保健医療科学

2021

Vol.70 No.1 p.13－21

Topics: Recent topics in public health in Japan 2021

＜ Review ＞
Human resources of health for universal health coverage in Japan:
in the era of COVID-19
KODAMA Tomoko
Department of International Health and Collaboration, National Institute of Public of Health
Abstract
Japan has achieved universal health coverage in 1961. Although Japan’s medical human resources are
becoming sufficient in terms of quantity, there is a need to address the uneven distribution and to improve
the quality of human resources. In recent years, there has been renewed interest in the role of public healthpersonnel in responding to health crises such as disasters and emerging infectious diseases including the
COVID-19 infection. Countries need to consider to build a tight network between public health and thehealthcare delivery system, and also to establish a dual track health system utilizing limited human resources while maintaining normal medical care in response to medical emergencies.
keywords: Human resources, universal health coverage, public health, health crisis, COVID-19(accepted for publication, December 22, 2020)

I. Introduction

view describes recent trends and future issues confronting
current health care human resources in Japan.

Human resource sufficiency in the health sector is aprerequisite to achieving SDG (Sustainable Development
Goals) 3.8, namely, ”Achieve universal health coverage, including financial risk protection, access to quality essential
health-care services and access to safe, effective, quality
and affordable essential medicines and vaccines for all”
which is to be achieved by 2030 [1]. In Japan, as medicalcare becomes more sophisticated with the advancementof medical technology, the use of IT advances, and older
population increases, various issues are expected to arise
in medical human resources in the future. In addition,
emerging infectious diseases such as COVID-19 will require a response to health crisis management. To provide
high quality health care services to all people with limited
human resources, it is necessary to deal with the uneven
distribution of health care workers in different regions, todivide the service tasks, and to have a continuous educationand training system, which are common issues in the world,
including both developing and developed countries. This re-

II. Sanitation administration and human resources in Japan
1. Progress of sanitation administration
Japan’s sanitation administration system began with theestablishment of the Medical Affairs Division of the Ministry of Education in 1872. The prototype of the present
public health center dates back to 1874. It handled sanitaryadministration, medical affairs, pharmaceutical affairs, public health, and medical education[2]. The biggest issue inpublic health administration during this period was the control of infectious diseases, such as cholera, typhoid fever,dysentery, diphtheria, rash typhus, and pox. Local hygiene
administration was incorporated into policy administration,and various environmental sanitation regulations were developed.
In 1937, with the enactment of the (former) Public HealthCenter Law, Japan’s first public health center was estab-

Corresponding author: KODAMA Tomoko
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
Tel: 048-458-6150
Fax: 048-469-2768
E-mail: kodama.t.aa@niph.go.jp

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KODAMA Tomoko
lished with the aim of eradicating tuberculosis and improving maternal and child health. Public health centers werethen given the functions of health counseling and healthguidance in 1947 in addition to administrative functions, andwere positioned as central institutions for the improvement
and promotion of public health in the community.
In recent years, with the declining birth rate and aging
population, changes in the structure of diseases, especially lifestyle-related diseases, and diversification of local
residents’ needs, public health administration has beenrequired to emphasize the perspective of individual habitants. Therefore, the Public Health Center Law was revised
and renamed the Community Health Law in 1994. Thislaw reviewed the division of roles between prefectures andmunicipalities and established a new community health system.
2. Current sanitation administration and human resources
The various activities of hygiene administration can bebroadly classified into four categories, namely, 1) general hygiene administration; targeting life in the home andcommunity, 2) school health administration, 3) occupational
health administration, and 4) environmental health administration. The basic system of general health administrationin Japan has been established by the national government(Ministry of Health, Labour and Welfare), prefectures(health administration departments), public health centers,
and municipalities (health administration sections), withpublic health centers and municipal health centers as thebases of activities. (Figure 1)
Public health centers are institutions that play a central
role in public health activities such as disease prevention,
health promotion, and environmental sanitation (Table 1).
The number of public health centers in Japan, which was
848 at the time when the Community Health Act was enacted in 1994, has gradually been consolidated based on theprinciple of matching areas defined as secondary medicalcare areas or long-term care insurance support plans, andthe number has decreased to 469 as of April 2020 [3].
There is a huge difference in the number of full-time staff
per 1,000 population by prefecture (Figure 2). Prefectureswith large cities, such as Tokyo, Osaka, and Kanagawa, havean extremely small numbers of health center staff per 1,000
people. These densely populated areas are therefore forced
to implement public health administration through different

Figure 1 Public Health Administration System

Table 1 Services provided by health centers as stated in the Community Health Law① Dissemination and improvement of ideas concerning community health② Demographic statistics and other statistics related to community health③ Improvement of nutrition and food hygiene④ Housing, water supply, sewerage, waste disposal, cleaning, and other environmental sanitation⑤ Medical and pharmaceutical affairs⑥ Activities performed by public health nurses⑦ Improvement and promotion of public health services⑧ Maternal, infant, and elderly health⑨ Dental health⑩ Mental health⑪ Health care for people who need long-term treatment due to diseases for which there is no established treatment method or otherspecial diseases⑫ Prevention of AIDS, tuberculosis, venereal diseases, infectious diseases, and other diseases⑬ Hygiene testing and inspections⑭ Maintenance and promotion of the health of other local residents
Specific examples of health center operations reported among COVID-19 measures
Consultation centers for returnees and contacts established at public health centers
Coordination of consultations with outpatient clinics for returnees and contacts
Transport of specimens to local health laboratories
Administrative inspections (PCR tests)
Explanations and negotiations with medical institutions and coordination meetings
Information sharing with and advice to municipalities
Active epidemiological surveys (including cluster measures)
Daily monitoring of the medical condition of hospitalized (or home-based) patients
Liaison and coordination between medical institutions in the event of a positive patient outbreak, etc.

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Human resources of health for universal health coverage in Japan: in the era of COVID-19

Figure 2 Number of full-time health center staff per 1,000 population by prefecture
Table 2 Numbers of full-time and part-time staff employed by health centers and municipalities in FY 2018.
Full-time
907
123
2,463
3,186
26,342
175
726
89
145
101
699
471
4
701
44
3,542
332
15,56955,619ｎPart-time*
49,51824,005
12,312
5,973
388,124
139,471
341,262
27,0892,229
2,738
145,868
5,436
229
13,9091,246
158,841
52,047
842,794
2,213,091

n/1000 population
Full-time Part-time*
0.007
0.388
0.001
0.188
0.019
0.096
0.025
0.047
0.206
3.039
0.001
1.092
0.006
2.672
0.001
0.212
0.001
0.017
0.001
0.021
0.005
1.142
0.004
0.043
0.000
0.002
0.005
0.109
0.000
0.010
0.028
1.244
0.003
0.408
0.122
6.599
0.436
17.329Part-time/Full-time ratio
Physicians
54.6
Dentists
195.2
Veterinarians
5.0
Pharmacists
1.9
Public Health Nurses
14.7
Midwives
797.0
Nurses470.1
Assistant Nurses
304.4
Physical Therapists
15.4
Occupational Therapists
27.1
Dental Hygienists
208.7
Medical Radiation Technicians
11.5
Medical X-Ray Technicians
57.3
Clinical Laboratory Technicians
19.8
Medical Laboratory Technicians
28.3
Registered Dietitians
44.8
Nutritionists
156.8
Others
54.1
Total
39.8
(Re-listed)
Mental Health Welfare Practitioners
929
19,385
0.007
0.152
20.9
Mental Health Welfare Counselors
1,203
0.009
ー
Nutrition Advisors
1,062
0.008
ー
Food Sanitation Inspectors
5,758
10,971
0.045
0.086
1.9
Environmental Health Inspectors
5,104
13,157
0.040
0.103
2.6
Medical Inspectors
9,076
12,204
0.071
0.096
1.3
＊Total number attending work
Source; Report on Regional Public Health Services and Health Promotion Services. Ministry of Health, Labour and Welfare

mechanisms than other prefectures.
There are various occupations such as physicians, dentists, pharmacists, veterinarians, radiologists, clinical laboratory technicians, dietitians, and public health nurses, whoare engaged in their duties at public health centers (Table 2).
Public health nurses account for the largest number of bothfull-time and part-time employees. The ratio of part-time
vs full-time is the highest for midwives, who are supposed

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KODAMA Tomoko
to be engaged in mother and child health projects. The
percentage of medical qualification holders such as physicians, nurses, midwives, etc. is small among full-time staff
because medical procedures excluding vaccinations andblood collection are not conducted at public health centersin principle.
The number of physicians at public health centers is 907,
which has slightly increased from 891 in the previous year.
According to the Community Health Law, the director of apublic health center is required to be a physician who has
been engaged in public health practice for at least three
years, or who has completed a training course at the National Institute of Public Health [4], or the director’s skills
and experience must be comparable to those of a physician (Article 4, Paragraph 1 of the Order for Enforcementof the Community Health Law). Although the number ofphysicians engaged in public health has slightly increased
in recent years, the 2018 survey shows that 4,106 (1.3%)
were engaged in administrative, industrial, and publichealth work. Therefore, the Order for Enforcement of the
Local Public Health Law stipulates that in cases where itis extremely difficult to secure a physician, a technical staff
member who is recognized to have the expertise necessary
for public health administration equivalent or superior tothat of a doctor may be appointed as the director of a publichealth center for a period of two years or less.
There are local health research institutes in most prefectures and designated cities. They conduct various tests andexaminations, collect, analyze, and provide public healthinformation, conduct surveys and research, and provide
training and guidance to improve public health. The total
number of full-time employees is reported to be 2.9 per
100,000 people in 2012, with disparities across the country
depending on the size of the local government [5].
A municipal health center is an organization that pro-vides comprehensive interpersonal health services such as
health counseling, health examinations, and health guidance
to local residents that is mainly operated by public healthnurses. While the public health center is a wide-area, specialized, and technical center for community health, themunicipal health center plays a role as a comprehensive
center for health promotion at the municipal level [3]. The
most employees are public health nurses, amounting to
26,000 full-time staff in health centers and municipalities
nationwide. Public health nurses perform diverse tasks,
and the content of their work varies depending on theirposition (Figure 3). Half of the work of municipal publichealth nurses concern health and welfare services, while ahigher proportion of their work concerns communication
and administration, district management, and coordination
education and training services in prefectural public healthcenters. The activities of public health nurses have changed
and expanded over time, and in 2013, a notice from the
Ministry of Health, Labour and Welfare clarified the roles ofpublic health nurses affiliated with prefectural health centers, municipalities, and these main offices.

III. Human resources involved in the provision of medical care
Since Japan achieved universal health coverage in 1961,
it has maintained a system that provides medical care to all
people. The UN’s Universal Health Coverage sets thresholds of hospital access and medical personnel (physicians,
psychiatrists, surgeons) per population as follows; 18 beds
per 10,000 population, Physicians 0.9 per 1,000 population,
psychiatrists 1 per 100,000 population, surgeons 14 per
100,000 population [1]. These indicators are significantly
higher in Japan as in other high-income countries.
In Japan, the “National Medical Service Law” enacted

Figure 3 Activities performed by Public Health Nurses

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Human resources of health for universal health coverage in Japan: in the era of COVID-19
in 1941 clarified for the first time the distinction between
hospitals and clinics (10 or more beds are considered ahospital). Although the government injected public funds
and promoted the establishment of a large number of medical institutions across the country, this did not solve theshortage of medical care at the time. At the end of the war
in 1945, the medical supply system was in a state of complete destruction, and the Medical Service Act was newly
enacted in response. The Medical Service Act was enacted
in 1948, and Article 1 states, “The purpose of this Act is tocontribute to the maintenance of the health of the people byensuring a system for the supply of medical care throughthe establishment and management of hospitals, clinics, andmidwifery clinics, and by providing for the necessary matters to promote the development of these facilities” [6]. In
the post-war period of devastation, the number of infectious
diseases increased and the main focus was on acute patientswith those diseases. There was an urgent need to improve
the quality of medical institutions and the facility standardsof hospitals to ensure a proper level of medical care.

IV. Securing the number of physicians
The numbers and ratio of registered medical professionals employed nationwide (per 100,000 population) are
shown in Table 3. The number of physicians in Japan at
the end of 2018 was 327,210 (258.8 per 100,000) according
to the survey of individual reports in the national survey,
and 246.7 per 100,000 according to the survey of medical
facilities, which is lower than 350 per 100,000, the OECDaverage for practicing physicians [5]. Countries with similar
numbers of physicians as Japan were Canada at 272, US at
261, and South Korea at 239 per 100,000, respectively andcountries with higher numbers were Austria at 5.24, Norway at 4.81, Switzerland at 4.34, and Denmark at 4.19 per1000 population, respectively [7].
The sufficiency of physicians depends on changes in thesocial and medical environment, but in recent years there
has been a debate about a shortage of physicians. With theincreasing sophistication and specialization of medical care,it has become more difficult for one physician to remain
updated in various fields and divisions. The long working
hours of physicians has become a serious problem and it has
become more difficult to balance work and family life. Thisis due in part to the recent increase in the number of female
physicians, who have left the profession due to childbirthand childcare [8]. An increased demand has also been pointed out, namely, an increasing number of patients wishing toreceive medical care on holidays or at night and requesting
to visit major tertiary hospitals and specialists. Further, theincreasing number of documents that physicians need tofill out and the increasing number of medical disputes also
annoy physicians.
In light of this situation, the Ministry of Internal Affairs
and Communications (MIC), the Ministry of Education,
Culture, Sports, Science and Technology (MEXT), and theMinistry of Health, Labour and Welfare (MHLW) formulated the New Comprehensive Measures to Secure Doctors
in 2006, and these included the creation of base hospitals
for pediatrics and obstetrics, the establishment of networks
among medical institutions, and the further disseminationof a pediatric emergency telephone consultation service [9].
In 2008, the MHLW stated its “Vision for Securing Safe andHopeful Medical Care” and proposed measures to increase
the number of physicians[10].
To improve the quality of physicians, the MHLW Ordinance on clinical training was revised in 2009, and it
strengthened the criteria for designating clinical training
hospitals and set conditions for the recruitment capacityof interns by local governments (prefectures) to reduce an

Table 3 Number and ratio of registered medical professionals employed nationwide(per 100,000 population)n
per 100,000 population
Physicians
327,210258.8*
Dentists
104,908
83.0
Pharmacists
311,289
246.2
Public Health Nurses
52,955
41.9
Midwives
36,911
29.2
Nurses
1,218,606
963.8
Licensed Practical Nurses
304,479240.8
Dental Hygienists
132,629
104.9
Dental Technicians
34,46827.3
Anma Massage Shiatsu Practitioners
118,916
94.0
Acupuncturists
121,757
96.3
Moxibustion Therapists
119,796
94.7
Judo therapists
73,017
57.7(Source: Survey of Physicians, Dentists and Pharmacists and Health Administration Reports in FY
2018. Ministry of Health, Labour and Welfare)*The number of practicing physicians is 246.7 according to the National Survey of Medical Institutions.

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KODAMA Tomoko
Table 4 Employers of physicians, dentists, and pharmacists

Hospitals
Clinics
Health care facilities for the olders
Government
Industrial physicians
Health and sanitation services
Pharmacies
Pharmaceutical companies

Physicians
n=327,210
208,127（63.6％）
103,836 (31.7%)
3,388 (1.0%)
1,835 (0.6%)
1,231 (0.4%)
1,040 (0.3%)-

Dentists
n=104,908
11,672 (11.1%)
90,105 (85.9%)
34 (0.0%)314 (0.3%)
59 (0.1%)-

Pharmacists
n=311,289
54,150 (17.4%)
5,806 (1.9%)816 (0.3%)
6,661* (2.1%)
180,415 (58.0%)
41,303 (13.3%)(Source) Survey of Physicians, Dentists, and Pharmacists in FY 2018.
*Includes the government

uneven balance of physicians. The report compiled in 2018stated that (1) the recruitment capacity should be reviewed,(2) regional quotas should be addressed, and the role ofprefectures should be strengthened, (3) achievement targets, strategies, and evaluations should be reviewed, and(4) core clinical training hospitals should be enhanced andstrengthened (starting from 2020)[11]. In addition, basedon the amendment of the Medical Practitioners Act in 2018,the authority to designate clinical training hospitals andto set the recruitment capacity of clinical interns in theprefecture was transferred to local government to secure
physicians. The current number of clinical training hospitals is 2,553, and the number of residents enrolled is 18,179(including 11,156 at clinical training hospitals and 7,023 atuniversity hospitals) [12]. In 2018, the MHLW expressed
opinions to the Japan Medical Specialists Organization and
18 academic societies to secure training opportunities forresidents according to the revised Medical Service Act andMedical Practitioners Act to improve an uneven distributionof specialists. With the new medical specialist system, an
upper limit (ceiling) is set on the number of major specialty
areas of physicians recruited in the five large cities (Tokyo,
Kanagawa, Aichi, Osaka, and Fukuoka).
Table 4 shows the employers of physicians, dentists, andpharmacists. While 60% of physicians work in hospitals and
30% in clinics (or establishments), 86% of dentists work inclinics and 58% of pharmacists work in pharmacies. These
data show that dentists working in hospitals, for example,
represent a minority in the dental profession, but their actual working conditions in hospitals are similar to those ofphysicians[13].

V. Human resources to respond in an emergency situation
The national disaster prevention and response system
is implemented in accordance with the Disaster Countermeasures Basic Act. Based on this Act, the MHLW has formulated the Disaster Prevention Work Plan (2019), which18envisages preventive (disaster prevention) measures,
emergency measures, and recovery and reconstruction
measures related to healthcare, welfare, and daily hygiene.
In particular, the notification stated that it is advisable toseek human support to assist the Health Care Coordination
Headquarters in its work when it is deemed necessary[14].
Therefore, the Disaster Health Emergency AssistanceTeam (DHEAT) was designed to support the smooth implementation of information collection, analysis, and overall
coordination necessary for health crisis management conducted by the public health coordination headquarters of thedisaster-affected prefectures [15]. DHEAT is a public support team operated by staff members of other prefectures
than the disaster-struck one who have undergone specialized training and education to support the smooth implementation of information collection, analysis, and overall
coordination necessary for health crisis management by the
public health coordination headquarters and the health centers of a disaster-struck prefecture.
The recent case of COVID-19 infection reminded us of
the need for collaboration between the health administration and the medical care-providing bodies in the community. Public health centers play a major role in preventing the
spread of infection.
To reduce the workload on public health centers and to
speed up the sharing and understanding of information,
Health Center Real-time Information-sharing System on
COVID-19 (HER-SYS) has been developed and introduced
as an emergency response by the MHLW [16]. By using
this system, information can immediately be shared among
related parties such as public health centers, local governments (other departments than the public health centers),
medical institutions, and contractors for related work. Dueto the spread of COVID-19 infection, public health centers
are still short-staffed and further urgent action is needed.
The MHLW, in cooperation with the IT Office of the
Cabinet Secretariat, has established the Information andTelecommunications Infrastructure Center (Gathering
Medical Information System on COVID-19: G-MIS) to col-J. Natl. Inst. Public Health, 70 (1) : 2021

Human resources of health for universal health coverage in Japan: in the era of COVID-19
lect information from medical institutions (approximately
8,000 hospitals with 20 or more beds) nationwide, including
the status of hospital operations, hospital beds and medical
staff, and the availability of medical equipment (e.g., ventilators) and medical materials (e.g., masks and protective
clothing). It is expected that this information site will beutilized for the supply of goods (masks, etc.) and to coordinate the transport of patients, thereby helping to secure thenecessary medical care system. The development of such anationwide information system will reduce human labor andplans can be made for the deployment of valuable humanresources.

VI. Conclusion
Japan has achieved universal health coverage in 1961. Although the quantity of Japan’s medical human resources isapproaching a sufficient number, it is necessary to addressan uneven distribution and to improve the quality of thehuman resources. In recent years, there has been renewedinterest in the role played by public health personnel when
responding to health crises such as disasters and emerging
infectious diseases including COVID-19 infection. Countries have to consider building a tight network between the
public health and the healthcare delivery systems and toalso establish a dual track health system utilizing limited
human resources who maintains routine medical care while
responding to medical emergencies.

Acknowledgment
This research was supported by Health Labour Sciences
Research Grant (20BA1001), the Ministry of Health Labourand Welfare, Japan.

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stf/seisakunitsuite/bunya/0000121431_00129.html (inJapanese) (accessed 2020-11-13)

J. Natl. Inst. Public Health, 70 (1) : 2021

Human resources of health for universal health coverage in Japan: in the era of COVID-19＜総説＞
コロナ時代におけるユニバーサルヘルスカバレッジに向けた人材育成
児玉知子
国立保健医療科学院国際協力研究部

抄録
日本は1961年に国民皆保険を達成した．我が国の医療人材は量的には十分なものになりつつあるが，現在はその偏在への対応や人材の質の向上が求められている．近年，災害などの健康危機やCOVID-19感染症をはじめとする新興感染症への対応における保健医療人材の役割が改めて注目されている．各国は，公衆衛生と医療提供システムの緊密なネットワークを構築するとともに，医療緊急時には通常の医療を維持しつつ，限られた人的資源を活用したデュアルトラック型の医療システムの構築を検討する必要がある．
キーワード：人材，国民皆保険，公衆衛生，健康危機，COVID-19

J. Natl. Inst. Public Health, 70 (1) : 2021

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