Journd of the National Institute of Public Health 2010 Vol. 59 No. 1 p.43−50

Topic：Health Care System as Social Common Capital〈Review〉
Accessibility in the Community Healthcare System
Eiji SATOH
Assistant Researcher, Department of Facility Science, National Institute of Public Health

Abstract
Japan is seeking a new system and method for providing efficiency-based healthcare in order to cope with changes in thesocial structure. As a means of discussing ways to maintain our healthcare system, a relationship between healthcare facilities
and users should be evaluated and measured so it can be used as one kind of barometer. Having medical facilities in accessible
locations is the lifeline for the healthcare system. In order to establish a stable healthcare system, it is significant to secureaccess within a certain space and time distance.
Therefore, the first step of this study is to evaluate and analyze the relationship between healthcare facilities and users
through simple physical distance（space accessibility）, and then consider the healthcare system as “Social Common Capital”.
keywords: accessibility, physical distance, network distance, GIS（accepted for publication, 10th Feb. 2010）

Japan is seeking a new system and method for providing

Ⅰ．Introduction

efficiency-based healthcare in order to cope with theToday, the healthcare system in Japan is facing achanges in the social structure. As a means of discussing

major transition period from many different aspects.

ways to maintain our healthcare system, a relationshipDue to the nation’s financial deterioration, the government

between healthcare facilities and users should be evaluatedhas been taking a restrictive policy on healthcare

and measured so it can be used as one kind of barometer.

expenditure. Meanwhile, a number of issues have been

The placement of healthcare facilities is conducted

pointed out; a loss of healthcare affiliation between

in diverse ways: Public healthcare facilities provide

medical education institutions and regional/rural hospitals

healthcare, comfort and safety as social welfare. Privatecaused by the reformation of the doctor and intern

healthcare facilities provide community-based healthcare as

dispatch program, an insufficient number of healthcare

well as business based. From a viewpoint of “Social

professionals,

andCommon Capital”, with its high expectations for stability

resources owing to the widening gap in regional populationand great social significance, we must pay special attention

and age group of residents. In some regions, healthcare

to “healthcare as social welfare”. In some cases, healthcare

systems such as emergency medical and perinatal services

facilities are placed in areas with many residents. In otherhave been falling apart. Local government is undercases, many residents happen to live in an area withincreasing strain because of the collapse of the healthcare

healthcare facilities. Therefore, the location of healthcare

system. One of the fundamental issues of this phenomenon

facilities and the expansion of residential areas cannot be

is a lack of perspective such as management concept in

explained as a simple or one-sided correlation. However,designing the healthcare system, placement of medical

having medical facilities nearby residential areas is anfacilities based on hospital function and estimatedapproved requirement of a healthcare system as it must

utilization, and the regional difference on medical treatment

provide emergency care for acute injury and illness,fee “value”.

treatment and control of chronic illness and healthdisproportionate

healthcare

needs

2-3-6 Minami, Wako-shi, Saitama 351-0197, Japan.
E-mail：e-satoh@niph.go.jp

J. Natl. Inst. Public Health, 59（1）: 201043

Accessibility in the Community Healthcare Systemmanagement with preventive healthcare. Having medical“Social Common Capital”, a minimum requirement offacilities in accessible locations is the lifeline for thesociety, physical distance to the healthcare system ishealthcare system. In order to establish a stable healthcare

measured based on the simplest model in which the user

system, it is significant to secure access within a certain

chooses the nearest healthcare facility.
The measurement was done using the GIS（Geographic

space and time distance.
In a previous study related to the optimization of theInformation System）method. Due to the various data

healthcare system, Cluyer１） analyzed healthcare service

obtainable, part of Yokohama City and the entire Kanagawa

equity in its relationship with access needs and outcome.

Prefecture were experimentally chosen as the target area

２）

Endo et al . analyzed the relationship between the medical

for analysis.

expense insurance and income level. There have been

1）Investigating the Location of Healthcare Facilities

various research on healthcare equity in recent years.

The location of healthcare facilities in the target area

However, since many of them focus on medical expense

was investigated. The addresses available to the public

insurance, there have not been enough studies on

were used to determine the location and then classified

healthcare security based on the obvious and realistic

by types of medical department. In this study, 4 types

location for healthcare facilities or actual situation of users.

of departments are shown: Departments of internal

The studies by Yamada et al３）. and Kawaguchi et al４）. took

medicine, pediatrics, gynecology and emergency.

these perspectives into account and conducted a research2）User Specificationon the available hours of emergency medical services.

Considering the conditions mentioned previously, in

These studies are valuable as they investigated the actual

order to measure an accurate distance for users, thedata of medical facility utilization from the viewpoint of theresidential location of users must be obtained. Since

healthcare facility. On the other hand, reviewing healthcare

this is quite difficult, a virtual urban space was createdfacility locations to provide the types of healthcare serviceson the GIS in which the population is distributed bythat should be guaranteed in the first place is essential inbuildings. Data obtained from the Urban Planningplanning a new healthcare service system. Therefore, theBasic Survey, which includes building type such as

first step of this study is to evaluate and analyze thehouse, apartment, store or office, was used to allocate

relationship between healthcare facilities and users throughthe population within the target urban district using

simple physical distance（space accessibility）, and thenconsider the healthcare system as “Social Common

the total floor area of buildings classified as residences.
3）Measuring the Distance

Capital”. When taking practical matters such as emergency

In Japan, there have been many discussions on the

medical services or convenience into consideration, thelocation of medical facilities and accessibility of residents toanalysis on time distance becomes necessary in addition to

medical facilities in the medical care zone. Most of thespace distance. In order to calculate the time distance, theanalysis on the medical care zone has been conducted by

space distance must be calculated first. With a perspective

measuring the relationship between medical facilities andon further developing the research in the future, this study

their users by straight-line distance, or by outlined distancedeals with physical distance as its most fundamental point.

Ⅱ．Discussion on Accessibility
In this study, accessibility refers to simple and physicaldistance（space distance）between healthcare facilities andusers. When defining the users on the premise of “Social
Common Capital”, users are those who use the healthcare
facilities. Therefore, instead of limiting the definition ofusers by their present health condition such as current
patient or utilization, this study covers all the utilization
possibilities in future, thus every resident within the area isincluded as users. In addition, when a person needs
medical treatment, a healthcare facility is chosen by various
factors such as its size, reputation or availability oftransportation to get there. However, since this study is
focused on the placement of the healthcare facility as

44

Fig. 1．Outline of Each DistanceJ. Natl. Inst. Public Health, 59（1）: 2010

Eiji SATOH

in which the population is concentrated in a median point ofthrough 5.

area. However, through such a method, it is difficult to fully1）The road network data within the target area is loaded.

understand the actual state of accessibility of residents to

In this measurement, the road network data for car

the closest medical facility. Therefore, in order to analyze

navigation systems was used. In Fig. 2, the road networkand obtain more accurate data on the accessibility ofdata and the prefecture border in Yokohama City is

residents to medical facilities, this study adapted the virtual

shown.

urban space mentioned above and actual road network to2）Based on the addresses obtained, the location of medical

measure a network distance that is close to the actual travel

facilities were converted into coordinate values in

distance（Fig. 1）.

latitude/longitude and plotted on the map. Fig. 3 shows
the location of gynecology departments as an example.

Ⅲ．Method of Measurement

The total number of plotted points are; 1192 for internal

The procedure of measurement is illustrated in Fig. 2

medicine, 584 for pediatric, 141 for gynecology and 4 forFig. 2．Target Region with Network of Roads

Fig. 4．Measurement of Network Distance Every 100m

Fig. 3 ．Plot of the Location of Medical Facilities

Fig. 5．Details of Results

J. Natl. Inst. Public Health, 59（1）: 201045

Accessibility in the Community Healthcare Systememergency departments.

internal, pediatric, gynecology and emergency departments.

3）In addition, the distance zone in every 100m network

Table 1 shows the data of distance by each department.

distance was created from medical facility plotting. In

The total population of Yokohama City is around 3.3

Fig. 4, the results are colored accordingly to eachmillion（Census 2006）. 80% of the total population, about 2.6

distance zone. A more detailed map is shown in Fig. 5

million residents, live within 700m of internal medicine,with the rectangular shapes indicating buildings. Using

900m of pediatric and 1700m of a gynecology department.

the calculation method mentioned in Chapter 2, theIn the graph for the number of residents by each

information on population allocated in the buildings

department and distance zone, for the 3 departments ofclassified as residence in the target area is embedded.

internal medicine, pediatric and gynecology, the number of

The number of residents by each distance zone wasresidents suddenly increases towards the peak, drops

measured based on such information.

dramatically to a certain distance and slowly decreases.
Although the number of departments used is significantly

Ⅳ．Result of Measurement

different, there was similarity in the pattern of distance andpopulation measurement. For the emergency department,

1）Measuring Results in Yokohama City
Fig. 6 through 9 indicate the measurement results of

the number repeatedly increased and decreased towards

Fig. 6．Result of Survey for Internal Medicine

Fig. 7．Result of Survey for Pediatrics

46

J. Natl. Inst. Public Health, 59（1）: 2010

Eiji SATOH

Fig. 8．Result of Survey for Gynecology

Fig. 9．Result of Survey for Emergency

Table 1．Summary of Each Distance
Department

Max Distance（m）

Peak Distance（m）

80% of Total Population（m）

Average（m）Internal Medicine

2,500

400

700

510

Pediatrics

3,000

500

900

610

Gynecology

5,000

1,000

1,700

1,206

Emergency

15,000

5,100

9,200

6,197

the peak, then decreased again by repeatedly increasing

In Fig. 10, the measurement results for emergency

and decreasing. There was more distribution in thedepartment in the entire Kanagawa Prefecture and its

distance zone of around 10 to 12 km area.

impacted area around the borderline of Tokyo is shown.
Also, Fig. 11 shows a relationship between population and2）Measurement Result for Emergency Department in
Entire Kanagawa Prefecture

distance. Fig. 12 shows a relationship between population
density and distance collected every 500m.

J. Natl. Inst. Public Health, 59（1）: 201047

Accessibility in the Community Healthcare System

In Kanagawa prefecture, it is evident that the distance tothe population density increases at around 41km due to thethe emergency department becomes very far in the

reduction of the evaluated area around the borderline in themountainous regions in the west of the prefecture. A small

west of the prefecture.

mountain population is visible at around 25km. In addition,

Fig. 10．Result for Emergency Department of entire Kanagawa Prefecture

Fig. 11．Relationship between Population and Distance48

J. Natl. Inst. Public Health, 59（1）: 2010

Eiji SATOH

Fig. 12．Relationship between Density and Distancedepartments, as this study included all the users within

Ⅴ．The Analysis and Summary

the target and even included the users who are not in need

1）Social Common Capital and Accessibilityof medical treatment, the measurement results are

From the measurement results of internal medicine inoverestimated. However, from a social common capital

the Yokohama City, all citizens have access to internal

point of view, there should not be any area without standard

medicine clinics within 2km. Considering that internal

accessibility to medical facilities. Although it is questionable

medicine clinics are open to all age groups and genders of

to say that all users must be provided with every type ofusers, the healthcare system in this region is wellhealthcare system, it is necessary to choose what should bemaintained. The Yokohama City is in a concentrated

provided and how to manage the system provided. That is

population district with robust industry and economic

the ideal social common capital. Also, for medical

activities. Therefore, the supply and demand for healthcare

departments catering for users with special needs, policy

is in good balance and the role of healthcare as social

induction for an urban structure may be considered. In

common capital can be consigned to the market-base.

some municipal governments, policy induction tied up withDifferent results must be expected when the same analysis

exclusive healthcare has been successful and apparent. In

is conducted in the area with no urbanization. Especially inthose towns, parents experience a supportive environment

the rural area with a high aging population, the idea offor raising children or elderly people are provided withaccessibility becomes more significant. Access to healthcare

more comfortable living. Such evaluation is effective from afacilities have a variety of conditions; some patients go to

viewpoint of accessibility.

the facility by themselves while others have healthcare

Healthcare such as emergency departments that require

professionals coming to their home. However, from afast and immediate action must be provided without

viewpoint of efficient utilization in human capital, a mobile

restricting its users. However, from the measurement

healthcare facility is not an easy task to perform. Instead ofresults of Yokohama City and Kanagawa Prefecture, it isgoing to see patients outside, the doctors can see moredifficult to say that such healthcare is provided with equity.

patients in a clinic during the time spent for traveling which

This tendency is more pronounced in areas like those west

leads to more efficient healthcare. In addition, it is difficultof Kanagawa with low population densities. Assuming ourto provide advanced medical treatment with a doctor

future society is to have fixed or decreased medical

visiting a patient’s home due to limited facilities. Therefore,

resources, the fundamental issue is how to assign medical

it is clear that a patient will still receive advanced medical

resources, such as the location of healthcare facilities andtreatment if necessary at a medical facility even if doctor

how to provide healthcare. The most efficient method is tovisits are introduced. It is necessary to examine amaintain one’s objectivity and lay out a solution in ahealthcare system as social common capital from aquantitative manner. Therefore, analyzing accessibility has

viewpoint of various methods using the analysis of

the potential of realizing such possibilities.

accessibility as a base point. In pediatric and genecology2）Future Development

J. Natl. Inst. Public Health, 59（1）: 201049

Accessibility in the Community Healthcare System

In this study, the population was counted by simple

care. Journal of Health Economics 1993；12（4）：431-57.

distance. However, it is also possible to calculate the time２）Endo H, Komamura K Fairness in government-run

distance by incorporating the speed of walking, cars

insurance and healthcare access for elderly. Nationalpassing or travelling on the highway as data. By analyzing

Institute of Population and Social Security Research,using time distance, more accurate and realistic evaluation

The Quarterly of Social Security Research 1999；35（2）/analysis can be conducted, thus making it possible to build
a healthcare system as social common capital.
Also, in providing emergency medical service for a broad：141-8.
３）Yamada Y, Kawahara K, Kawaguchi Y. Research on
emergency medical system from a viewpoint ofarea, a seamless analysis without any area restriction will

emergency transportation access time - Discussing thebring opportunities to study medical service systems.

emergency medical intensification simulation in

In addition, by using methods such as the Travel Cost
Method which includes moving distance and economic

Ibaragi prefecture -. Journal of the Japan Society for
Healthcare Administration 2008；45：71.

indices, analysis on maintenance resources such as how the４）Kawaguchi H, Kawahara K. Research on access time toeconomic resources should be spent or obtained is also

emergency medical facility: From the results ofnecessary.

estimated access time using the GIS. Journal of theJapan Society for Healthcare Administration 2006；43

References（1）：35-46.

１）Cluyer AJ. Equity and equality in health and health

我が国はいま，変化した社会構造に対応し，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，ヘルスケア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．
医療機関の設置は，公的医療機関：社会保障としての医療，安心・安全，など，民的医療機関：地域密着型医療の提供，
ビジネスベースなど，様々な形で行われている．このうち，より持続性への要求が高く社会的な意義が深い「社会的共通資本」の観点からは特に，「社会保障としての医療」に注目する必要がある．住人が多い地域に医療機関が置かれることもあれば，医療機関がある地域に住人が多く住まうことになることもあり，医療機関の設置位置と住居地域の拡がりは単純
あるいは一方的な因果関係として説明はできない．しかし，住居地域の近隣に医療機関が存在することは，負傷や病気のとき（急性期）の処置，慢性的な疾病の治療やコントロール，健康の維持管理（予防医療），などヘルスケアシステムの成立要件そのものでもある．医療機関がアクセス可能な位置にあることはヘルスケアシステムの生命線であり，一定のレベ
ルで空間的・時間的距離以内でのアクセスを保障することが，持続的なヘルスケアシステムの構築に際して重要であると考える．
そこで本稿では，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・分析し，「社会的共通資本」としてのヘルスケアシステムについて考える．実際問題として緊急時の医療提供や利便性を考慮すると，空間的な距離に加えて時間的な距離の分析が必要となるが，その算出には空間的な距離の算出が最初期の段階として必要である．本稿はこうした発展的研究を見据え，まず最も基本となる物理的な距離を取り扱うものとする．
対象地域は，種々のデータの取得しやすさから．横浜市，および一部の分析においては神奈川県全域とした．また本稿
では，内科，小児科，産婦人科，３次救急の４種の診療科別に分析結果を示す．
佐藤栄治

50

国立保健医療科学院施設科学部客員研究員

J. Natl. Inst. Public Health, 59（1）: 2010