2019 Survey on Healthcare in Japan

Health and Global Policy Institute
September, 2019

Ⅰ．Summary
Health and Global Policy Institute has conducted regular surveys of public opinion on healthcare issues since 2006
to gain a better understanding of public perceptions and a better awareness of the health services and health carepolicies that the public desires. Continuing on from previous surveys, the 2019 survey included questions on thelevel of satisfaction that the public feels with the current healthcare system. The survey also inquired about public
participation in healthcare policy and sustainability of the National Health Insurance system. In addition, it inquired
about issues that have been garnering attention recently, namely high-cost drugs, antimicrobial resistance, andvaccines.
(1) Survey Highlights
Satisfaction levels towards healthcare and healthcare systems


62% of respondents were satisfied with healthcare and healthcare systems in Japan. The highest
satisfaction was reported for “safety of care.”Public participation in healthcare policyAbout 80% of respondents want their opinions reflected in the healthcare policy creation process.

Sustainability of the National Health Insurance system and high-cost drugs
About 80% of respondents supported providing health insurance coverage for high-cost drugs.

Antimicrobial resistanceOver half of respondents did not know that antimicrobials and antibiotics are ineffective for treating thecommon cold or influenza.

Vaccines

About 70% of respondents did not know that the HPV vaccine is effective at preventing HPV infection andthe conditions that lead to cervical cancer.

(2) Future discussion points in healthcare policy suggested by survey results

Public satisfaction towards medical safety and the quality of technology was high, so it is safe to say thatthe public recognizes the value of the work done by healthcare providers in clinics and hospitals. On theother hand, opportunities for the public to be involved in promoting countermeasures for each disease
have been limited. This has resulted in in low satisfaction levels towards both the transparency of thehealthcare system policy creation process as well as measures to reflect public opinion in that process.
Approximately 80% of respondents stated that they want their opinions reflected in healthcare policy.
Examination committees for policy formulation and other such groups should include public interest
members and members of committees representing people receiving healthcare. In addition, it may benecessary to hold discussions on and rebuild mechanisms and systems for reflecting public opinion in
healthcare policy in the future.
1

Respondents showed clear support for providing public medical insurance coverage for high-cost drugs.
This raises the question of how to develop recognition that some items will not be covered due to limited
financial resources. Given the fact that drug spending accounts for less than 20% of total healthcare costs,
the question of how to improve the overall efficiency of the healthcare system in a way that the public
will support must be clarified through future surveys.

In the field of vaccines and antimicrobial resistance (AMR), it was clear that information based on scientificevidence has yet to penetrate among the public. To ensure the health of every member of society
regardless of their literacy on the topic of vaccines and AMR, it will remain important to examine methodsof disseminating evidence-based information and developing evidence-based policies.

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Ⅱ．Overview of Survey
An internet-based public opinion survey was administered to 2,000 males and females over 20 years of age
throughout Japan during July 2019. The breakdown of respondent demographics is shown in Figure 1. The survey
was distributed to 2,434 individuals. It was administered only to those who gave informed consent after having readan explanation of the survey’s objectives. The questionnaires were self-administered, and a serial number was given
to each respondent to ensure anonymity.
In recent years, there has been a decline in the efficacy of traditional survey methods due to factors such as
decreased response rates for mail-in surveys or in-person interviews and expansions in survey restrictions, which
has led to higher expectations for internet surveys. However, the conduction of a survey on the internet introduces
a fixed sampling bias in that it selects only for respondents who can use the internet, and hence have a certain levelof education, as internet literacy is generally correlated with education level1, 2, 3, 4, 5. It is important to take thislimitation into account when interpreting the results of this survey.

1)
2)
3)
4)
5)

Smith MA, Leigh B, 1997, Virtual subjects: Using the Internet as an alternative source of subjects and research environment. Behavior Research
Methods, Instruments, & Computers, 29, 496–505.
Osumi N, Maeda T, 2007, Problems with online surveys - Observations from experimental investigations (Part 1) (From members). Japan
Association for Public Opinion and Research Newsletter Yoron, 100, 58-70.
Osumi N, Maeda T, 2008, Problems with online surveys - Observations from experimental investigations (Part 2) (From members). Japan
Association for Public Opinion and Research Newsletter Yoron, 101, 79-94.
Miura A, Kobayashi T, 2015, Monitors are not monitored: How satisficing among online survey monitors can distort empirical findings. Japanese
Journal of Social Psychology, 31, 1–12.
Hanibuchi T, Muranaka A, Ando M, 2015, Challenges of Data Collection through Internet Research: Analysis of “Frivolous” Responses, Response
Time, and Geographical Pattern. E-journal GEO, 10 (1), 81-98.

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Ⅲ．Survey Results(1) Satisfaction levels towards healthcare and healthcare systems


62% of respondents were satisfied with healthcare and healthcare systems in Japan. The highest satisfaction
was reported for “safety of care.”

Respondents were asked to rate various items concerning healthcare systems in Japan on a four-point
scale that included “satisfied,” “somewhat satisfied,” “somewhat dissatisfied,” and “dissatisfied.” 11.0%
of respondents selected “satisfied” and 51.0% answered “somewhat satisfied” on the topic of overallsatisfaction level, showing that 62.0% of respondents were satisfied with healthcare and healthcare
systems in Japan (Figure 2).

Examining individual items, the highest level of satisfaction could be seen for the safety of healthcare, forwhich 71.8% of respondents selected “satisfied” or “mostly satisfied.” Second was “quality oftechnologies for diagnosis and treatment,” which received positive ratings from 68.4% of respondents(Figure 2).

“Reflection of public opinion in the healthcare policy creation process” had the lowest level of satisfaction
at 33.7%. The next lowest items were “transparency of the healthcare policy creation process” (33.8%)
and “simplicity of healthcare policy” (37.4%) (Figure 2).

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[Commentary]On the topic of healthcare and healthcare systems in Japan, our survey indicated that respondents were highly
satisfied with the safety of healthcare and the quality of technology used for diagnosis and treatment. However,
responses concerning healthcare systems indicated significantly low satisfaction levels. This demonstrates thatmany members of the public perceive the policy creation process as unfair and lacking in transparency due tothe complexity of healthcare systems or because public opinion is absent from the process.

Given the results of HGPI's past public opinion surveys, this is a clear trend.



Healthcare systems greatly affect the everyday lives of members of the public. Not only is it necessary to
publicize information concerning healthcare systems in a way that can be easily understood, it is also necessarythat measures are taken to disclose the policy creation process for healthcare systems and to involve the public
in said policy creation process.

5(2) Public participation in healthcare policy
About 87% said cooperation between various stakeholders is important to provide better healthcare, but
only about 39% felt that stakeholders are cooperatingOn the topic of providing better healthcare to the public, respondents were asked if they felt it is importantfor various organizations or their representatives outside of medical institutions or the government (suchas private businesses, research bodies, and members of civil society) to cooperate. Respondents were
provided two options, to agree or to disagree. 86.8% of respondents indicated that they believe
cooperation between various stakeholders is important (Figure 3).

Respondents were also asked if they think that that the aforementioned people and organizations fromvarious fields in Japan are currently cooperating to provide better healthcare. Respondents were
presented with five options: “they are cooperating,” “they are cooperating to a degree,” “they are mostly
not cooperating,” “they are not cooperating,” and “unsure.” 31.8% respondents selected “they arecooperating” (5.4%) or “they are cooperating to a degree” (26.4%) (Figure 3).

6About 80% want their opinion to be reflected in the healthcare policy creation processRespondents were told that the participation of citizens and people receiving healthcare in policy
discussions led to the establishment of the Cancer Control Act in 2006. They were then asked if theywanted their opinions reflected in healthcare policy in a similar manner to create and provide healthcare
or social support that reflects the opinions of the public and people receiving healthcare. 79.6% ofrespondents wanted their opinions reflected while 20.5% did not (Figure 4).

7

Most of the respondents with medical histories said they wanted their opinions reflected in healthcare policy
during the policy creation processThe responses people with medical histories gave to the previous question was compared with the
responses of those who had no medical histories (Figure 5). More of the respondents with medical
histories (84.2%) wanted their opinions reflected in healthcare policy compared to respondents with no
medical histories (77.8%) (Figure 5).

8About 47% thought that people receiving healthcare should proactively inform others of their needs toensure their opinions are reflected in healthcare policyRespondents were asked which actions people receiving healthcare should proactively take to ensure that
their opinions are reflected in healthcare policy (Figure 6).



46.9% of respondents said that people receiving healthcare should proactively provide information about
their needs, making it the most popular response. The other most popular responses were “the people
receiving healthcare should learn about healthcare policy” (22.1%), “multiple organizations representing
people receiving healthcare should cooperate to enhance their ability to publicize information” (17.8%),
and “people receiving healthcare and organizations representing them should make policy proposals”(12.4%) (Figure 6).

[Commentary]

There is widespread belief that medical institutions and the government must cooperate with various
stakeholders like private businesses, research institutes, and people and organizations from civil society
to achieve better healthcare. However, many believed that these stakeholders are not currently
cooperating in Japan, indicating a significant gap between the hopes of the public and reality.

 Given the fact that about 70% of respondents wanted their opinions reflected in healthcare policy, it isimportant to proceed with a strategic and unified approach using a platform that allows stakeholders toshare information and cooperate to solve problems. People who are currently experiencing or haveexperienced disease had particularly strong feelings on this topic. To promote policy proposals from thesestakeholders, it is necessary to provide them with continuous support to popularize peer support and todevelop their ability to propose policies and promote wider understanding of healthcare policy.
9 In the field of disease countermeasures, the Cancer Control Act specified that people with cancer andtheir family members will be included on the Cancer Control Council. The law established after that act
called the Basic Act on Stroke, Heart Disease and Other Cardiovascular Disease Measures also emphasizes
the participation of those most affected. Similarly, in other areas of disease, people receiving healthcare
and other parties most affected are participating in deliberation councils, investigative meetings, andother gatherings held by the government and administrative districts throughout Japan. Further
discussion is necessary to create processes and mechanisms for incorporating the opinions of people
receiving healthcare and other parties most affected into policy and to build consensus on scientificallysound, effective methods of policy promotion.

 HGPI operates NCD Alliance Japan, a civil society platform for gathering multi-stakeholders to take a crosscutting approach to NCD prevention and control. NCD Alliance Japan is working to create a better
healthcare environment for the people living with NCDs, by co-creating policy recommendations andempowering people living with NCDs as active participants through the policy making process.

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(3) The sustainability of the National Health Insurance System
Will National Health Insurance continue as high-cost drugs appear one after another? About 46% ofrespondents thought that the National Health Insurance system will still exist in 2040
Respondents were asked if they think Japan's National Health Insurance system will still exist as it does
now in 2040. Respondents could choose one of five options: “believe,” “somewhat believe,” “somewhat
doubtful,” “doubtful,” and “unsure.” 14.2% of respondents selected “believe” and 31.5% selected“somewhat believe” for a total of 45.7% of all respondents (Figure 7).



On the other hand, 11.6% of respondents were “doubtful” and 21.8% or “somewhat doubtful” for a totalof 33.4% of all respondents. 21.0% of respondents said they did not know (Figure 7).

11Younger generations were more doubtful of the continued existence of the National Health Insurance system,
mostly those in their 30s
Respondents who were “doubtful” or “somewhat doubtful” of the continued existence of the National
Health Insurance system were compared by age group (Figure 8).

Doubtful response rates by age group were: those in their 20s, 38.4%; those in their 30s, 40.6%; those in
their 40s, 39.1%; those in their 50s, 33.6%; those in their 60s, 24.7%; and those in their 70s, 28.2% (Figure8).

The average rate of doubtful responses per age group was 33.4% (Figure 8).

[Commentary]The average negative response rate was 33.4% with a pessimistic trend for respondents in their 20s, 30s,
and 40s. These age groups showed the most concern about the failure of insurance finance.

On the other hand, 21% of respondents said they did not understand the issue of the National Health
Insurance system’s continued existence. Measures are needed to improve literacy among people who feelthat the issue does not concern them.

12(4) High-cost drugs


Respondents did not want an increase in individual burden due to high-cost drugs


Respondents were asked to rate to the following eight methods for effectively using high-cost drugs withlimited financial resources. They were presented with four options: “support,” “somewhat support,”“somewhat oppose,” and “oppose” (Figure 9).
-

Only provide coverage when the drug is effective (for people who will see clear improvement(Example: Provide coverage only for those with outlooks of complete recovery))-Lower the cost of drugs (however, this carries the possibility of decreasing the number of new
drugs made available in Japan)-

Create a waiting list and allow people to receive treatment in some order, for example in orderof severity (with the risk of longer wait times)-

Obtain financial resources by increasing the national debt and provide treatment to everyone
regardless of the cost of drugs-

Introduce an age limit to people who are covered (for example, by making people over 75
ineligibles for coverage)-

Make high-cost drugs that are difficult for individuals to afford ineligible for coverage throughNational Health Insurance (make them pay themselves or pay through private health insurance)-

Increase public taxes and provide treatment to everyone regardless of the cost of drugs-

Increase the amount people have to pay out-of-pocket after receiving care

72.3% of respondents selected “support” and “somewhat support” for “only provide coverage when the
drug is effective,” making it the most popular option. It was followed by “lower the cost of drugs” (69.1%)
and “create a waiting list and allow people to receive treatment in some order, for example in order ofseverity” (67.3%) (Figure 9).

Fewer respondents supported “deny public health insurance coverage” (43.9%), “increase taxes andprovide universal coverage” (39.0%), and “increase out-of-pocket costs after receiving care” (35.9%)(Figure 9).

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

About 80% supported NHI coverage for high-cost drugs

Respondents were presented with the following specific example of a high-cost drug being covered by National
Health Insurance. They were asked to indicate their support with one of four responses: “support,” “somewhat
support,” “somewhat oppose,” and “oppose” (Figure 10).
In May 2019, a new drug called Kymriah became eligible for National Health Insurance (NHI) coverage. Kymriah has
been found to be highly effective at treating certain diseases that do not respond to normal treatment such as
leukemia. Kymriah is a high-cost drug with a retail price of ¥33,493,407, but it was deemed eligible for coverage
under NHI. For example, its cost for users with annual incomes between approximately ¥3.7 million and ¥7.7 million
is about ¥400,000. The difference is covered by insurance premiums and taxes.
When asked about covering high-cost drugs with National Health Insurance, 20.4% of respondents
selected “support” and 58.0% selected “somewhat support” for a total of 78.4% of all respondents (Figure
10).

[Commentary]While awareness of the problem of high-cost drugs is high in the media and among the public, it is only
one issue facing the effort to balance innovation and sustainability in the healthcare system. Because drug
spending accounts for less than 20% of the total cost of healthcare, discussions on maintaining an effective
National Health Insurance system based on the value it provides to people receiving healthcare should
not only focus on the cost of drugs. Broad discussions that include the public on improving the overall
quality and efficiency of healthcare technologies and services are necessary.



Based on public support for high-cost drug coverage through National Health Insurance, we anticipate
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future public opinion surveys will cover issues related to that topic, such as the scope of insurance
coverage for retail drugs that contain the same effective ingredients as prescription drugs.

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(5) Antimicrobial resistance

About 40% did not know about antimicrobial resistanceRespondents were asked about their awareness of microbes for which antibiotics and antimicrobials are
ineffective (known as antimicrobial resistant bacterium). They were provided with three options: “I know
a lot about it,” “I have heard of antimicrobial resistant bacterium,” “I know nothing about it” (Figure 11).

The most common response was “I have heard of antimicrobial resistant bacterium” at 47.3% and theleast common response was “I know a lot about it” at 14.2%. Meanwhile, 38.6% of respondents selected“I know nothing about it” (Figure 11).

17Over half did not know that antimicrobials and antibiotics are ineffective for treating the common cold or
influenza

48.8% of respondents knew that antimicrobials and antibiotics are ineffective for treating the common
cold or influenza while 51.2% did not (Figure 12).

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

About 40% said they can ask doctors or pharmacists about the necessity of antimicrobials or antibiotics when
they are prescribed

Respondents were asked if they can question doctors or pharmacists on the necessity antimicrobials andantibiotics when they are prescribed. Respondents were given three options: “I can ask,” “I can ask when
prompted,” and “I cannot ask” (Figure 13).



The most popular response was “I cannot ask” (42.0%). 18.1% of respondents said they can ask and 40.0%
said they can ask when prompted (Figure 13).

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The more knowledgeable respondents were about antimicrobial resistance, the easier it was for them to ask
doctors and pharmacists about the necessity of antimicrobials and antibiotics


We split respondents into groups based on their response to the question, “Did you know that there aremicrobes (called antimicrobial resistant bacterium) for which antimicrobials and antibiotics are
ineffective?” and compared their ability to ask doctors or pharmacists about the necessity of
antimicrobials and antibiotics when they are prescribed.

Of the respondents that had knowledge of antimicrobial-resistant bacterium, 23.1% responded “I can ask”
and 43.8% answered “I can ask when prompted.” Fewer respondents among those who did not know
about antimicrobial-resistant bacterium selected “I can ask” (10.1%) and “I can ask when prompted”(26.7%) (Figure 14).

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On the topic of antimicrobial-resistant bacterium, respondents were most interested in the appropriate useof antimicrobials


Respondents were informed that the number of antimicrobial-resistant bacterium is increasing and that
this is becoming a significant problem in Japan and abroad. They were then asked to select what
information about antimicrobial-resistant bacterium interested them most (Figure 15).



The most popular response was “if antimicrobials are used inappropriately, they are less effective whentruly needed” (40.8%), followed by “antimicrobials are ineffective for common cold or influenza” (23.1%),“by using antimicrobials properly, the country can reduce overall national healthcare spending” (16.3%),
and “annually, approximately 700,000 people die due to antimicrobial-resistant bacterium” (13.2%)(Figure 15).

2190% have not seen the government’s AMR Action Plan educational materialWhen asked if they had ever seen educational materials published as part of the AMR Action Plan adopted
by the Japanese government in 2016, 90.5% of respondents said they had not (Figure 16).

[Commentary]

Based on the fact that antimicrobial-resistant strains cause approximately 700,000 deaths per year
worldwide, the WHO adopted the Global Action Plan for AMR in May 2015. Countermeasures inJapan are advancing after the enactment of the National Action Plan on AMR in April 2016.



As part of that effort, HGPI has united with related academic societies and citizen groups to form
AMR Alliance Japan, which has created policy proposals to promote AMR countermeasures.

On the topic of future activities and policy promotion, the survey showed that the public is not wellinformed about AMR. The more knowledge respondents had about AMR, the easier it was for themto question doctors and pharmacists about the necessity of antimicrobials and antibiotics. For thatreason, methods for effectively publicizing AMR information and for developing public recognition ofthis issue must be examined to enable more people to make accurate decisions on antimicrobials
and antibiotics.

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(6) VaccinesAbout 70% knew that vaccines use the immune mechanismRespondents were asked if they knew that vaccines work by using the immune mechanism to attack
pathogens that invade the body from outside. 70.2% knew while 29.2% did not (Figure 17).

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

About 69% of respondents knew that all vaccines, such as the influenza vaccine, can have side effects


69.4% of respondents knew that all vaccines have side effects compared to 30.7% who did not (Figure 18).

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

About 68% knew that immunity gained through immunizations can prevent the spread of infectious diseases
in a group even if someone in the group gets infected

67.8% of respondents knew that the spread of an infectious disease in a group can be prevented if many
people in that group are vaccinated and gain immunity (called “herd immunity”) while 32.2% did not(Figure 19).

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

About 70% of respondents did not know that HPV vaccine is effective at preventing HPV infection and theconditions that lead to cervical cancer.


32.0% of respondents knew about the Human Papillomavirus (HPV) vaccine’s ability to prevent HPV
infection and the conditions that lead to cervical cancer while 68.1% did not (Figure 20).

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

About 68% of respondents knew that rubella infection during early pregnancy can increase the child’s riskof being born with congenital rubella syndrome

67.7% of respondents knew that the risk of a child being born with congenital rubella syndrome is greater
if their mother does not possess adequate rubella immunity and is infected by rubella during earlypregnancy. 32.4% of respondents were unaware of this fact (Figure 21).

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

About 62% knew that rubella is currently spreading in Japan because there was a period when vaccination
for it was incomplete

61.9% of respondents knew that rubella is currently spreading in Japan because there was a period when
vaccination for it was incomplete. 38.2% of respondents were unaware (Figure 22).

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

About 30% would get vaccinated for rubella if their local government provided vaccination vouchers, while
about 27% want it included in yearly health examinations provided by employers


Respondents were asked what policy or type of support would make them want to get vaccinated forrubella if they were not already vaccinated. The most popular response was “if my local government
distributed vouchers for rubella vaccinations at healthcare institutions” (32.2%) followed by “if thevaccination was conducted as part of my employer's yearly health examination” (26.8%) (Figure 23).



10.7% of respondents selected “I want to be able to go for the vaccination during working hours, like theyearly health examination,” 9.6% replied “if I had opportunities to learn about the necessity of rubellavaccination and obtain accurate information about its side effects,” 6.1% selected “if National Health
Insurance provided a discount for rubella vaccination,” and 1.9% answered “if I could receive shopping
vouchers or coupons by getting the rubella vaccination” (Figure 23).

On the other hand, 12.8% of respondents did not think they needed to be vaccinated for rubella.

[Commentary]

About 70% of the public was aware that vaccines work by using the immune mechanism, thatvaccines have side effects, and about herd immunity. On the other hand, respondents knew very
little about HPV vaccination, which can lower cervical cancer rates. Although the government has
halted the active promotion of HPV vaccination, the public is unaware of HPV vaccination and its
effects and more and more people are unaware that the vaccine even exists. This creates the riskthat the number of people in the community with HPV will increase. Knowledge about vaccines
based on scientific evidence must be provided to the public at various places including in schools.
29

While the MHLW and local governments have been proactively publicizing information about the
rubella vaccine, some still do not believe they need to be vaccinated for rubella. This shows thatfurther efforts to develop public recognition of the necessity of rubella vaccination are necessary.
Incentives should be provided to encourage the public to get the vaccine, such as vaccination
vouchers and vaccinating during annual health examinations.

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Ⅴ．“2019 Survey on Healthcare in Japan” survey team
(Titles omitted, in alphabetical order by last name)Yuko Imamura (Senior Associate, Health and Global Policy Institute)
Hiroko Nishimoto (Manager, Health and Global Policy Institute)
Kenji Kawabata (Part-time Lecturer, Tokyo University of Science)
Yukiko KAWATA (Program Specialist, Health and Global Policy Institute)
Kento Suzuki (Intern, Health and Global Policy Institute)
Akane Koyama (Intern, Health and Global Policy Institute)
Matt McEnany (Manager, Health and Global Policy Institute)
Ryoji Noritake (CEO, Board Member, Health and Global Policy Institute)

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Health and Global Policy InstituteOtemachi Financial City Grand Cube 3F, 1-9-2 Otemachi, Chiyoda-ku, Tokyo, 100-0004 JAPAN
Tel: 03-4243-7156 Fax: 03-4243-7378 E-mail:info@hgpi.org
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