Lean Health Care: Implement value-based health care
The health care system should be designed to maximize value attainable through current resources.
Value-based improvements in quality and efficiency should be implemented to drive better care atlower costs. Japan’s diversity demands a health care system responsive to variations in regional
characteristics.
Key suggested actions:
By 2020・ Systematic implementation of health technology assessment
・ Increase quality of health care services through professional initiatives (e.g., prevention ofexcessive care and medical errors)
・ Develop and make general practitioners who coordinate a community-based, integrated
health care system accessible throughout Japan
By 2035
・ Evaluate health technology for value-based outputs, such as efficacy, and set reimbursement
rates based on these values
・Benchmark performance to compare outcomes

2. Life Design: Empower society and support personal choice
The health care system should empower people to make the health care choices that are best forthem while supporting them to play an active role in maintaining their health. The system must also
recognize that aspects of health are influenced by environmental and social factors (social
determinants of health) that extend beyond individual choice.
Key suggested actions:
By 2020
・ Realize a “Tobacco-free” Tokyo 2020 Olympics through a suite of interventions that bring
Japan up to the standards of the WHO FCTC (e.g., smoking prevention for youth, tobacco
tax increase, packaging and advertising regulations, smoking cessation support andtreatment)
・ Accelerate the use of evidence-based preventive measures with emphasis on slowing diseaseprogression and associated health care cost reductions

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・ Increase quality of life and social productivity through investments in health
By 2035
・ Achieve a “Tobacco-free” society by 2035
・ Support the widespread use of a portable information infrastructure that includes long termcare information
・ Provide the public with one-stop, holistic health and lifestyle services that integrate
multiple fields of care to support autonomy and agency in health・ Build communities from a social determinants of health (SDH) perspective
3. Global Health Leader: Lead and contribute to global health
The health care system should have the capacity to address domestic health security and provide
international support for emerging and re-emerging infectious diseases that are not confined bygeography. By taking an active role in the global policy making process and working to improve thehealth of those around the world, Japan can create a virtuous cycle in which it improves upon its
own health care system while contributing to economic growth.
Key suggested actions:
By 2020・ Establish a health emergency management system (build a Center for Health Promotion
and Protection)
・ Establish a health care system capable of delivering health care to all, despite nationality or
language, before the Tokyo 2020 Olympics
・ Provide leadership and support to Asia and other regions as they work to develop coresystems, such as universal health coverage and drug approval processes
By 2035
・ Strengthen capacity to lead global infectious disease control and disaster support efforts intimes of crisis
・ Contribute to the strengthening of existing global health systems and the creation of a new
global health governance structure
Governance
The health care system will require reform that is committed to transparency and accountability and,in return, is supported by a secure financial structure that promotes these same values. The futurealso requires the ability to enact reform based on mid- and long-term perspectives, facilitate
localized responses, encourage evidence-based policy making, and cultivate capable policy
professionals.

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Infrastructure
1. Innovation
The creation of new value and new ideas sparks societal change. Innovation cannot stop at
technological development, but must extend to the systems that interact with these technologies(e.g., human resources, information, investment).
Key suggested actions:
By 2020・ Establish a platform for clinical trials
By 2035
・ Secure research funding from a variety of sources for diseases, such as cancer and dementia
・ Make Japan an epicenter of innovation, where creative people and ideas gather and grow
2. Information
More efficient use of information can drastically improve health care performance, quality, value
and safety. A health care database should be developed and utilized to support telemedicine
applications such as remote diagnosis, remote treatment, and telesurgery.
Key suggested actions:
By 2020
・ Build and utilize a health care network that links data using unique identifiers・ Support healthcare and disease management through analysis of check-up and treatment data
By 2035
・ Utilize the data network to develop a policy evaluation process on prevention, diagnosis,
treatment, disease management, care services, and long-term care
3. Sustainable financing
To build a health care system for the next generation, we must develop sustainable funding sources
through on-going discussion on the role and function of public health insurance, benefit andcost-sharing, and new approaches to funding.
Key suggested actions:
By 2020・ Allow for immediate adjustments when health care costs exceed projections (e.g.,
adjustments to benefits, preventive measures, resources)
By 2035・ Establish a financial support mechanism to complement public insurance
・ Transfer authority to prefectures so regional disparities can be addressed8

4. Health professionals
Health professionals need to be mobilized, with their employment structure reviewed, andmechanisms need to be implemented that enable health professionals to focus on delivering the best
possible care. People, especially those with multiple health issues, will be better supported by healthprofessionals with knowledge of prevention, public health, communication, and management.
Professionals must also be supported to function in multidisciplinary environments that integrate
health care and social welfare.
Key suggested actions:
By 2020
・ Educate capable professionals by increasing the number of graduate schools of public health
By 2035
・ Develop a shared foundation for medical and social welfare qualifications (i.e., collaborative
facilitation and curriculum)・ Introduce a quota in areas that continue to face physician shortages and misdistribution of
specialties
5. A world-class Ministry of Health, Labour and Welfare
We envision a transformed Ministry of Health, Labour and Welfare prepared for a new era of healthcare and equipped with personnel committed to necessary change. Rather than vertical management
and communication, the organization should enhance horizontal integration and seek opportunities
to respond to and connect with what is happening in the health field and wider community. From aninternational perspective, the MHLW must strive to be recognized as an organization that respondswith both accuracy and speed to global and domestic health crises.
Key suggested actions:
By 2020・ Appoint a Chief Medical Officer (CMO) to advise the Prime Minister and Health Ministeron health policy and health initiatives (five-year term)・ Formulate a global health initiative that streamlines Japan’s efforts in global health andinternational cooperation
・ Establish a Bureau for Medical Innovation that drives efforts to evaluate health technologies
and develop innovations in health
By 2035
・ Take the lead in global discussions and policy development

9Final ReportCotents
1. Background................................................................................................................................... 15
2. A Health Care System for 2035 ................................................................................................... 16(1) Why focus on 2035? ................................................................................................................. 16(2) Vision for health care in 2035 ................................................................................................... 17(3) Japan’s health care system in 2015: Background and issues .................................................... 18(4) The paradigm shift required by 2035 ........................................................................................ 19
3. Key Principles ............................................................................................................................... 21
4. Three Pillars of Japan Vision: Health Care 2035 ...................................................................... 23(1) Lean Health Care: Implement value-based health care ............................................................ 23(2) Life design: Empower society and support personal choice..................................................... 23(3) Global health leader: Lead and contribute to global health ...................................................... 23
5. Governance to Realize Our Vision.............................................................................................. 25
6. Actions to Achieve Japan Vision: Health Care 2035 ................................................................. 27(1) Lean health care: Implement value-based health care .............................................................. 27
i. Deliver high-quality, more efficient health care .......................................................................... 27
ii. Reorganize health care to promote local autonomy ................................................................... 29(2) Life design: Empower society and support personal choice..................................................... 32
i. Empower people to make the health care choices that are right for them ................................... 32
ii. Create a society that contributes to and supports healthy lifestyles ........................................... 34(3) Global health leader: Leading and contributing to global health.............................................. 37
7. Infrastructure for Achieving Japan Vision: Health Care 2035 ................................................ 39(1) Innovation ................................................................................................................................. 39(2) Information ............................................................................................................................... 40(3) Sustainable financing ................................................................................................................ 41(4) Health professionals .................................................................................................................. 43(5) A world-class Ministry of Health, Labour and Welfare ............................................................ 45
8. Looking Ahead.............................................................................................................................. 47
Conclusion......................................................................................................................................... 48(Appendix) Japan Vision: Health Care 2035 Timeline ................................................................. 49

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1. Background
The hope for healthy longevity is an aspiration that unites countries and spans generations. With theworld’s highest life expectancy and outstanding health standards, Japan has succeeded in bringing
its population extremely close to realizing this aspiration. Yet, projected increases in health care andsocial security costs amidst slow economic growth and a major demographic shift are placingpressure on public financing and the sustainability of the health care system is now in question. To
ensure sustainability and equip the health care system to meet current and future health care needs,
we must break away from the patchwork style of health policy making that has thus far sustained
the system and embrace comprehensive reform building upon a forward-looking and long-term
vision.
Comprehensive reform means the opportunity to rebuild the health care system into one withgreater potential to serve its constituents and increased capacity to contribute to economic andsocial prosperity in Japan and around the world. This will require a fundamental shift in how weapproach health care that ensures potential in new areas and sectors, such as technology, is nolonger ignored. Through this transition, we can transform what appear to be challenges into vibrant
opportunities.
The goal of Japan Vision: Health Care 2035 is to construct a long-term vision of Japan’s health caresystem that breaks beyond the current system’s constraints. We seek to accomplish this goal bydefining the key principles and values that should be reflected within the health care system andproposing suggestions for critical reforms with a focus on the year 2035.
Through our discussions, various questions and debates arose. What existing policies should be
strengthened? What key issues have been repeatedly sidelined due to politics? Where and how does
public input fit? How can Japan best contribute to other countries through health? What can Japanlearn from the health care experiences of other countries?
Our vision outlines a health care system that will support Japan as it faces challenges associatedwith an unprecedented demographic shift both to develop as a nation and to become recognized as
the authority on healthy longevity. The Japan Vision: Health Care 2035 Report describes this visionand includes recommendations on the specific reforms required to make this vision a reality.

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2. A Health Care System for 2035
(1) Why focus on 2035?
Health care reform cannot be limited to short-term measures, but must be built upon a long-term
perspective that reflects a shared vision and a common set of values. Health care reform debate has
been on-going for years1 and experience reveals that major health care reform takes a minimum of
five to ten years to move from deliberation to actual change. Currently, we stand at a criticaljuncture in health policy as the government is working to consolidate multiple public fiscal systems
by 20202 and implement the community-based integrated care by 2025.3 Therefore, it is criticalthat, amidst these changes and given the domestic policy process, we craft a long-term vision of thehealth care system now that extends beyond these targets.
Over the next 20 years as the 65 and over population grows and the overall population shrinks,
Japan’s demographic shift will bring growth and diversification of health care needs that will
require greater resources.4 Meanwhile, alongside increased use of new medical technologies, healthcare costs are likely to continue to rise.
The children of baby boomers will reach old age in the year 2035 requiring a health care system
rebuilt to sufficiently meet their needs. The next two decades will likely bring transformations in theway people live and work as well as changes to broader social and economic structures. By 2035,
low to mid-income countries will have achieved health standards that approach those enjoyed byhigher-income countries,5 leading to a second wave of population ageing. Additionally, because
innovation cycles are thought to last around 20 years,6 in two decades major advances in healthcare-related technologies can be expected.
Against this rapidly evolving backdrop, in order to continue to maintain the highest of health1

Examples include, the 1997 "21st Century Health Care: Ensuring a quality medical care and health insurance system"(Ruling Party Health Care Reform Council), the 2001 "Health Care System Reform: building a health care system that
corresponds to the low birthrate and aging society" (Ministry of Health, Labour and Welfare), and the 2005 "Principles
of Health Care Reform" (Government and Ruling Party Health Care Reform Council).
2

During the 186th Session of the Diet, Prime Minister Abe announced his intentions to achieve primary balanceby 2020 by stating, “Fiscal reconstruction is not possible without economic revitalization. Virtuous economic
cycles contribute to fiscal balance of the central government and local governments. My goal is to decrease the
GDP to debt ratio by half by 2015 and be out of debt by the end of fiscal year 2020.”
3
By 2025, the baby boom generation will be 75 and older. Housing, health care, nursing care, prevention, andsocial support will need to be comprehensively delivered to support this population in living the lifestyles of theirchoosing. To address this dire need, the community-based integrated care systems must be created. (Reference:
Regional Comprehensive Care System:
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/hukushi_kaigo/kaigo_koureisha/chiiki-ho ukatsu/) See, forexample,http://www.mhlw.go.jp/english/policy/care-welfare/care-welfare-elderly/dl/health_and_welfare_bureau.pdf.
4
According to the Cabinet Office’s 2012 White Paper on Older Persons, the population of older persons will peakin 2016, when 17.61 million baby boomers enter old age. A downward trend will continue until 2031. Then, as
16.76 million second-generation baby boomers enter old age, the older population will increase until 2041. A
decrease is once again expected to follow. It should be noted that the population of those over 75 will continue toincrease and, not only continue to grow, but surpass the 65-74 year-old population by 2017.
http://www8.cao.go.jp/kourei/whitepaper/w-2012/zenbun/index.html
5
Jamison DT et al. Global Health 2035: A World Converging within a Generation. Lancet 2013; 382: 1898-955.
6
Christensen CM, Grossman JH, Hwang J (2008). The Innovator’s Prescription: A Disruptive Solution for HealthCare, New York: McGraw-Hill.
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standards and reduce the financial burden future generations will face, a paradigm shift must takeplace. This shift will enable Japan to address changes in health care needs, globalization, andadvances in technology. It is with this in mind that twenty years from now, the year 2035, has been
established as the target for this policy vision.
(2) Vision for health care in 2035
Demographic shift aside, over the next 20 years, health care in Japan and around the world willneed to be prepared for changes in personal values, workstyles, social and economic conditions,public finances, and technological advances that are not easily forecasted. However, the following
trends should be considered as we look forward:
•

•

•

•

Progressive ageing and population decline will make it difficult for local governments tomaintain current community structures and, in some cases, put governments in dire financial
situations. In urban areas, the shortage of health care workers will become more serious as theolder population rapidly increases and more urban residents require care services.
In response to rapid growth of the 75 and older population and the rise in the number of older
persons living alone, the demand for health care services will increase alongside shifts in thevariety, quality, and quantity of health care services delivered to respond to these populations.
We can also expect continued progress of health care technology. Some examples of thistechnology include:
1. The widespread use of wearable technologies that collect health data and the creation of amanagement system for individual health data that enables disease control, healthmanagement, and other health care services to be delivered at a more individual level.7
2. The development of new cancer treatments, major advances in the early diagnosis andtreatment of dementia, and development of treatments for intractable diseases using
regenerative medicine and gene therapy.
3. The development of diagnostic devices, devices for nursing and long-term care, androbotic technology that will support tele-medicine and automated diagnosis leading tomore efficient delivery of health care and long-term care services.
Continued globalization will result in a world that is more socially and economically connected.
Opportunities for cooperation in the areas of health care service and health care workforce will
increase alongside this trend.

Yet, regardless of ever-changing surroundings, health care must remain steadfast to a set of values
and responsibilities. The goals of the health care system are to provide responsive care so that eachmember of society can enjoy a healthy life and to deliver excellent health outcomes sustainably,
contributing to prosperity in Japan and around the world. A health care system built on these values
will make it possible for all people, regardless of age, disease, or disability, to realize their fullpotential in a society marked by mutual respect. By supporting people and their communities tothrive through health, employment opportunities will increase and social prosperity will be followedby economic prosperity especially in the more rural areas of Japan.

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In contrast, ethical issues that will need to be addressed are likely to accompany the collection and use of
personal health data.
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The Health Care 2035 Advisory Panel created a vision for a health system that embodies the above
points through in-depth discussions on the values that drive such a system and the actions andinfrastructure required to transform the present system into one built to address current and futureneeds.
(3) Japan’s health care system in 2015: Background and issues
The system of universal health coverage that Japan achieved in 1961 was made possible by years of
rapid economic growth and premised on the youthful population structure of that era. The healthcare system has since succeeded in fostering equality, offering a solid safety net that protects allfrom devastating health-related financial crises,8 providing people with the freedom to choose theirproviders (free access), and delivering some of the best health outcomes in the world—all at a
relatively low cost.9 These achievements are owed to the ingenuity of those who designed thehealth care system and the public who worked to implement it.
Yet, the circumstances facing health care have changed significantly. Rapid ageing, a low birthrate,changing disease structures (including the increasing prevalence and complexity of lifestyle-relateddiseases and co-morbidities), and increasing demand for health care resources make the future of
the existing system uncertain. Medical demand is changing in response to developments intechnology and innovation, and the globalization of health care continues to expand. It has become
clear that the health care system in its current form cannot adequately address these changes.
The health care and long-term care services that are currently being provided are not necessarily
consistent with what patients value. The health care profession has become increasingly specialized,
and hospitals are providing advanced treatment at levels that exceed international standards. Yet, theprovision of basic primary care and care for long-term, chronic diseases has become a criticalissue.10 In particular, long-term rehabilitative care and long-term nursing care remain disconnectedfrom the community and day-to-day lives of families who need or may soon need these services.
Associated issues also need to be addressed, including supportive services for those who can nolonger perform activities of daily life and the way end-of-life care should be carried out.
Japan has also not yet started to fully utilize electronic medical records (EMR) to share patient
health data between health care facilities. The lack of integration often results in patients being
required to make frequent and repetitive visits to various providers leading to excessive diagnosis,
treatment, and medications. 11 In addition to affecting patient experience, this lack ofcommunication makes health care less efficient and burdens health care providers with excessive
workloads that restrict their ability to excel in their duties.

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This refers to the goal of financial risk protection.
United Nations, Department of Economic and Social Affairs, Population Division (2014). World Population
Prospects: The 2012 Revision, Methodology of the United Nations Population Estimates and Projections. Working
Paper No. ESA/P/WP. 235. An international comparison of total medical costs as a share of GDP reveals thatJapan was ranked tenth among OECD countries (in 2012).
http://www.mhlw.go.jp/file/06-Seisakujouhou-12400000-Hokenkyoku/0000076442.pdf.
910

Hashimoto H, Ikegami N, Shibuya K, Izumida N, Noguchi H, Yasunaga H, Miyata H, Acuin JM, Reich MR. Cost
containment and quality of care in Japan: is there a trade-off? Lancet 2011;378:1174-82.
11This includes the under-provision of medical care as well as medical related accidents.
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Until now, the health care system has been subjected to a series of shortsighted reforms, leading to asense of fatigue within the system. Cost containment, for example, has been largely carried out
through adjustments to the fee schedule. These adjustments succeed in achieving short-term
spending cuts, but lower fees often result in higher demand that drives health care expenses up.
Cost-cutting, progressive cost share increases, and benefit reductions are limited in effectivenessand are insufficient means of supporting a forward-looking health care system.
Relying on short-sighted adjustments to maintain the current system will no longer suffice. Present
circumstances require that we innovate to restructure the health care system upon a set of newvalues and a long-term vision. Through this, Japan also has the opportunity to support populations
around the world by becoming a model for healthy longevity in an ageing society for othercountries that will quickly find themselves with a similar demographic.
(4) The paradigm shift required by 2035
The issues raised above require that we move beyond system maintenance and focus on integrating
health care into social and community frameworks around the country. This will require that weconnect to and consider various elements, including resources of the private and nonprofit sectors;
lifestyles and behaviors; work environments; housing and communities; economics; and the valuesof the people the health care system is built to serve. Health care must be rebuilt as a new social
system.
A health care system that successfully integrates services like long-term care, housing,community-building, and workstyles requires a shift in values, key principles, and thoughtprocesses. The health care system of the next 20 years requires a paradigm shift that transforms it
into the multidisciplinary health care system we envision. These changes will shift the focus asfollows:
From quantitative increases to qualitative improvements
A shift from the provision of identical services to diverse populations and regions toward theprovision of services appropriate to individual needs that undergo on-going quality and efficiency
improvement.
From focus on inputs to focus on patient-centered value
A shift from management and evaluation based on the quantity of inputs, such as physicalinfrastructure, human resources, and services provided, toward management and evaluation basedon how efficiently these inputs are used and their related outcomes.
From government regulation to autonomy
A shift from a system in which the central government dominates major policy decisions andindustry trends toward a system in which autonomy is prioritized and patients, health care
professionals, insurers, and all health care stakeholders actively contribute to health policy making.
From cure-focused services to care-focused services
A shift from health care services that focus on curing disease and extending life toward health care19

services that focus on caring and supporting quality of life. Care-focused services provide support
that extends beyond physical health to include mental and social well-being, especially for thoseliving with long-term or chronic illness.
From fragmentation to integration
A shift from a system that is fragmented and vertical toward a system that supports cooperation andcollaboration between providers and across sectors through a common set of values and a sharedvision. Such a system will be capable of responding to the increasingly diverse and complex healthcare issues of the public.

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3. Key Principles
A health system that reflects the elements outlined above requires a reformed foundation guided bythree key principles: fairness, solidarity built on autonomy, and shared prosperity for Japan and theworld.
Fairness
Fairness is absolutely essential if a health care system is to gain the trust and support of the people itserves. A fair system is one that forgoes a focus on short-sighted sustainability and aspires to bothsupport and gain the support of generations to come; does not result in health disparities related toage, family situation, income, or occupation; and evaluates health care based on the value of theservices it provides.
Solidarity built on autonomy
Medical care alone does not deliver good health. Individuals play a critical role in maintaining good
health in their daily life, within their communities, and in society. The health care system must
contribute to creating an environment that empowers all people to make informed choices about
their health in a variety of settings, including in the home, workplace, and community.
It is the responsibility of the health care system to provide an adequate safety net and support active
participation in health, not to solely rely on individual efforts and behavioral changes. As income
inequality increases and income related health disparities become more prevalent, it is critical toensure that all members of society have equal access to this support.
Local health care systems must be enabled to operate autonomously with active community
participation while maintaining high standards for transparency and accountability. Local-level
involvement will help both health care providers and consumers understand health care resource
limitations leading to more careful and considerate use of these resources.
Shared prosperity for Japan and the world
Investments in health care provide opportunities not only to promote good health outcomes, but tofoster economic and social stability and development. Because health care is a sector that can both
add value and contribute to a sustainable society, a wisely designed health care system can support
sustainability and drive prosperity in Japan.
Specifically, an effectively functioning health care system:
・ Provides relief to people suffering from anxiety about health-related issues. Freedom fromavoidable anxiety can improve job performance and increase productivity resulting in a stronger
economy.
・ Leads to the development of services and products that add new value and encourages
infrastructure improvements.
・ Supports a strong financial system by increasing and expanding job opportunities in local
economies.
Japan must strive to lead the world through health by taking leadership in addressing global healthissues and supporting people around the world to live healthy, active lives with respect for the wide
variety of lifestyles and workstyles that exist. Through the pursuit of globally innovative initiatives,21

Japan has the opportunity to deepen global cooperation and build a world of shared prosperity.

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4. Three Pillars of Japan Vision: Health Care 2035
Based on the goals and key principles detailed above, we have outlined a vision for health care in2035 that focuses on three key concepts: Lean Health Care, Life Design, and Global Health Leader.
(1) Lean Health Care: Implement value-based health care12
A sustainable, world-class health care system in 2035 requires that we focus on maximizing patient
value. However, measuring health care value remains a challenge because policies that guideeffective and efficient resource utilization and policies that link patient value to pricing andbudgeting have yet to be implemented.
Critical to lean health care is the efficient use of limited resources to maximize health care value,
which often means providing high value services at a reasonable cost. A key concept for the healthcare system moving forward is the ability to provide better health care with fewer resources.
(2) Life design: Empower society and support personal choice
Health care choices and the information needed to make these choices are currently largely limited.
The health care system, while supporting people to actively participate in their health, should
empower people to make informed health care choices by ensuring that trusted sources of
information are easily accessible. This is the essence of life design.
The system must also recognize that health extends beyond individual responsibilities and is
influenced by a combination of environmental and social factors, known as social determinants ofhealth (SDH).13 A health care system that factors in SDH has greater capacity to support all
members of society, including vulnerable populations, in enjoying healthy, fulfilling lives thatreflect their unique values. The consideration of social and structural barriers to health better
enables the creation of a society of mutual respect in which everyone, regardless of age, disease or
disability, can thrive. This approach will also contribute to the integration of health as a regular partof daily life.
(3) Global health leader: Lead and contribute to global health
To increase Japan’s capacity to address domestic health security and provide international support
for emerging and re-emerging infectious diseases that are not confined by geography, such as
pandemic influenza and the Ebola virus disease, Japan must strengthen emergency and disastersupport capacity and establish a function that enables Japan to act as an administrator of global
health emergency management.
We envision a health care system that will become a new global model. By contributing to global
policy-making and sharing Japanese health policy lessons with the world, a virtuous cycle will
result in which health care in Japan and in other countries improves resulting in opportunities for
12“Lean” in this context refers to the quality of succinctness with no unnecessary components.
Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health Equity throughAction on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health.
Geneva, World Health Organization.
13

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growth in other sectors.
Through this type of engagement, Japan will build international trust, engage other countries inmutually beneficial partnerships, and, as a result, become a trusted leader during critical healthemergencies.

245. Governance to Realize Our Vision
Health care that integrates the vision detailed above will require a health care system committed totransparency and accountability. Specifically, it will require governance that combines a secure
financial structure with sound service provision. Reform of the decision-making andconsensus-building processes for securing, distributing, and evaluating the system’s resources willbe essential.
Japan’s health care system can be characterized by the health insurance fee schedule that dictates
reimbursement levels for nearly all health care services and products that are provided in Japan.
Through this system, health care costs are contained at the macro level through the use of global
rate revisions while a certain level of flexibility remains at the micro level to accommodate
technological innovations and changing health needs through adjustments to benefits andreimbursement rates for particular services or products. This structure of governance, which has
won praise internationally, should be preserved and strengthened through the implementation ofnecessary reforms.
The fee schedule is revised every two years and, during this process, efforts to restrain medical fees
have led to patchwork fiscal adjustments and reforms. Moving forward, Japan will need to consider
implementing a process that would make it possible to revise the system from a mid- to long-term
perspective. Implementing unified elements, such as a multiple year budget that includes the wholesocial security system, could balance resources between related systems and result in a more
optimized health care system.
A significant portion of health care costs are financed with public funds making it essential tocommunicate how these funds are being used. This includes sharing information about how
insurance coverage and prices are determined, how diseases and other health issues are being
addressed, and how local health care plans are devised. Policy development then becomes a partner
to government bodies, health care providers, patients and the general public. Objectives withdetailed criteria must be used to monitor the success and failure of policies. The current progress
toward these objectives must be communicated to all relevant parties, especially during staff
transitions. Increasing the transparency of policy content and policy progress ensures that all parties
are better able to address critical issues.
Japan will also need to strengthen the analytical capacity of the Central Social Insurance Medical
Council, a group that plays a key role in the revisions of the fee schedule. Increased use of strategic
and scientific evidence and a structure to support each Council member in using relevant data will
ensure that available resources are used more efficiently. Identifying the mechanisms that policies
are built upon and creating objective measures for policy effectiveness could also contribute to thiseffort.
To support the creation of stronger policy, the periodic implementation of the PDCA
(plan-do-check-act) cycle based on such evaluative frameworks is crucial. Increasing the strength ofpolicy evaluation will require that a system for gathering relevant data be designed, the personnel toempirically analyze data based on local needs be recruited, and a mechanism for improving existing
systems and drafting policies be created. Overall optimization of health care will thus require25

policymakers to improve systems, foster personnel, and strengthen functions.
Given the major shift in population structure driving population ageing and decline, the health caresystem’s needs are growing larger and more diversified. Challenges at the regional level vary byregion, making the implementation of a uniform system difficult. We must consider a system thatenables the safety net of universal health coverage to continue to be provided while supporting adecentralized system that allows communities to achieve their “optimum” 14 state given theirsituation and the challenges of the region.
Another characteristic of the Japanese health care system is that both patients and private-practiceproviders have the luxury of choice. Patients are free to choose where they receive health care andprivate-practice providers are free to choose their field of medicine and where they practice. In theyears ahead, along with ensuring that patients have adequate access to health care, primary careproviders will be needed to act as community-based coordinators capable of supporting patients andtheir communities.
Japan will be shifting toward a framework of the community-based integrated care, in which each
local government will be asked to take the lead in designing a system to meet the health care andlifestyle needs of its residents. Yet, it will be essential that the central government remains actively
involved in providing technical advice and other support during this process. The new approach,centered on decentralization and greater autonomy for local health care systems, should be
implemented to ensure local governments are empowered to make critical structural decisions while
the central government continues to be accountable for the implementation of basic services andevaluation of necessary reforms to the system.

14

This refers to that area’s optimum performance given regional characteristics.
26

6. Actions to Achieve Japan Vision: Health Care 2035
(1) Lean health care: Implement value-based health carei. Deliver high-quality, more efficient health careAims for 2035
Provide access to high quality health care that is efficient, affordable, and designed to meet avariety of needs.
Deliver integrated health care that includes health promotion, prevention, diagnosis, treatment,disease management, long-term care, and end-of-life care.
Implement an assessment system that focuses on patient value, rather than the quantity ofresource inputs, and meets global standards.
Significantly expand the range of care options through improved benchmarking andinformation disclosure.
Examples of suggested actions:
1. Develop health technology assessment and incorporate evaluations into the reimbursement
system・ Aim to establish a system to measure the cost-effectiveness of medical technologies that will
begin initial implementation during the fee schedule revision process of fiscal 2016.
・ Place emphasis on the effective use of contributions collected through taxes and healthinsurance premiums to deliver high quality care at reasonable prices as opposed to continuing toautomatically associate the most advanced, expensive, and technology-heavy interventions withgood health outcomes.
・ Set up a division within the Ministry of Health, Labour and Welfare to oversee the ongoingassessment of technologies and health outcomes15 staffed by specialists from within the
Ministry, specialists from other ministries, and outside experts to facilitate governmental andnongovernmental coordination.
・ While implementing health outcome assessments that focus on both cost-effectiveness andperformance measures, integrate global measures to assess health outcomes, such as QALYs,
with careful consideration for patient-centered values. Instead of transplanting these measuresdirectly, they should be followed by benchmarks that match circumstances in Japan andperformance of key health care services should be systematically evaluated. In addition, in order
to better integrate health care and long-term care services, the system for setting medical fees
should be reevaluated to reflect, for example, evaluations that measure whether patient needs
are being met.
2. Support health care providers to deliver care more efficiently and to recognize the critical role
they play in the community-based integrated care
・ Encourage hospitals to improve care services and increase cost-effectiveness by better
understanding how they fit into the larger community. Through this understanding, hospitals
will also be better equipped to participate in collaborative systems that support service
improvements while strengthening their performance as community partners.
15

See Chapter 7 (5) of this report.
27

・ Expand use of the National Clinical Database (NCD).16 Through use and analysis of NCD data,
medical institutions will be better able to choose the most appropriate course of care given risk
analysis outcomes and to assess their own performance in light of national benchmarks leading
to improved treatment outcomes. These types of provider-led initiatives should be actively
encouraged.
・ Support voluntary initiatives led by professional societies and other stakeholders, such as therecent “Choosing Wisely”17 campaign that originated in the US and is now spreading to othercountries, that encourage consumers to make more informed choices related to diagnostics andhealth care services in an effort to use resources more efficiently.
・ Ask medical institutions and professional societies to assess the delivery of health technologies
and treatment procedures among individual health care providers and within the larger
community in order to identify under- or over- utilization of health services using the tools
listed above. Once these issues have been discovered, measures should be implemented todeliver appropriate levels of care and incentives should be provided to encourage providers tomake improvements.
・ Encourage collaboration and the sharing of data not only within communities, but acrosscommunities in order to ensure that people have access to the most appropriate treatment
options in the most appropriate treatment settings.
3. Increase patient ability to make informed health care choices
・ Empower patients to make informed decisions about their health care and treatment options byimplementing a system for facilities to communicate with consumers using the tools listed
above. Ensuring that people are informed of both the benefits and risks associated withtreatment options can contribute to reducing under- or over- utilization of health services.
・ Improve how people consult with their general practitioners or insurers when making healthcare decisions. In particular, insurers’ ability to provide health management support to each
insured person is of critical importance. Efforts should be made to strengthen capacity of
insurers to efficiently provide people with appropriate and timely information and advice.
・ Encourage insurers to share and utilize individual health data to improve the quality andefficiency of health care. Insurers will also become critical partners in prevention and healthmanagement by ensuring that all have access to integrated care, by identifying personal healthrisks, and by offering appropriate services to address those risks.

16

The National Clinical Database contains information on surgical procedures. Currently, information on over
95% of the general surgical procedures performed at the 4,000 participating medical institutions is stored in the
database, totaling approximately 1.2 million surgical procedures annually. This information can be used foraccessing potential health risks or health facility benchmarking.
17“Choosing Wisely” is an independent initiative started by physicians to reduce wasteful medical care andprocedures. Implementation of excess medical testing increases the risk of false positives, which can lead toadverse events. For example, positive MRI findings are usually followed by invasive examinations, in some cases,
for liability reasons. Also, it is often more cost-effective to use older drugs rather than the newest, most expensive
drug. The wide variety of drugs prescribed to older persons increases risk of side effects and can cause adverse
events. Choosing Wisely (www.choosingwisely.org) is an initiative launched by the American Board of Internal
Medicine to improve the quality of health care by identifying medical tests and procedures that may be overused.
28

ii. Reorganize health care to promote local autonomy
Aims for 2035
Strengthen health care governance by integrating it into everyday life through the provision ofservices that meet the needs of the community as decided by members of the community.
Supplement community efforts to design systems of the community-based integrated care andhealth provision built to meet community needs by ensuring the central government is active inproviding support and technical assistance.
Create health care systems centered on the needs of the communities they serve and sharelessons learned through this process domestically and internationally.
Examples of suggested actions:
1. Strengthen community health care governance・ Allow communities to make their own decisions when developing systems of thecommunity-based integrated care. To plan a health care system that addresses local issues andmeets community needs, it will be essential that communities engage administrators, health careproviders, insurers, civil societies and community members to ensure a wide range ofperspectives are included in decision making.
・ Secure the human resources necessary to effectively develop systems of the community-based
integrated care. This requires that we develop capable leaders with the management skills tocoordinate with experts in other fields and that we create a certification system to ensure
consistent service delivery within medical specialties, including medical care, long-term care,and rehabilitation services.
・ Stabilize and strengthen capacity to draft and implement policies at the municipal level to meet
community health care needs, including the ability to regulate hospital beds. Under theleadership of local leaders, foster and secure human resources in the area of health policy.
Limited resources coupled with growing health care needs require that local governments shareresources, rather than struggle to provide all services on their own.
・ Ask that the central government remains steadfast to its responsibility for the health care system
despite movement toward local autonomy by providing necessary support and establishingappropriate laws and regulations. The national government should assist with fundamental
services and encourage local governments to become more autonomous through incentives,
regulations, and other structural reforms.
2. Secure health care, insurance, and long-term care services based on community data and needs
・ Support prefectures’ ability to use comparative health data to understand population needs andappropriately allocate resources through analysis of linked health care utilization and systematic
data collection using health ICT. These efforts will lead to improved quality of care and support
further reorganization of the health care system through adjustments to key elements including
hospital functions and the quantity of inpatient beds.
・ By conducting comprehensive analyses at both macro and micro levels18 to determine thecauses of regional disparities, we better understand the appropriate level of responsibility
18

For example, the ratio of medical treatment beds to the inpatient rates vary by up to six times by prefecture.
Fairness and efficiency of medical care requires that regional variation is taken into consideration when
determining whether an approach is appropriate or not.
29

prefectures19 should be asked to take on. A structure should be introduced that requires
prefectures to face fiscal consequences when regional disparities are found to be associated withreasonably avoidable action or inaction on the part of the prefecture. At the same time,
prefectures should be given the authority to provide fiscal incentives to support municipalities
that proactively work to support the health of their population. A structure must also be
implemented to reduce regional differences in long-term care benefits that are a result of thevarious long-term care certification standards amongst prefectures.20
・ Consider introducing a system that ties service reimbursement rates to the quantity of services
provided thereby allowing service reimbursement rates to increase or decrease depending on
how actual utilization rates compare to utilization targets. Align health care costs to health careneeds of prefectures through strategies that, for example, allow prefectures where health carecosts have exceeded the estimates in the government’s Medium and Long-Term Medical Care
Expenditure Regulation Plan21 to decide reimbursement rates on their own.22
・ By 2050, 60% of Japan’s residential areas will see their populations decline by around half andnearly 20% of those areas will be completely depopulated.23 To address these demographic
changes, efforts must begin now to establish an ICT infrastructure and develop ICT-capable
human resources that can deliver a variety of services, such as remote medical care, essential
health care services, and support services, in areas with limited medical resources. Rapid
population decline requires that a mechanism be created to coordinate community building andsystems of the community-based integrated care.
・ Japan faces a misdistribution of physicians that, if continues to persist, will require strategies toensure more equitable distribution of resources to meet the needs of people in all areas andsupport the career paths of physicians. Establishing physician quotas and revising factors that
affect professional autonomy, including where to practice and what to specialize in, arestrategies that should be considered.
3. Make general practitioners who coordinate the community-based integrated care accessible
throughout Japan・ Alongside changing health care needs associated with the demographic shift, the growth of
medical specialization, and increasingly complex health technologies, general practitioners will
become essential to the coordination of health care services based on patient needs. Byenhancing general practitioners’ role as coordinators in care, patients will have access toessential health care services, while being better informed when choosing between healthfacilities.
・ To foster this type of system, training in comprehensive health care will need to be provided to19

To support a sustainable health care system, an amendment was made to the National Health Insurance Law(May 27, 2015) that calls for prefectures to take responsibility for the financial management of National Health
Insurance.
20
Currently, health care costs, including those related to regional variation, are putting pressure on the nationaltreasury and regions with excessive expenses are being covered by national income tax. This concept refers to theidea of asking high-cost regions to take more financial responsibility.
21
The Security of Medical Care for the Elderly Law (1982, Law No. 80) requires that prefectures create a five
year plan to address medical expense utilization once every five years. These plans are designed to support
effective utilization of resources and affect the health care budgeting process.
22
In the case that prefectures are asked to bear the costs related to regional differences, areas with positive
outcomes will be rewarded to support health promotion and prevention efforts.
23
Long-term Country Outlook: Interim Report (Ministry of Land, Infrastructure, Transport and Tourism)
http://www.mlit.go.jp/common/000135838.pdf
30

general practitioners and, over the next 10 years, general practitioners with this training must be
integrated into health systems throughout all regions of Japan.
・ Conduct multi-faceted evaluations of care delivered by general practitioners engaged in systemsof the community-based integrated care. Access to primary care is of critical importance tochildren and older persons. To increase this access, Japan should consider adjusting patient costshare associated with care provided in non-primary care settings. This could lead to reduced
consumption of unnecessary services and products.
・ Support collaborations between local government, health care facilities, long-term care facilities,
and non-profits that support the delivery of the community-based integrated care. Home-based
health and long-term care services can lead to fiscal and social strains and can require thatfamilies play a larger part in health care, so it is essential that communities consider how tocoordinate these types of services alongside improvements to local housing and facilities
options.

31

(2) Life design: Empower society and support personal choicei. Empower people to make the health care choices that are right for themAims for 2035
Increase awareness of health issues and empower people to actively participate in their healthcare choices.
Establish means to support people in making lifestyle and health related choices.
Build a strong evidence base and develop metrics related to health and prevention, so people
will better understand the mechanisms of health motivating them to make wiser choices.
Examples of suggested actions:
1. Empower people to choose the health care that is most appropriate for them・ Build a platform that narrows the information gap between patients and physicians so thatpatients are able to make informed treatment decisions with the understanding that health careinvolves a certain level of uncertainty. One way of achieving this would be, for example, tobuild an information infrastructure and secure the human resources required to support people inidentifying the health care and health care facilities that best fit their needs.
・ Lack of patient engagement and the patient-provider information gap have, in some cases, led tounreasonable expectations and responses to health care. This can be addressed by increasing
health literacy through efforts of the educational system, providers, government, organizations,and insurers.
・ Quality of death will become of critical importance as we approach 2035, when annual deaths inJapan will exceed 1.6 million.24 To increase the quality of end-of-life care, efforts need to bemade to utilize advance directives so people can outline where and how they would like toreceive health care when they are best able to make such decisions, resulting in improved
quality of death. It will also be essential to engage the public on this topic through educational
initiatives by involving insurers, local governments, and general practitioners.
・ Under Japan’s current system, people have the freedom to access any medical institution of theirchoosing. Yet, in some cases, health care institutions may limit the amount of information madepublic to prevent over-access to certain treatments or to reduce potential risks. Unfortunately,
this leads to fewer opportunities for medical care. In addition to regularly assessing the qualityof physicians and medical institutions, issues including the scope and method for releasing
information should be examined. Other ways to control access, such as through adjustments tothe copayment rate, should be considered.
・ Consider adjusting patient cost burden depending on individual health care choices. For
example, ask patients to pay different copayment rates depending on whether they choose
brand-name drugs or generic drugs or whether they choose home-based care or hospital-basedcare.25
2. Support people to actively engage in health management
・ Empower people to make better informed health care and health management decisions by24

According to the Population Projection for Japan (January 2012 estimate) report, there will be 1.66 million
deaths in 2035.
25
Care delivered by the family and associated opportunity costs should be factored into calculations of healthcare costs when care is delivered at home.
32making personal electronic health records that include long-term care data accessible through a
portable data infrastructure.
・ Make it easier for people to manage their health. For example, help people understand how
over-the-counter drugs26 can be used safely to self-treat27 when appropriate. Initiatives like thiscan help create patient-friendly pharmacies contributing to on-going pharmaceutical sector
reform.
・ To address confusion and anxiety that may follow developments in areas including diagnostics
and genetic analysis, we must establish a framework of laws and policies regarding the handlingof such information. The public should have access to expert medical advice that takes into
account the person’s unique social and economic circumstances. In addition to making
information accessible, trained personnel must also be made available to support people inchoosing relevant information.

26

Refers to pharmaceutical products that can be purchased at pharmacies and drugstores without a prescription.
Refers to the concept of taking a pro-active approach to health and addressing very minor health issues on
one’s own.
27

33

ii. Create a society that contributes to and supports healthy lifestyles
Aims for 2035
Ensure that communities and society as a whole become environments that contribute to healththrough the implementation of the community-based integrated care.
Build a society where people actively support the health of others in a variety of settings,
including at work and in the community.
Collect and utilize scientific evidence to become a global leader in the field of preventive
medicine.
Achieve a “Tobacco-free” society.
Examples of suggested actions:
1. Build communities and a society that contributes to health・ To address the expected increase in the number of older persons who live alone and to countersocial isolation, build communities from a social determinants of health (SDH) perspective
enabling people to easily integrate healthy habits into daily life.
・ Deliver health care and support services that are integrated to support community building andinclusion of all people in the community, regardless of age, physical condition, or income level.
To contribute to this effort, create comprehensive community care centers, where people can go
to receive information and advice in local areas.
・ The community-based integrated care systems and health communities cannot be createdthrough government initiatives and public services alone. It is essential to engage a variety of
stakeholders, including health care providers, industry representatives, and community members,in this process by integrating their perspectives and encouraging them to play an active role
through the creation of a collaborative platform that links the public and private sectors.
・ Link community care centers, social support centers, public health nurses, local welfare officers(minseiiin), schools, and other community-based leaders and organizations so that community
members, including low-income residents and residents with dementia, can access one-stop
consultation and support services on a wide range of health and lifestyle issues. This is anotherarea where the private sector and non-profit organizations must play a key role.
・ Design communities that utilize local characteristics to strengthen health and long-term caresystems. Include health care policy in community planning policy, and create workplaces andpublic spaces that integrate healthy food options and healthy lifestyles into the design, so people
feel encouraged to, for example, be more physically active. To support these efforts, 30
municipalities nationwide will be recognized as Health Care 2035 Model Cities and their efforts
will be shared.
・ Strengthen measures and support services for high-risk populations to ensure all members ofsociety have access to a healthy lifestyle by recognizing the health impact of SDH factors, suchas income, stress, working environment, and isolation.
2. Support the ability to live a healthy lifestyle throughout the entire life course
・ Society must play an active role in supporting people to be healthy throughout the entire life
course, from childhood to old age. This will require that we support people of all generations tobecome more health literate by providing opportunities to learn about health starting in daycare
centers and nursery schools and continuing into the workplace and the community.
34

・ Establish a system that ensures women receive comprehensive health care over the course of
their lives and provides adequate social support to both men and women during conception andpregnancy, childbirth, and parenting. Efforts must be made to strengthen support systems thatenable people to continue to work in good health while taking on a caretaker role for bothchildren and parents.
・ The health of workers is an important asset for companies and other organizations. Measures toaddress mental health must be strengthened as mental health has critical impact on productivity.
We must create a model for early detection of and response to mental health issues, such as
depression, and support must be provided to companies that attend to the mental well-being of
employees. Alongside these efforts, community-level mental health measures must also be
strengthened.
・ Strengthening preventive health measures for older persons that address issues such as
pneumonia and malnutrition that are grounded in the unique characteristics of this stage of life
is crucial. By reducing the risk of frailty-related incidents and preventing social isolation, webuild a society where older persons play an active role at work and in the community.
・ Dental health is critical to health overall as it extends beyond the oral cavity to affect outcomes
related to, for example, aspiration pneumonia or diabetes. To better support health maintenanceand prevention throughout the life course, dental care must be directly linked to health care.
・ The health of older persons today has advanced alongside progress in health care. In response tothis, the mandatory retirement age should be abolished contributing to growth of the working
population. People should no longer be discouraged from pursuing multiple career changes
throughout their lives. We support the health and longevity of older persons by supporting older
persons to remain engaged in society through employment.
3. Promote prevention and health while strengthening the evidence base・ Investing in health improves quality of life and leads to increased productivity. Therefore, weshould pursue this type of investment with a focus on supporting older persons to remain
independent longer. The working population as well should be encouraged to manage theirhealth and take part in preventive health measures.28 These investments also have potential tospill over into the employment and economic sectors by generating business growth in suchareas.
・ Actively promote preventive health measures that have been shown to be effective (e.g.,smoking cessation and vaccines). In particular, secondary and tertiary prevention of chronic
disease has been correlated with reduced health care costs and should, therefore, be pursued. For
example, efforts should be made to encourage those who are statistically at high risk fordiabetes to seek early medical attention through the use of health data and other prevention
tools.
・ Compared to evidence related to diagnosis and treatment, evidence related to prevention isseverely lacking. For example, the effect of incentives on behavior change is limited.29
Therefore, efforts need to be made to accelerate initiatives in preventive health by bringing
28

This also includes the concept of pre-disease (or me-byo) that refers to the state of health when moving towarddisease (includes symptoms such as cold hands, fatigue, digestive issues).
29

Cutler DM. Behavioral health interventions: What works and why? In: Anderson NA, Bulatao RA, Cohen B, editors.
National Research Council, Critical Perspectives on Racial and Ethnic Differences in Health in Later Life. Washington,
DC: The National Academies Press: 2004. Committee on Population, Division of Behavioral and Social Sciences andEducation.

35

together data from checkups and clinical care as well as medical life logs and body sensors.
Japan should seek to become a leader in data collection and utilization to provide scientificevidence regarding disease prevention and health promotion.
4. Realize a “Tobacco-free” society
・ Scientific evidence shows that tobacco prevention reduces the risk of serious disease andreduces health care costs. While the WHO is supporting efforts to bring about a tobacco-freeworld by 2040, Japan seeks to work more quickly toward a “Tobacco-free” society so that,among other things, the 2020 Tokyo Olympic and Paralympic Games will be free of
second-hand smoke. There are ongoing efforts in cooperation with the Tokyo Metropolitan
Government to establish the legal and policy structure to support these efforts. To bring thesmoking rate close to zero by 2035, serious measures should be implemented that include
raising the tobacco tax, restricting advertising and packaging, supporting smoking cessation,and educating people on tobacco prevention.

36

(3) Global health leader: Leading and contributing to global health
Aims for 2035
Build a health care system that allows Japan to respond to issues of global health security andprovide global leadership in partnership with other nations.
Contribute to improvements in global health and reduction of inequality by participating in
global policy making and sharing Japan’s health care model. These efforts will support Japan inbeing recognized as a leader in healthy longevity.
Japan is becoming a central figure in the global health care network as it leads efforts to reformthe health care ecosystem and transforms into a health care service hub poised to meet the
medical needs of those around the world.
Examples of suggested actions:
1. Establish a health emergency management system
・ Create a Center for Health Protection and Promotion (tentative name) tasked with promptly
communicating key actions in the event of a critical infectious disease outbreak and leading
efforts to prevent the disease from spreading beyond the country of origin. In times of non-crisis,
the center will coordinate efforts related to public health and will also provide support tocountries or regions unable to fulfill the functions outlined in the WHO’s International HealthRegulations30 by dispatching personnel and other resources to help strengthen health caresystems.
・ In the mid- to long-term, establish a public health security system in partnership with othercountries, particularly those in Asia and the Western Pacific, to provide assistance during global
health crises, including the dispatch of Disaster Medical Assistance Teams,31 Japan Disaster
Relief Teams,32 as well as personnel from the Self-Defense Forces, non-profits, and civilsociety.
2. Take the lead in global rule-making
・ Contribute globally through health care diplomacy, including the diffusion of Japanese healthcare and systems, and make Japan a world leader in the field of healthy longevity. In particular,
Japan should contribute to the development of age-friendly communities as well as thedevelopment of strategies to address non-communicable diseases, such as dementia.
・ Actively make use of global events, such as the meetings of G7 nations, to take the lead in
health care agenda-setting including universal health coverage by convening a Global HealthSummit (tentative name), of which Japan could become the permanent host.
・ Promote exchange between government officials, health care providers, and researchers todevelop future health leaders who have a global perspective by, for example, supporting
30

World Health Organization. International Health Regulations (2005).
http://www.who.int/ihr/publications/9789241596664/en
31
DMAT refers to expert teams composed of doctors, nurses, and logistics specialists (as well as other medical
professionals and support staff) that are immediately dispatched to a disaster site (within 48 hours of its
occurrence) to provide medical assistance to the injured.
32
The Japan Disaster Relief Team Dispatch Law (1987, Law No. 93) stipulates that JDR teams are to bedispatched abroad, particularly to developing countries, to respond to large-scale natural disasters that haveoccurred or are expected to occur. They can also be dispatched at the request of national, based requests forassistance from governments in the areas affected or international organizations in the areas affected.
37

younger personnel to participate in conferences such as the annual World Health Assembly. A
mechanism must be developed that pools and supports future global health leaders from boththe public and private sectors.
・ Support a social impact investment structure and other such measures aimed at comprehensively
and strategically contributing to global health. Significantly increase Japan’s health-related
ODA from its current level of 2% of total ODA to around 20%, a level equivalent to that ofEurope and the United States. Japan should also increase voluntary contributions to the WHO
and other international organizations, and play a part in the construction of an effective systemof global health governance through effective actions by public-private partnerships led by
Japan.
3. Promote the global development of health care・ In an increasingly borderless world, health care personnel must be trained and certified to carefor people from around the world. Domestically, Japan must quickly establish necessary
systems for foreign visitors to access the health care services and interpretation services theyneed prior to the 2020 Tokyo Olympic and Paralympic Games. Such efforts will allow Japan to
showcase its health care system to the world.
・ Japan can globalize its health care by helping Asian countries build systems in such areas asuniversal health coverage and regulatory science related to pharmaceuticals and medical
devices.
・ Support should be offered as a package encompassing not only preventive measures, treatment,
pharmaceuticals, and medical devices but also the development of medical personnel and IT
infrastructure that serve as the basis for those goods and services.
・ In addition to supporting individual hospitals and sending outstanding doctors overseas, Japan
will promote global partnerships by providing systems of community health care. Linking coreclusters of hospitals with “super clinics”33 in remote areas to support the health care needs oflarge areas is one example of a strategy that can be effectively applied abroad. Developments
abroad should involve more than diagnosis and treatment, but include the exportation of thecommunity-based integrated care and long-term care systems through the sharing of systemdesign and operations methods.
・ Domestic health care policies will be continually verified and improved by strengthening
comparative analysis and understanding policy trends in other countries. Through joint researchand collaborative efforts to address emerging problems, Japan can become a stronger global
health leader.
・ In partnership with other relevant ministries and agencies, the Ministry of Health, Labour andWelfare should play a leading role in global health by formulating plans to hasten
comprehensive initiatives and pushing forward the policies needed in line with such initiatives.

33

This term refers to the setting up of bases for medical treatment in remote areas staffed with medical specialists.
The medical teams at these clinics can be dispatched to locations inside and outside Japan during an emergency,such as a natural disaster or pandemic.
38

7. Infrastructure for Achieving Japan Vision: Health Care 2035
A health care system for the next 20 years built upon the three pillars of this vision will require
integrated, cross-cutting initiatives, systems, and resources that call for restructured infrastructure in
the following five areas.
・ Innovation
・ Information
・ Sustainable financing
・ Health professionals
・ A world-class Ministry of Health, Labour and Welfare(1) Innovation
Innovation is more than technological development. Innovation brings change to society throughadded value and new ideas. If we are to achieve long, healthy lives faster, easier and cheaper,
innovative strategies in health care are critical. Essential innovations will be those that cut acrossfields of diagnosis and disease care and include prevention, risk management, rehabilitation, andlong-term care.
Alongside development of technology, systems that foster these developments must be reformed topromote innovation. These systems must actively encourage and incorporate innovation while
investing in the foundation of industry. Funding and guidelines must be established so innovation
can more easily be adopted. The integration of outcome assessments will lead to increased
competition.
To increase innovation in health care, we must look beyond the field of basic and clinical medicine
and seek a cross-disciplinary approach that integrates fields such as public health, epidemiology,
health economics, health policy, business administration, economics, behavioral science, andengineering. This will also contribute to the creation and implementation of national and local
health care policy and policy assessment. We must continue to support the creation of environments
for research, education, and training that promote interdisciplinary and practical initiatives.
Create a high-quality system for collecting statistical data, support cancer and dementia prevention,and further efforts in the prevention of disease relapse. As society continues to age, it will be
critically important to secure new avenues to fund research as genomics and cohort studies expand
clinical trial and clinical research opportunities. Possible ways to diversify new research funding inthese areas include donations, private funding, and insurance savings, in addition to expanding
basic policy expenditures.
Organizations including Japan Agency for Medical Research and Development (AMED), theNational Centers, major hospitals conducting clinical research, pharmaceutical and medical
equipment manufacturers, and the Pharmaceuticals and Medical Devices Agency (PMDA) should
cooperate to build a network, apply data on registered patients’ diseases, and accelerate
development of infrastructure to facilitate the collection of clinical trial data. This will increase thevalue of the clinical development field while reducing research and development costs for39

participating manufacturers and increasing the speed of clinical development through theincorporation of knowledge from both domestic and international sources.
Research and development in regenerative medicine requires a world-class research environment.
Regenerative medicine offers hope for sufferers of intractable diseases and can contribute to thediscovery of new drugs. With a focus on practical use, the Ministry of Health, Labour and Welfare
has designated certain cities as centers for regenerative medicine where researchers and relatedindustries from around the world can gather to drive research growth. These cities will strongly
boost efforts to reduce the costs of regenerative medical research and performance, while
simultaneously improving to meet global safety standards.
To ensure that people from around the world can benefit from pharmaceutical and medical device
developments, international cooperation on regulations in these areas will be essential. Exerting
leadership in this field and spearheading the establishment of global standards would bolster Japan’scompetitiveness. To strategically promote the harmonization of international regulations, it isnecessary to establish a regulatory science initiative that clarifies long-term priorities to guidepolicies while concurrently pursuing programs that support these goals. For example, theestablishment of an Asia-based pharmaceutical and medical equipment training center within the
PMDA that trains those responsible for overseeing pharmaceuticals in other countries should beconsidered.
In addition to increasing capacity of human resources in Japan, attracting international talent toJapan is critical to accelerating innovation. Building platforms within industry, government, andacademia for those from Asia and around the world to learn and share information about health care
will benefit Japan as well as other countries in sharing knowledge while gaining access to
cutting-edge knowledge and innovation from around the world.
(2) Information
By 2035, Japan must drastically improve health care quality, value, safety, and performance throughthe use of ICT. The utilization of an extensive health care database will lead to increased quality,
patient value, and performance while enhancing the safety of health care. Essential to this process
will be ensuring that the public understands the benefits of such a system.
Japan has yet to sufficiently connect its health care databases and data sets, which include the
National Database (NDB) on claims and services, the Kokuho Database (KDB) on national healthinsurance, the long-term care claim database, and data on nursing care authorizations. Each of thedata sets including comprehensive health care data and long-term care data should be linked andcombined into one database, provisionally named the Health Care Data Network 2035 (HDN2035),
that is reflective of the Diagnosis Procedure Combination (DPC)34 code datasets. Currently, when34

A reimbursement fee system combining a comprehensive assessment driven payment system for in-patient carecomponent (for basic hospitalization fee, examination, medication, injections, diagnostic imaging, etc.) based on a
per-diem rates established by the MHLW for the most high-cost procedures and diseases that require the greatest
medical resources for treatment during a hospital stay and services (including basic hospitalization fees,
examinations, medications, injections, and diagnostic imaging). This system also includes a fee-for-service
component (for services including surgery) operations, etc.
40

individuals change insurers, their health data within the KDB and NDB is lost. To prevent this typeof loss and ensure continuity, regardless of insurer, an individual ID number for use within systems,
including the health care system, is essential. This will enable benchmarks to be set and verified
making it possible to assess treatment outcomes by analyzing the links between risk factors andpatient conditions; to determine how service and pharmaceutical redundancies can be avoided; toidentify ways for insurers to best address prevention; and to track health care benefits.
Improvements must be made to the National Clinical Database (NCD) and health care databases. In
addition to creating a database of the scale of the NCD that contains data related to all diseases,
improvements must be made to the quality and quantity of the statistics in major databases
including the DPC database, the NDB, and the KDB. A foundation that establishes a legal
framework and standardizes statistical practices, like the Health Insurance Portability andAccountability Act (HIPPA)35 in the United States, must be created so that government, academia,
research institutes, academic societies, and other organizations are able to use a wide variety of data
while firmly protecting privacy. Efforts to increase quality must extend beyond medical specialties
to other parts of the health care system through, for example, the creation of a database to support
improvements in the quality of nursing care.
Cancer treatments that span the life course will improve through the ability to link cohort data
available through the cancer registry with vaccination, examination, treatment, and long-term caredata. For long-term care insurance, combining long-term care authorization data with long-termcare claim data enables better understanding of service usage patterns and the health status of thoseusing such services. This will allow local authorities to further reform systems for providing
long-term care based on the data.
In addition to data management, a strong ICT infrastructure enables remote diagnosis, treatment,
and surgery, meaning that people can safely receive high-quality treatment in areas without
specialists and ensuring access to health care throughout the entire life course moving fromprevention to diagnosis, treatment, disease management, long-term care, and end-of-life care.
Physicians can also provide treatment more efficiently by focusing on medical decisions andinterventions, and working to build consensus with patients along the lines of treatment needs.
(3) Sustainable financing
Because increased use of public funding to support the Japanese health care system leads to budget
deficits that put financial pressure on future generations, it is critical that we address the financial
health of the system through sustainable means. And while the population of those over 75 is
expected to plateau between now and 2020, estimates show that 2021 will see a rapid increase inthis population making a long-term outlook critical.
Setting prices to reflect effectiveness and quality of health care will ensure greater access toworld-class care available within the health care system. Yet, these initiatives should be
35

The United States’ Health Insurance Portability and Accountability Act was passed in 1996 and enacted in 2003.
It promotes conversion of health-related data to electronic form, while setting standards for safety and privacy
protection.
41

accompanied by an ongoing discussion of the role and function of public health insurance, thebalance between benefits and costs, new approaches to funding, and other efforts that address thesustainability of the health care system to ensure least impact on future generations.
i. The role and functions of public health insurance
The role and function of public health insurance must be reevaluated while ensuring the systemremains centered on basic principles, such as the provision of appropriate health care services andsafeguarding the public from serious health issues. Such evaluation will reveal a core set of services
that the public health insurance system must continue to provide. Services that fall outside of thescope of the functions of the public health insurance system will require new financial structuresthat enable people to access such services when necessary.36 Financial support structures, including
donation-based systems, that complement public health insurance will become critical.
ii. Securing funding
A renewed understanding of the role and functions of public health insurance, as described in (i),will require resources that include out-of-pocket payments, insurance premiums, or taxation.
Reviews of each funding sources will be necessary to ensure fairness and equity. Efforts to ensure
public buy-in for necessary increases will be required. To ensure fairness between generations,these reviews must be made from a mid- to long-term perspective and payments should beredesigned to be in proportion to benefits.
Certain age groups, such as those aged 75 and over, are afforded out-of-pocket payment reductions.
However, there is a need to discuss how to achieve a basic balance with younger generations. Even
within the same age group, populations face a variety of social and economic conditions that call fora similar system of out-of-pocket payment balancing. While maintaining the health care system’s
basic responsibility to cover necessary and appropriate health services and safeguard against serious
health issues, adjustments to fees based on disease class should be considered. For example, feesthat are unreasonably low could be increased, people could be asked to may more out-of-pocket to
be seen for minor health concerns like the common cold, and those facing serious illness could be
asked to pay less. Changes to fees within the long-term care insurance system should also be
considered, such as the introduction of user fees for services based on care plans developed by caremanagers.
We should also consider, from the perspective of making fees fair based on the ability to pay,developing a system to ensure out-of-pocket payments and insurance premiums are determinedbased on not only income, but assets. Another consideration might be to incorporate reverse
mortgages following death.
The costs and services associated with pensions and long-term care provided to older persons is ofmuch concern. However, social insurance benefits for those raising children do not gain adequate
attention. To ensure fairness, these benefits need to be examined depending on whether
beneficiaries support dependents or not. Also, the system of increasing national health insurance
premiums based on the number of children needs to be examined.
36

There are a variety of potential approaches that support the inclusion of new services by regional andemployment-based insurance, including the provision of supplementary insurance or the exclusion of certain
cost-ineffective services for minor, non-life threatening from the scope of insurance.

42

To ensure the sustainability of public funding, various strategies must be considered, including
increasing taxes or imposing new taxes on products that affect health, such as tobacco, alcohol, andsugar. Environmental taxes could also be used to fund social security. However, it has been shownthat there is a link between socioeconomic factors and lifestyle37 so people with low incomesshould be given additional support in making healthy lifestyle choices.
Further, as fiscal adjustment systems are becoming more complex making the connection between
insurance benefits and cost share increasingly difficult to decipher, it is critical to implement ways
to ensure the public is aware of how the employer-based health insurance system contributes to theinsurance scheme for older persons.38
iii. Strengthening financial governanceInsurers in 2035 will be asked to balance the benefits they provide with the fees they collect while
contributing to a sustainable insurance system. The system should comprehensively support theinsured by providing prevention and health management services and implementing initiatives that
increase health literacy and improve health care quality using tools, such as ICT.39
Making health care costs reasonable will require that expenses be evaluated regularly against
expected costs. To address cases where resulting expenses exceed expectations, reasons for major
discrepancies must be analyzed, efforts to prevent further increases in expenses that may include a
review of benefits should be implemented, new sources of funding should be discussed with therelevant parties, and a system for making mid-term adjustments should be created. Accordingly, we
will promote initiatives to transfer authority to prefectures so regional disparities can beaddressed.40(4) Health professionals
Physicians and other health care professionals require adequately equipped working environments
in order to continually provide high-quality care. To create a strong health system, it is necessary to
hold ongoing discussions on the health care professionals required by the ideal system, taking into
account advances in technology and changes that arise over time, and to develop human resources
who are competent in those areas.
37

Shakai keizaiteki yoin to kenko-shokuseikatsu: Nihon ni okeru jittai to kongo no seikatsu hogo jukyusha shien
ni mukete (Social Economic Factors and Health and Eating Habits: The State of Affairs in Japan and Working toSupport Future Public Welfare Recipients). Second Ministry of Health, Labour and Welfare Social Welfare and
War Victims’ Relief Bureau Social Welfare Recipient Health Management Research Group document.
http://www.mhlw.go.jp/file/05-Shingikai-12201000-Shakaiengokyokushougaihokenfukushibu-Kikakuka/0000064
273.pdf
38
Prefectures and other bodies should be allowed to play a more active part in overseeing the health insurance
and health care systems to support systems for those who are making contributions to employer-based healthinsurance for employed people.
39
To foster sustainability, there is a need not only for government regulations and industry standards for healthcare professionals, but also for functions that allow insurers to independently set reimbursement fees, designate
medical institutions authorized to treat patients with health insurance coverage, and grant region-specificqualifications and licenses.
40
Measures such as introducing fees based on regional disparities between prefectures, as noted in Chapter 6 (1),should also be considered.
43

Physician placement and employment structure should be reviewed and concentration should beplaced on fostering productivity through the use of various tools, including advanced technology.
For example, productivity could be increased by training physicians to be able to treat patients who
present with multiple health issues and training physicians in the areas of prevention, public health,communication, and management. Other efforts to contribute to increased productivity include
reform of state examinations and medical education, expansion of team-based health care, andcreation of a system to train hospital specialists who become community-based general practitioners.
Training for physicians and other health care professionals should be made more efficient andeffective through the use of MOOCs41 and other ICT methods, comfortable working environments
should be created for health care professionals, and model career paths for female physicians should
be developed.
Through various efforts that include increasing the number of graduate schools of public health,those with potential in the area of health policy must be supported through training and careerdevelopment systems made available in regional areas. Management of health care facilities must
be improved through training that extends beyond clinical practice and data science and includes amultidisciplinary approach featuring leadership training and courses on management and publichealth.
Analysis of each region is necessary to determine which medical departments face shortages due toageing physicians and uneven distribution of physicians. During this investigative process,prefectural governments, which are responsible for creating health care plans, should implement
policies to prevent physician shortages and create strategies to ensure departments, including
general practice departments, facing shortages have an adequate number of physicians. Specifically,
this means creating policies that encourage physicians to transfer from highly competitive
departments to those that are understaffed. These policies could include incentives such as grants
and advanced training programs that make moving more attractive. Policies that address uneven
distribution of human resources in clinical and specialist research are also needed.
As regional hospitals start to specialize, cooperation must be strengthened between specialists andgeneral practitioners in order to form organic networks. This should be followed by increased
cooperation within and between local governments.
In many cases, smaller health care facilities in rural areas lack access to advances in medical
technologies and knowledge creating the need for systems that make it possible to concentrate on
clinical and general research even in these areas. Physicians could have access to the latest
information, research, and clinical medicine practices through the establishment of regionally based
research networks and the expansion of clinical trial networks.
In addition to the global trends of population ageing and NCDs, countries in Asia share thechallenge of healthcare workforce shortages, funding shortages, and the transition tocommunity-based care. Medical schools should establish month-long training programs oncommunity-based care in Japan and health care in other countries, particularly in developing
41

Massive open online courses (free, web-based course services that offer certifications).
44

countries. Further, systems to support postgraduate programs that provide opportunities for clinicaltraining in other countries as well as “glocal”42 clinical training held in regional areas of Japan andin Asia should be established.
In an ageing society, delivering comprehensive care to address the multiple health issues patients
present is essential. Unfortunately, this is often not possible because of the divisions between
different specialties and between different roles, such as doctors, nurses and other para-medicals. To
address workforce shortage across specialties while contributing to the implementation ofcomprehensive care, after review of multiple roles each qualification plays, we should allow
professionals who have adequate experience and training to fulfill an expanded list of roles within
their job classification. Home health care will also face workforce shortages. To prepare foradvancements in health care and as specialty nursing develops, the health care services delivered bypara-medicals will need to be expanded.
An ageing society coupled with a low birthrate requires that we train a workforce capable ofmultiple job functions in both the health care and social service sectors. This will concurrently
support the growth of the community-based integrated care by training human resources to workwithin these systems. While taking local needs and professional specialization in consideration, acommon set of medical and social service qualifications should be established for those working in
the community-based integrated care systems. We should also support the skill development ofadministrative and other critical support staff across Japan’s various regions who contribute to thefunctioning of the public health insurance system.
(5) A world-class Ministry of Health, Labour and Welfare
The Ministry of Health, Labour and Welfare (MHLW) and ministries and agencies that support the
MHLW have not been able to effectively optimize the social security system through critical
reforms of key cross-cutting systems and policy areas (including the pension system, health care,long-term care, housing, community development, and urban planning). It should be noted thatnational and regional governments pay out nearly ¥110 trillion in health care benefits when thenational budget is approximately ¥90 trillion, putting health care resource reform next to overall
economic reform in terms of Japan’s most critical issues.
Reform of the management structure of the MHLW is also required to fully implement Japan
Vision: Health Care 2035. Fragmentation within the organization slows processes and leads toinefficiencies. Increased pressure in the areas of pensions, health care, long-term care, social
services, and employment will require that capable human resources are secured to meet theseneeds.
MHLW leadership must be provided with the appropriate tools to make timely and necessary policy
decisions. Currently, cross-sectional communication is becoming more difficult despite the need forleadership to address an increasingly broad spectrum of issues. In addition to job function reform
and workforce strengthening, cross-cutting management and communication capacity that extends
42

Clinical training systems, which include clinic training in regional areas of Japan as well as overseas
experience for a fixed period in Asian countries or other locations.
45

to regional bureaus must be increased to allow for proactive communication with healthprofessionals in the field.
Health policy discussions and the establishment of shared benchmarks tend to occur within
European and North American governments. Japan, however, has yet to engage with neighboring
countries to understand, analyze, and engage in collaborative trend analysis. For example, Japan has
fallen behind in developing health technology assessment (HTA) as well as health care ICT despite
major advances taking place in the region. Looking forward to 2035, the MHLW must strive to berecognized as a global organization that moves quickly and precisely to support innovation andaddress health crises.
A Chief Medical Officer (CMO) should be appointed to serve a five-year term to advise the Prime
Minister and the Minister of Health on health policy. The role of the CMO should be filled by aperson with expertise in technology and public health who can provide recommendations toministers and other politicians from a neutral and objective stance. The CMO will need to besupported by a structure that ensures access to the most up-to-date health information and researchfrom around the world. Functions of the CMO will also require that communication must not only
come in from global sources, but that Japan sends communication outward as well. Additionally, a
Bureau for Medical Innovation should be established that horizontally drives health care innovationfrom the development stage to assessment of its effects on expenditure. The bureau would become abase for medical technology assessment and health care ICT.
Japan can contribute to global health needs by supporting health care development around the world.
In order to do this, establishing a provisionally-titled Global Strategy Officer will support thecreation of a comprehensive vision (Global Health Initiative) and strengthen Japan’s ability toengage in global dialogue and analysis enabling Japan to play a stronger leadership role.
Japan must take the lead in addressing urgent global health crises as well as emerging infectious
diseases by establishing crisis management systems and centers for infectious disease that serve as
public health command posts and detect potential threats, conduct P4-level investigations, develop
treatments, and ensure effective disease control measures are implemented when necessary. At thesame time, an organization that integrates multiple bureaus within the MHLW should be establishedto address the growing threat of non-communicable diseases (NCDs), support nationwide andregional health initiatives, and communicate NCD policy and health system information outward.
Strengthening institutional structure alone will not suffice. Human resource management must be
revised to include more active hiring of ambitious young talent and accomplished professionals.
And the current classification of human resources into administrative and technical staff should be
reexamined, so that staff are assigned to positions that match their abilities leading to improved
performance of the organization as a whole.

46

8. Looking Ahead
A headquarters should be established within the Ministry of Health, Labour and Welfare to carry out
the above proposals, encourage wide-ranging public discussion about the proposals, and, after
careful consideration, steadily implement practical, short-term policies. We should also create asystem for appropriately following up on the progress of Japan Vision: Health Care 2035.
Further, it is critical that the health care system not remain self-contained. We must enhance links
with long-term care services, community development and other related areas, and deepen debate topromote partnership and integration with these areas.

47

Conclusion
In compiling this report, we received valuable opinions on everything from present issues toawareness of future trends from four main advisors, as well as many experts and government
officials. We also gathered useful statements from 149 citizens during a campaign that ran from
April 24 to May 20, 2015, when people were asked to share their ideas with Health Minister
Yasuhisa Shiozaki. During the same time period, we gathered comments from all employees of the
Ministry of Health, Labour and Welfare. We looked through all of these various opinions andadopted some of them in the report.
The Health Care 2035 Advisory Panel, the authors of this report, is composed of members with anaverage age of 42.7 who are likely to still be working 20 years from now. We have conducteddiscussions while aiming not to be tied down by existing frameworks and limitations and trying toconstructively and creatively consider the world in 20 years. In making suggestions looking two
decades ahead, some proposals and examples of policy will arouse debate. We welcome feedback
and criticism on this report, and hope that it will be the start of national debate. We are sure thatdebate in itself will be the first step toward a brighter future.
Even around the world, there are few visions for health care policy similar to this report looking
ahead 20 years. This English version has been prepared alongside the original Japanese version topresent Japanese policy ideas to the world, deepen global debate, and make an intellectual
contribution both domestically and overseas.

48

(Appendix) Japan Vision: Health Care 2035 Timeline
By 2020・ Establish and implement
health technology
assessment system
・ Support practitioner-led
quality of care
improvements (including
prevention of excessive
care and adverse events)
・ Educate generalpractitioners to deliver thecommunity-based
integrated care and ensure
such practitioners areavailable throughout Japan・ Ensure that communities
and hospitals are able todeliver the best options
available to patients
Life design: Empower society ・ Establish the means toand support personal choicerealize a “Tobacco-free”
Olympic and Paralympic
Games (e.g., youth
smoking prevention
programs, raising the
tobacco tax, regulating
advertising and packaging,smoking cessation
programs and treatment)
・ Promote preventive healthmeasures that have shown
to be effective and pursue,
in particular, secondary
and tertiary prevention
strategies that reduce costs
・ Improve quality of life andincrease social productivity
by investing in health
Global health leader: Lead and ・ Establish a healthcontribute to global healthemergency management
system (an organization to
manage health emergencies
and disease control)・ Create a health caredelivery system prepared tomeet the needs of people
from around the world by
the 2020 Tokyo Olympic
and Paralympic Games
Lean health care: Implement
value-based health care49

By 2035
・ Evaluate provider
performance andeffectiveness of health careproviders and healthtechnology) based onvalue delivered to thepatient and reflect
evaluation in fee schedule・ Improve treatment
outcomes by monitoring
medical facility
performance and setting
benchmarks
・ Ensure that health,
medical, and long-termcare services that areavailable reflect regional
data and needs
・ Realize a “Tobacco-free”
society by 2035
・ Support the widespread useof electronic personal
health records that include
long-term care service
information
・ Establish centers where
people can access healthand social consultation
services in one place
・ Create communities andcities based on a social
determinants of health(SDH) perspective

・ Position Japan as anadministrator of global
health emergency
management and increase
capacity to lead during
international health crises,
such as infectious disease
outbreaks and disasters
・ Develop a system of healthsecurity that integrates
various stakeholders,・ Develop a mechanism topool and educate future
global health leaders fromboth the public and private
sectors
・ Support universal healthcoverage and regulatory
science capacity building in
Asia and around the world

Infrastructure
Innovation
toAchieve
Japan Vision:
HealthCare
2035

Information

Sustainablefinancing

Healthprofessionals

including the government,
Self-Defense Forces,
non-profits, and civilsociety・ Export medical care andlong-term care systems
based on care models,
including thecommunity-based
integrated care model・ Contribute to constructionof global health governanceby contributing tointernational organizations
and other means
・ Ensure adequate resources
for continued research of
diseases, such as cancer
and dementia
・ Attract people capable in
the field of innovation frominside and outside of Japan・ Build a clinical trial andclinical study platform・ Foster human resources andbuild research andeducational environmentsthat support the practicalapplication of research
efforts
・ Establish and utilize a・ Build infrastructure to
health care data network
enable delivery of(link data through use of
ICT-based health care that
health care ID)
includes remote screening,
treatment and surgery
・ Implement prevention,
health care, and disease・ Develop a policy evaluation
management services based
process that utilizes
on analysis of check up andprevention, diagnosis,
treatment data
treatment, disease
management, long-termcare, and end-of-life care(the final stage of life) data
・ Introduce a system that・ Establish a financial
allows for mid-term
support mechanism toadjustments when healthcomplement publiccare costs surpass
insurance
expectations
・ Enable prefectures toaddress regional disparities
by, for example,
transferring authority
・ Foster physicians with・ Develop a common set of
capacity in prevention,
medical and social service
public health,qualifications (e.g., sharedcommunication, andpromotion and training
management
programs)
・ Build a “glocal” clinical・ Address physician
training system
misdistribution throughstrategies that include
・ Foster health policy
50

professionals by increasing
the number of graduate
schools of public health,amongst other approaches
A world-class ・ Appoint a Chief Medical
Ministryof
Officer (for a term of five
Health,years)
Labourand ・ Formulate a Global HealthWelfareInitiative
・ Establish a Bureau for
Medical Innovation

51

placing physicians in areas
with persistent shortages
and setting physician quotas
・ Take leadership in global
dialogue and policy making

52

Health Care 2035 Advisory Panel
List of Members
Chair

Kenji Shibuya

Professor, Department of Global Health Policy, Graduate
School of Medicine, The University of Tokyo

MemberMachiko Inoue

Professor,

Department

of

FamilyandCommunity

Medicine, Hamamatsu University School of Medicine
Satoshi Ezoe

Senior Coordinator, Cancer Control and Health Promotion
Division, Health Service Bureau, Ministry of Health,Labour and Welfare

Kensuke Onishi

CEO, Asia Pacific Alliance for Disaster Management

Toshihisa Okamoto

Director, Office of Drug-Induced Damages, General
Affairs Division, Pharmaceutical and Food Safety Bureau,
Ministry of Health, Labour and Welfare

Kazumasa Oguro

Professor, Faculty of Economics, Hosei University

Kohei Onozaki

Board Member, President, Health and Global Policy
InstituteTakeshi Sakakibara

Counselor for Policy Planning Coordination, Heath
Insurance Bureau, Ministry of Health Labour and Welfare

Kazuhisa Takeuchi

Director, Welfare Manpower Promotion Office, Welfare
Promotion Division, Social Welfare and War Victims'
Relief Bureau, Ministry of Health, Labour and Welfare

Yasuharu Tokuda

Japan Community Healthcare Organization

Manami Hori

Professor, Course of Human Welfare Environment,
Department

of

Human

Development,

Schoolof

Humanities & Culture, Tokai University
Hiroaki Miyata

Professor, Department of Health Policy and Management,
School of Medicine, Keio University

Mayuka Yamazaki

Assistant Director, Harvard Business School Japan
Research Center

Yuji Yamamoto

Researcher, Sony Computer Science Laboratories, Inc53

List of Counselors
Counselor

Shigeru Omi

President, Japan Community Healthcare Organization

Tetsuro Kochiyama

President,

HealthInsurance

Claims

Review

and

Reimbursement Services
Toshihiko Miyajima

Director-General, Office for Social Security Reform,
Cabinet Secretariat

Yoshitake Yokokura

President, Japan Medical Association
as of 9 June, 2015

54

Brief Summary

Socio-economic changes require a paradigm shift
Issues and outlook

Paradigm shift

Address growing health care needs,changing social environments and values,
increasing inequity, and globalization
Transform health care into a horizontal
system that engages all sectors throughshared vision and values, in contrast to
maintaining the current system throughbasic cost share increases and benefits
cuts
Promote innovation in health caretechnologies and systems that drives
Japan's growth and development while
maintaining excellence in health
Tackle fiscal deficits and contribute toJapan’s economic stability
Position Japan as the authority on healthy
longevity by addressing population ageing
and a low birthrate

Existing model

Toward 2035

Quantity

Quality

InputsValue

Regulation

Autonomy

Cure

Care

Fragmentation

Integration

Health care for the next 20 years: Vision and actions
Goal

To build a sustainable health care system that delivers unmatched health outcomes through carethat is responsive and equitable to each member of society and that contributes to prosperity inJapan and around the world.

Principles

LEAN
HEALTHCARE

1

Implement valuebased health care

Shared prosperityof Japan and the world

Solidarity built
on autonomy

Fairness

Vision and actions for health care in 2035
LIFE
GLOBALHEALTH LEADERDESIGN

2

Empower society andsupport personal choiceBase reimbursement rates onvalue to the patient

Realize a “Tobacco-free” Tokyo
2020 Olympics

Support increased quality ofcare through professional
initiatives

Accelerate prevention anddisease management throughstrategic use of ICT

Develop and ensure accessthroughout the country to
general practitioners

Build communities from a social
determinants of health (SDH)perspective

3

Lead and contributeto global health

Establish a health emergency
management system (building a
Center for Health Protection andPromotion)
Provide support in developing
core systems, such as universal
health coverage and drug
approval processes
Develop a system to educate
global health leaders57

Health care for the next 20 years: Infrastructure
1. Innovation

2. Information

Establish a platform for clinical trials

Build and utilize a health care network thatlinks data using unique identifiers

Secure research funding through various
sources for diseases, including cancer anddementia

3. Sustainable financing

Promote care and disease management
through collection and analysis of check-up
and treatment data

5. A world-class Ministry of
Health, Labour and Welfare

4. Health care professionals

Allow for intermediateadjustments when healthcare costs exceed
projections (e.g., adjust
benefits, implement
preventive measures)
Establish a financial support
mechanism to complement
public insurance

Increase, where appropriate,
integration of paramedical
professionals

Establish a Chief Medical
Officer (CMO) position
Establish a Bureau for
Medical Innovation

Introduce quotas in areasthat continue to facephysician shortages andmisdistribution of specialties

Life in 2035
20年後の保健医療には、これが求められる
85 year old man, community
volunteer (current age: 65)▪ After visiting my family physician forjoint pain, I was referred to a local
specialist right away.
▪ Although I used to have to go backmultiple times, this time my specialist
had already received access to myelectronic health record so there
was no need for additional visits.

20 year old woman, student (current age: 0)▪ Since I was a child, I have had a rare disease that causes pain all over
my body. Yet, I have the understanding and support of those around me
and I can see my specialist using telemedicine, so I can live with thisdisease while studying and working just like everyone else.
▪ Information about this disease is registered in a database and I am
participating in the development of a new drug. This is thanks toJapan’s improved research environment.

▪ The specialist gave me different
treatment options using information ina database of patients just like me.
And she explained potential
complications so I was able tounderstand and decide on atreatment that’s best for me.

50 year old woman, contract
worker (current age: 30)▪ A single mom, I was able to raise my
two kids and continue to work in a local
factory.
▪ After graduating from high school, my
son wanted to find a job in our
hometown where he has lots of friends.
He likes people and wanted to make adifference, and now he is working in acare facility. I feel so proud when I hearothers say how how hard-working he is.
▪ My daughter got a scholarship to study
nursing at a local university. Next year,
she plans to start working at a nearby
hospital.
▪ Health care and caregiving havebecome the employment andeconomic drivers of this community.

48 year old woman, physician(current age: 28)

65 year old man, company employee andnon-Japanese resident (current age: 45)▪ Although I was busy 20 years ago, there were so
few surgery cases that I actually had to seek
opportunities to do surgery. This made it difficult toassess my own surgical skills.

▪ When I was transferred to Japan 20 years ago, myfamily had such a hard time figuring out where to go
and communicating during medical emergencies.

▪ I was very surprised the first time my hospital wasassessed using benchmarks and I saw the grade
we received.
▪ Since then, I have been working to build a new network of nearby hospitals
and staff and we have seen outcomes improve. Including young physicians
and staff, everyone is able to thrive in the workplace.

▪ Just before the Tokyo Olympics, things changed. And
now even those who don’t understand Japanese
can readily access medical care. I now enjoy life
here with a greater sense of security.
▪ Japan is known for high quality health care and age-friendly initiatives. The
world views it as a medically advanced country. And now we see people
coming to Japan from around the world to get medical care.

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