Journal of the National Institute of Public Health2013 Vol.62 No.1 p.46−51

Topics：Strategic management of evidence-based health and medical care policy: How to use new Digital Big Data in health care system＜Review＞
Establishing medical care zone from residents perspectives:
The accessibility of critical care in Kanagawa Prefecture and Iwate
Prefecture as case studies
Eiji SATOH１），Toshiro KUMAKAWA２）
１）
２）

Graduate school of Engineering, Utsunomiya University
Department of Health and Welfare Service Research, National Institute of Public Health

Abstract
In Japan, medical facilities are broadly divided into 3 categories: facilities established by public
administration such as country or prefecture, public medical facilities complied with publicadministration established facilities, and private medical facilities. When paying attention to the locationof these facilities, it is notable that the facilities in the first two categories are located in the central areaor frontier province by national policy, while the location of private medical facilities are associated witheconomic activities. However, in today’s Japan, the national medical facilities are being forced tointegrate or discontinue due to impairment of social capital.
Taking such situation into account, in order to secure equity in medical service for public, this study
conducts a fundamental investigation through capturing the location of medical facilities that actuallyshould be improved by national policy.
A relationship between the location of medical facilities and the residents receiving medical service
was analyzed in integrated way using GIS (Geographic Information System). In this paper, bycomparing the location of medical facilities in Kanagawa Prefecture and Iwate Prefecture, the service
system of medical facilities in the big city and provincial city is discussed.
As a result, it became evident that there is a difference in medical service system between the cities.
At the same time, there is also a significant difference between the systems within each city. For
example, about the emergency medical, there are 50 km or more of differences of the range to a
hospital between Kanagawa Prefecture and Iwate Prefecture.
This paper considers a tentative plan for national medical service system.
keywords: accessibility, the location of medical facilities, evaluation of a wide area, network distance(accepted for publication, 17th January 2013)

I.

Introduction

In Japan, medical facilities are broadly divided into: (1)facilities established by public administration such ascountry or prefecture; (2) public medical facilities compliedwith public administration established facilities; and (3)private medical facilities. When paying attention to thelocation of these facilities by category, it is notable that thefirst two categories are located in the central area or
frontier province according to the national policy, while thelocation of private medical facilities are associated with theeconomic profitability. The development of equal welfare
medical service that is not in line with the economic
activities has been conducted as the national policy in thepostwar Japan.

Corresponding author: Eiji Satoh
7-1-2 Yoto, Utsunomiya-shi, Tochigi-ken, 321-8585, Japan.
E-mail: e-satoh@cc.utsunomiya-u.ac.jp

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Establishing medical care zone from residents perspectives: The accessibility of critical care in Kanagawa Prefecture and Iwate Prefecture as case studies

However, in today’s Japan, the national medical facilities
are being forced to integrate or discontinue due toimpairment of social capital associated with a declining
population. While many problems have been pointed out,
the factors associated with such phenomenon include thepolicy to control the medical expense due to the worseningof fiscal conditions, the loss of medical liaison between
medical education institutions and regional/rural hospitals
caused by the reformation of doctor dispatch system
including for residents, insufficiency in healthcare
personnel, and also imbalanced medical needs and medical
resources caused by widening disparity of population andage group by area. In some areas, the medical system suchas emergency medical services and perinatal care havealready collapsed, increasing strain on the surrounding
municipals and creating a chain reaction of medical systemcrash.
One of the fundamental factors of these problems is alack of perspective in the followings; a management concept
in designing a medical system, a placement of medical
institutions that meets the function of hospitals andintended users, and the regional difference in the “value” ofmedical remuneration points.
Japan is currently trying to find a new medical service
system and an efficiency-oriented method to correspond tothe changed or rapidly changing social structure. As one of
the index to consider the sustainability of medical system inthe future, the evaluation and measurement of a
relationship between medical institutions and their users issuggested.
For evaluation and measurement, various methods havebeen established through the advanced information
technology of recent years [1-3]. Different social phenomenon
can be quantified which was not possible in the past.
Therefore, based on the idea in previous report [4], a
relationship between medical institutions and users isevaluated and measured by a simple physical distance(spatial accessibility) in this paper. Medical care zone isconsidered based on this evidence.
Practically speaking, when considering healthcaredelivery and its convenience in case of emergency, it
becomes necessary to analyze time distance along withspatial distance. In order to calculate this, the first step is tocalculate spatial distance. Looking toward the constructive
research, this paper first deals with physical distance,
which is the most fundamental.

II. Spatial accessibility
The accessibility discussed in this paper is simple andphysical distance (spatial distance) between medical
institutions and users. The user of medical service isdefined as someone who is able to use medical institutions.
Therefore, this paper does not specify users based on theactual record of the present moment such as people
currently receiving medical care or actual usage condition.
Instead, every resident in the area is included as a potentialuser. Also, at the time of visiting a medical institution, aperson essentially decides a destination based on multiple
factors such as the size of hospital, its reputation or travel
route. However, this paper considers the placement of
medical institutions that meets minimum requirements.
Therefore, based on the simplest model in which users
choose to go to the closest medical institution, the physicaldistance to medical institution is measured.
The measurement method is as follows. For themeasurement, GIS (Geographic Information System) wasused. The target area is entire Kanagawa Prefecture andIwate Prefecture. The outlines of both prefectures areshown in Figure 1.
1．Assessing the location of medical institutions
The location of target medical institutions was assessed.
Referring to the disclosed addresses, the location bydifferent medical department was confirmed. In this paper,
only the critical care is shown from the variousmeasurements.
2．Setting of users
Considering the preconditions as described previously,
although the residence of users must be confirmed tomeasure the distance to users in a precise sense, it isdifficult. Also, by using the result of urban planningbaseline survey that includes building classification such as

Table 1 the Outline of Target region

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Eiji SATOH， Toshiro KUMAKAWA

detached houses, collective housings, stores and businessoffices, it is possible to create virtual urban space in GIS
where the population is allocated to buildings in adispersive manner that proportionally distribute thepopulation of relevant address to the gross floor area of
each residences. However, the information in the urban
planning baseline survey is only for metropolitan areas andurban area. If the entire country is a measurement target or
the regions are outside of metropolitan areas, theinformation is not available. Therefore, for the analysis of
this paper, the basic unit block data from the National
Census in 2005 is used to grasp the level of concentration in
the district of residence, and analysis is made on the virtualurban space.
3．Measurement of distance
In Japan, there have been many arguments about medicalcare zone related to the location of medical institutions andaccessibility of residents. Most of the analysis in medicalcare zone has been conducted by measuring therelationship between medical facilities and their users withstraight-line distance, or by outlined distance in which thepopulation is concentrated in median point of area.
However, through such a method, it is difficult to fully
understand the actual state of accessibility of residents tothe medical institutions. Therefore, in this paper, the virtual
urban space mentioned above and the actual road network
were incorporated to measure the distance between
medical institutions and users by a road distance that isclose to the actual traveling distance. For the road network,
the numerical map25000 from 2002 was modified to create
the original road network that includes the newly
constructed roads in recent years.

III. Analysis result
The relationship between the distance to critical care andusers in both prefectures are shown in Figure 1 and 2. In
Figure 1 and 2, the distance is the horizontal axis andvirtual number of users who live in the distance zone is thevertical axis. Also, Figure 3 and 4 show the distribution ofdistance zone around the critical care medical facilities.
A comparison of two graphs clearly shows a majordifference in the healthcare provision system between theFigure 1 the Result of IWATE Pre.

Figure 2 the Result of KANAGAWA Pre.

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Establishing medical care zone from residents perspectives: The accessibility of critical care in Kanagawa Prefecture and Iwate Prefecture as case studies

cities. There is a difference in distance to the emergency
hospitals for users, which is within 48km for Kanagawa
Prefecture and about 100km for Iwate Prefecture.
Moreover, for the population in each distance zone, themaximum number of Kanagawa Prefecture is 0.61 million
people while it is about 33,000 people for Iwate Prefecture.

IV. Discussion
 Medical Service System as a National Policy
In order to secure equity in medical service for public as anational policy, it is necessary to reduce the distancedifference between these prefectures. In regional
prefectures with many mountains like Iwate Prefecture, it isnecessary to have many medical facilities due to limited
roads through the mountains. However, this method is notrealistic considering the current situation in Japan where
the social security payments will decrease in the future.
Instead of placing medical facilities, it is essential to provide
an emergency medical service system without a centersuch as an ambulance or a helicopter emergency medicalservice. However, this does not mean continuous capabilityof providing emergency medical service. There has been anargument that it is necessary to consider finding balance inthe finite social security payments and spatial development
such as a policy for shrinking cities or inducing residencearea.

Figure 3 the Visualized Result of IWATE The Significance of Medical Center
The comparison between Kanagawa Prefecture and Iwate
Prefecture shows an enormous difference in the intended
resident population for one medical center. It is about
754,000 people in Kanagawa Prefecture and about 443,000
people in Iwate Prefecture, showing obvious difference. In
the current Japanese medical system, the number ofmedical facility users instead of intended residents
population determines the significance. However, due to aFigure 4 the Visualized Result of KANAGAWA

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Eiji SATOH， Toshiro KUMAKAWA

major difference in the initial intended population, thesignificance of medical centers with less intended
population will decrease if the event probability of people inneed for emergency medical care is the same. In Figure 3,the significance of medical centers in Iwate Prefecture isshown with an indication that every center plays animportant role and shutting any of them down will cause aproblem. Therefore, it is necessary to make some kind ofcorrection to the evaluation of medical centers such as amajor correction on the additional local rates, which does
not depend on medical service fee.

V.

accessibility in somewhat businesslike manner or quantitative
way is considered beneficial. When examining medical
resource distribution, provision method of service thattakes the city structure into account and the their costeffective, it is possible to make evaluation and analysis
based on the evidence.

Acknowledgement
This research was financially funded by the Grant-in-Aidfor Scientific Research (KAKENHI) of Japan (Grant No.
23249029).

Conclusion
References

In this paper, through evaluating the emergency medical
service system of Kanagawa Prefecture in the metropolitan
area and Iwate Prefecture in the provincial area by distance,
the following issues were clarified based on the numericalevidence.
 In the provincial area with weak medical service
system, it is necessary to develop a service without
medical centers instead of improving service standards
by facilities.
 It is necessary to redress the evaluation standards ofexisting medical centers.
 Discuss the balance in spending of the social security
payments and spatial development.
Finally, in order to show a path toward solving theproblem, evaluating the location of medical facilities by50

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Establishing medical care zone from residents perspectives: The accessibility of critical care in Kanagawa Prefecture and Iwate Prefecture as case studies

住民視点による医療圏の設定―神奈川県と岩手県の３次救急のアクセシビリティを事例に―抄録
現在の日本では，人口減に連動した社会的資本の減少から，国策による医療施設が，統合，廃止に追い込まれる状況にある．それらの背景には，財政悪化に伴い医療費抑制政策がとられる一方で，研修医を含む医師派遣制度の変革による医療教育機関と地域・地方病院との医療提携の喪失，医療従事者の不足，また地域の人口及び居住者年齢層の格差の拡大に伴う医療ニーズ／医療資源の不均衡など数々の問題が指摘されている．すでに一部地域においては，救急医療や周産期などの医療体制が瓦解し，その周囲の自治体に負担が増すという医療システム崩壊の連鎖が生じている．これらの問題の根幹のひとつには医療制度の設計に際しての経営の概念，病院の機能と利用予測に即した医療機関配置，医療点数の「価値」の地域差，といった視点が欠落していることが挙げられる．
我が国はいま，変化した，または急速に変化しつつある社会構造に対応し，かつ効率性が重視された新たな医療提供体制及びその手法を模索している段階だと言える．今後，医療システムがいかに持続しうるかを考えるための一つの指標として，医療機関とその利用者の関係を評価・測定することが挙げられる．
評価・測定においては，近年の情報技術の発達により様々な手法が確立されつつある．従来数値化できなかった種々の社会現象を数値化することが可能である．
そこで本稿においては，医療機関と利用者の関係を，単純で物理的な距離（空間的アクセシビリ
ティ）によって評価・測定し，それを基底としたエヴィデンスに基づく医療圏を考究する．
キーワード：アクセシビリティ，医療施設立地，広域評価，道路距離佐藤栄治１），熊川寿郎２）
宇都宮大学大学院工学研究科
２）
国立保健医療科学院医療・福祉サービス研究部
１）

J. Natl. Inst. Public Health, 62（1）: 201351