Journd of the National Institute of Public Health 2010 Vol. 59 No. 1 p.21−30

Topic：Health Care System as Social Common Capital〈Review〉
Benefit Evaluation of the Health Care System as Social Common Capital:
Quality Measurement of the Health Care System
as Non-Market Goods and Services.
Toshiro KUMAKAWA
Department of Management Science National Institute of Public Health

Abstract
The purpose, the components, and the interrelations of the health care system change greatly because medical services andtheir environment change. As the economic framework, the population structure, and the social structure changed, medicine
and medical technology advanced. Because of these factors, types of diseases have been greatly transformed. For example, an“acute and infectious disease” type society existed until after World War II in Japan. After the post-war devastation, there wasa dramatic increase in economics that led to the “chronic and lifestyle-related disease” type society that exists today. Currently,
our society is transforming to a mixture of these two types of societies.
Japanese society in the 21st century is approaching a large transition stage because of globalization, informationization,
activation of activities such as NPO/NGO, diversification of individual values, correction of past stockholders' equity principle,
the ending of the 1955 system, a declining birthrate, a growing proportion of elderly people, and a change in social climate dueto the state finance crisis. Such a difficult situation is common worldwide, and for a breakthrough solution to these problems,
the concepts of “Sustainability”, “Social Responsibility” and “Social common capital” are being reviewed all over the world.
Generally, the value of the factor of social common capital is divided by use value and non-use value. Former value isclassified to rivalrous consumption and nonrivalrous consumption. Until now, evaluation of the value of a health care system as
the social common capital is mainly given priority as a direct use value. Policy and resource allocation are decided based onthat evaluation. It is necessary to reorganize the health care system in response to the changing patients’ needs in the 21st
century, such that priority of the allocation of limited resources is decided by mutual agreement of the citizens. It is importantthat not only the direct utility value of the health care system is measured, but other values are measured as well., Therefore, itis necessary that we expand our understanding of other representative measurement methods, such as the Travel Cost
Method, the Hedonic Approach and the Contingent Valuation Method.
keywords: Bebefit evaluation, Health care system, Sustainability, Social responsibility, Social common capital, Travel cost
method, Hedonic approach, Contingent valuation method（CVM）（accepted for publication, 24th Feb. 2010）

Ⅰ．Changes in disease composition in Japan

with chronic infectious diseases such as tuberculosis andsexually transmitted diseases, and the struggles against

The Japanese governmental organization for management

infectious diseases continued until after World War II. In

of public health was estblished in 1872, and, as in otherthe post-war devastation, there was a dramatic increase indeveloped countries, it started with measures for dealing

the spread of tuberculosis and other infectious diseases,

with acute infectious diseases. The next step was to deal

due to food shortages, the return of demobilized soldiers

2-3-6 Minami, Wako-shi, Saitama, 351-0197 Japan.
FAX：+81-48-468-7985
E-mail：kuma@niph.go.jp

J. Natl. Inst. Public Health, 59（1）: 201021

Benefit Evaluation of the Health Care System as Social Common Capitalfrom abroad, and other factors, and such diseases were awas the principal cause of death from 1950 to 1980, andmajor cause of death. Beginning in the early 1950s, themalignant neoplasm has been the principal cause sincenumber of deaths due to tuberculosis and other infectious

1981. Since 1975, the mortality rate due to cerebrovasculardiseases fell as a result of the development and widespreaddisease has decreased, but the mortality rates due to

use of antibiotics, the improvement and reorganization ofmalignant neoplasms and heart disease have tended toliving conditions, and improvements in prophylacticincrease. The mortality rate due to diabetes has also tended

techniques. However, at about the same time, starting

to increase, albeit slowly（Fig. 1）.

in the mid-1950s, the numbers of deaths due tocerebrovascular diseases, heart disease, and cancer rose
dramatically, and Japan’s disease composition changed
markedly within only a short period of time after World War
II.

Ⅱ．Classification of societies
by disease composition
From the evolution of the first humans until the Industrial
Revolution, chronic food shortages and malnutrition meant

In terms of age-adjusted mortality rates classified bythat the human population was perpetually beset bycause of death, the mortality rate due to cerebrovascular

infectious diseases, such as those caused by contagious

diseases decreased markedly from 1965 in both males andorganisms and parasites. However, in the industrial society

females. The rate of malignant neoplasm showed athat emerged after the Industrial Revolution, food supply

tendency to increase in males, but a tendency toward a slow

has increased massively, standards of living improved, thedecrease in females. The rate of heart disease showed apopulation increased, and urbanization progressed. Rapid

slow decrease in both males and females since 1980. The

advances in medical science during the 19th century also

status of mortality was affected by the age profiles of thesecontributed to a decrease in the death rate. In association

populations, therefore, in order to compare the mortality

with these changes, lifestyles gradually changed fromrates due to these diseases in populations with different

those that were typical in agricultural societies, and birthdemographic structures, it was considered appropriate torates thus declined. In addition, the development of

use age-adjusted mortality rates to ensure that the rates

chemotherapeutic treatments in the first half of the 20th

applied to a consistent standard population.

century resulted in the decline of numerous infectious

The changes in disease composition can be clearly

diseases, especially pediatric infections and juvenile

understood from the time-course of age-adjusted mortality

tuberculosis, leading to further decreases in the death rate.

rates classified by cause of death. In 1950, tuberculosis wasThese decreases in birth and death rates have led to an

the cause of 13.5% of deaths, but this proportion had fallen

aging of the population. Additionally, lifestyles in industrial

to 1% or less by 1980. In contrast, cerebrovascular diseasesocieties have resulted in large numbers of people with

Fig. 1．Annual Changes in Mortality rate classified by Major causes of Death in Japan（1899〜1998）

22

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

Toshiro KUMAKAWA

chronic illnesses such as heart diseases, cerebrovascular

due to tuberculosis increased in 1997, for the first time in 43

disorders, and cancer. Furthermore, progress in medical

years, and the increase in the number of tuberculosis

science has lowered the death rate of elderly people,

patients was particularly marked in people more than 70

resulting in a continuing increase in average life

years of age. In the aging society of the 21st century, it isexpectancy. This is not solely a problem in the developed

therefore expected that there will be numerous elderlycountries, but is now affecting many poorer countries,

people with functional disorders of one sort or another, andalbeit with a greater or lesser delay.

who will suffer from chronic diseases that gradually

On the other hand, numerous factors, including
developments in transport, have led to the emergence andincrease in severity, and are repeatedly complicated byacute diseases.

reemergence of infectious diseases. These factors have

Taking the above points into consideration, societies canresulted in a large increase in the international movement

be classified as belonging to one of the following threeof people and foodstuffs, large-scale deforestation, global

types, on the basis of disease pattern characteristics:

warming, and the diversification of human values. The
approaches to be taken in response to outbreaks of（1）Acute and infectious disease model society

emerging and reemerging diseases have, therefore,

In these societies（Fig. 2）, the principal causes of deathbecome a major global concern. For several infectious

are amoebic dysentery, bacterial infections such as typhoiddiseases, the numbers of people affected had decreased tofever, leprosy, malaria, tuberculosis, cholera, diphtheria,

the point that the diseases were no longer public-healthtetanus, epidemic meningitis, pneumonic and bubonicproblems. However, diseases such as tuberculosis, cholera,

plague, bacterial dysentery, and other infectious diseases.

yellow fever, rabies, malaria and bilharzia, have since

The characteristics of these societies are as follows:

become more prevalent, and are therefore termed（a）They are pre-industrial, agricultural societies, withreemerging diseases. Emerging diseases, on the otherperpetual

hand, include new cholera strains, pathogenic Escherichia

malnutrition.

problemsoffoodshortages

andcoli O157, human immunodeficiency virus（HIV）and（b）They involve subsistence lifestyles.

Helicobacter pylori infections, all of which were previously（c）Birth and death rates are high, thus the population

unknown, but have since become local or international

pyramid is conical in shape.

public health problems. Elderly people tend to be
immunocompromised, and consequently have high potential（2）Chronic and lifestyle-related disease model society

as targets for new infectious diseases. In Japan, both the

In these societies（Fig. 3）, the principal causes of death

number of new tuberculosis cases and the morbidity rate

are lifestyle-related diseases such as cerebrovascularFig. 2．Acute and infectious disease model society

J. Natl. Inst. Public Health, 59（1）: 201023

Benefit Evaluation of the Health Care System as Social Common CapitalFig. 3．Chronic and lifestyle-related disease model society

Fig. 4．Combined-type disease model society

disease, heart disease, and cancer. The characteristics of（3）Combined-type disease model society
In these societies（Fig. 4）, there are numerous elderly

such societies are as follows:（a）They are industrial societies, originating from thepeople with functional disorders of various types, and deathIndustrial Revolution to the present day, withtends to result from a gradual physical decline involving

sufficient food supplies, and with populations

exacerbation of chronic diseases, complicated by repeatedconcentrated in urban areas.

acute diseases. The characteristics of such societies are as（b）Many people have sufficient time for leisure and（a）They are 21st-century information societies, in which

education.
（c）Birth and death rates are low, thus the population
pyramid is bell-shaped.

24

follows:
new information technology has become widelyused.

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

Toshiro KUMAKAWA（b）There is a wide diversity in people’s values, and agreat deal of international movement of people,

environment, and corruption prevention.
While attention to Corporate Social Responsibility（CSR）
increased worldwide, the International Organization forgoods, and other items.
（c）Average life expectancies are high and birth rates areStandardization（ISO）began to work on the standardization

low, thus the population pyramid is amphora-shaped.

of CSR. It examined the process of the multi-stakeholder, inDuring the 21st century, numerous developed countries,

which experts from consumer, government, industrial

including Japan, are expected to shift from chronic-disease

world, worker, non-governmental organization（NGO）,

societies, with mainly lifestyle-related diseases, to combined-

service, support, research, and other different stakeholders

type societies, with mainly chronic geriatric diseases.

participated from 80 countries around the world, including
developing countries. Thus, because it was not only

Ⅲ．Social responsibility

corporations that were responsible for social responsibility,

Advanced countries rushed into the 20th century, which

the name CSR was changed to SR（Social Responsibility）” inwas an era of industrialized societies and mass production.

February 2003, and it is scheduled to be issued in 2010 as

The population continued its explosive increase, which led

the standard ISO26000 of SR.

to serious problems of human rights, inequality, and other

A worldwide movement that values SR does not exclude

social problems. On the other hand, pollution and the

medical treatment. The combination project between

destruction of the environment on a worldwide scale, such

American and European medical science associationsas acid rain, destruction of tropical forests, desertification,

settled on principles set forth in “Medical professionalism

ozone layer depletion, and global warming by thein the new millennium: a physicians’ charter”, and madegreenhouse effect, became the basis of progress by thethem public to Lancet and Annals of Internal Medicine at

human race. There has been environmental overload thatthe same time in February, 2002. The principles of this new

resulted in poorly planned rainforest destruction byphysician’s charter were three-fold（a principle of theslash -and- burn farming, and excessive consumption of

welfare priority of the patient, a principle of patient

resources and energy by the well-to-do population

autonomy, and a principle of social justice）. Social justicecontinued.

should be mentioned specifically, because the physiian's

Rapid economic development and globalization duringsocial responsibility “The medical profession must promote

the last several decades have created a strong worldwide

justice in the health-care system, including the fairinterdependency in all respects. A private think tank, “thedistribution of health-care resources. Physicians shouldClub of Rome”, published the report “The Limits towork actively to eliminate discrimination in health care,

Growth” in 1972, and the concept of “Sustainability” gained

whether based on race, gender, socioeconomic status,

attention at that time. In 1987, the World Commission on

ethnicity, religion, or any other social category.” is clearly

Environment and Development of the United Nations

declared. This is a significant point in the “Hippocrates'

published a report, “Our Common Future”, whichoaths” that have been handed down from the Greeks aboutemphasized that human beings must sever the vicious circle

2500 years ago.

of current development and environmental destruction,
maintain the environment and the resource bases, andcreate a Sustainable Development model.

Ⅳ．Social common capitalMoreover, one significant modification to the idea of

To realize Sustainable Development, it is necessary that

economics occurred after the 1980’s. Instead of theall organizations, including for profit and nonprofit

traditional framework of capitalism and socialism, a neworganizations, governments, and international organizations,concept of system principles began to be promoted. This

need to work cooperatively, especially if the expectation is

was the movement to evaluate the role and function ofgreat for the enterprise that is the subject of economic

economics following the dramatic incidents associated withactivity. In 1998, the concept of “Triple Bottom Line” wasthe disappearance of Soviet socialism in August 1991, and in

advocated. That concept suggested that for the sustainable

response to various problems of nature, culture, society,development of the enterprise, it was necessary to improve

human rights, .and other conditions created by socialist and“Result of an environmental side” in addition to “Result of acapitalistic systems, and to search for the possibility offinancial side”, and “Result of the social column” overall. In

sustainable economic development. One embodiment of

the World Economic Forum in 1999, the United Nations

this new concept of system principles was a social common

advocated The Global Compact, which was the corporate

capital.

activity indicator concerning human rights, labor, theSocial common capital is a social device by which all

J. Natl. Inst. Public Health, 59（1）: 201025

Benefit Evaluation of the Health Care System as Social Common Capital

people manage a fertile economic life, establish an excellent

Many composition factors of a social common capital

culture, and continually maintain a stable, attractive,

commonly have externality. For example, the forest is

humane society. Social common capital is comprised of acomposed of various types of trees within a certain constantscarce resource, which is not admittedly owned or

region, and many kinds of mushrooms, ivies, undergrowth,managed privately, but in which there are a few situations

small animals, and other organisms are included. The soilthat take the form of being owned or managed privately.

and water are important composition factors of the forest,.

Even when there is some ownership pattern, social

The forest soil contains abundant organisms, and rain watercommon capital is never managed according to ais purified by the soil, becomes water with a moderatebureaucratic standard, but instead is controlled greatly by amineral constituent, and supports agriculture and fisheries.

market standard. Each social common capital must be

Moreover, the forest has the important functiont ofmanaged by relevant occupational specialist groups

absorbing the carbon dioxide in the atmosphere andaccording to their special findings and occupational ethics.

combating global warming. In addition, the existence of the

A concrete form of social common capital is divided into

forest performs the key role of providing a place where

three patterns: natural environment, social infrastructure,people can find relief of the mind. The function of the forest

and institutional capital. A natural environment consists ofis not only to grow and deforest trees for various

various composition factors such as forests, rivers, lakes,

appropriated usages, but also to have an external effect thatmarshes, coastal wetlands, oceans, water, soil, and thecannot be measured. Therefore, management of the forest

atmosphere.

should be done from a social viewpoint, and should not beThisnaturalenvironment

is

not

only

indispensable to man’s livelihood, but also serves animportant function for economical, cultural, and social
activities. A social infrastructure is composed of roads,
bridges, railways, high and low water services, electric

based only on a market standard.

Ⅴ．Benefit evaluation of social common
capital as non-market goods and services

power, gas, and other factors. This social infrastructure

In general, the value of the non-market goods andmight have either a public or private ownership pattern.

services, which is the composition factor of a social

The institutional capital consists of various system elements

common capital, is divided by the Use Value and the Non-like medical treatment, education, finance, administration of

use Value. The benefit categories in the Use Value are

justice, and other elements, although it is not necessarily

classified

distinguished from the natural environment or a social

Nonrivalrous consumption of goods and services. The

infrastructure. Regarding the health care system, it has thebenefit categories in the Non-Use Value are classified into

institutional capital and the characteristic of both sides of a

Option Value, Pure existence value and Altruistic existencesocial infrastructure.

value（Fig. 5）. However, valuation of the composition factor

into

the

Rivalrous

Fig. 5．Benefits of Social Common Capital as Non-Market Goods and Services

26

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

consumption

and

the

Toshiro KUMAKAWA

value of a current, social common capital is given priority

forth by Waugh in 1928, and was further developed andchiefly in the Use value, and the policy and the resource

adjusted to the micro economic thesis by Rosen in 1974.

allocation are decided based on the result.
Japanese society is approaching a large transition stage（3）Contingent Valuation Method（CVM）

information

CVM might be called the constructive market method

technology, activation of civic action as Non Profit

and a value consideration method. This is a method ofOrganization（NPO）/ Non Governmental Organization

directly questioning the testee who utilized the composition（NGO）, diversification of individual values, correction offactor of social common capital on their Willingness to Pay

past stockholders’ equity principle, the ending of the 1955

（WTP）: the amount of money thought that he or she may

system, the complications of an aging society with fewer

pay when assuming that it is necessary to pay expenses tochildren, and the crisis of state finances in the 21st century.

improve the quality or Willingness to Accept（WTA）, which

It will be necessary to construct a new healthcare systemis the amount of compensation necessary for making

that embodies the concept of “Sustainability”, continuously

amends for effect level when quality deteriorates. Ciriacy-offers the people high-quality, efficient healthcare services

Wantrups put forth this idea in 1947, the first application by

in a complex, difficult environment. For the construction of

Rowe and D 'ange and Blook-shire was introduced in 1980,

a new healthcare system, up till now, only a direct use value

and it has since been developed in the field of

has been measured for the non-market goods and services

environmental economics. The primary merit of CVM isof the healthcare system; however, it will be necessary tothat it is not only the composition factor of a social common

measure other values in the future. For example, the Travel

capital that is realistic or exists, but also the quality of theCost Method, the Hedonic Approach, and the Contingent

composition factor of a virtual, social common capital andValuation Method have been proposed as typical measuring

the economic evaluation concerning the state are possible.

with globalization, the development ofmethods in the field of environmental economics.
（1）Travel Cost Method
This is a method of evaluating the value of thecomposition factor of a social common capital from theperspective of whether or not it is worth using it to the

Ⅵ．Example of CMV：Evaluation of existencevalue of the regional medical careprovision system by the contingent
valuation method
1）Purpose

point whereby much of the access cost is paid with money,

The purpose of this study was to survey residents’for example, going to a park. Theoretically, the Travel Cost

willingness to pay for the proposed construction of the

Method valuates the consumer surplus by the Marshallregional medical care provision infrastructure concerningtheory. This idea was demonstrated by Hotelling for themultiple medical care functions, in order to valuate thisfirst time in 1947. The Travel Cost Method utilizes awillingness as the degree of benefits of the medical carequestionnaire survey and works by presuming thetreatment system in a regional society, or to estimate it

frequency for visiting equation（demand function）is based

based on the contingent valuation method.

on the results of the survey. Moreover, it should be noted,2）Methods

the option value is not appreciable in the travel cost method.

This study selected the City of Yokohama in Kanagawa
prefecture as the object of analysis. Residents of Yokohama
from their teens to their eighties were abstracted from

（2）Hedonic Approach
Hedonic approach is an evaluation method based on theregistered panelists of a net research corporation, and thecapitalization hypothesis, which means the value of each

2,000 responses reflected the actual age and gendercomponents of social common capital is capitalized to thecomposition ratio in a respondents’ panel. The survey wassurrogate market like land market（land price）or labor

divided into two periods: February 23 to 27 and March 23

market（wage）. In this evaluation procedure, the value ofto 27, 2009（no duplication of respondents）.

each components of social common capital is evaluated in

The questions asked in the survey, which were preceded

monetary based by regression analysis on the land priceby an explanation of the state of regional medical care infunction or wage function in which dependent variable is

Yokohama City, concerned people’s willingness to pay taxes

price and explanation variables are some characteristics

of 10,000 yen/year for 30 years. The taxes funded theincluding the components of social common capital. This

implementation of an infrastructure plan for generalidea originated through the presumed Hedonic priceinternal medical care, such as pediatric care, obstetrics

function of asparagus, the tomato, and the cucumber put

care, and emergency medical care, that provide personal

J. Natl. Inst. Public Health, 59（1）: 201027

Benefit Evaluation of the Health Care System as Social Common Capital

medical roles:, specifically “to ensure that all residents canwalk one kilometer or less from their present homes to atleast one institution providing each of these medical

Table 1 ．General internal medical careservices.” The questionnaire also inquired about the sex,age, occupation, household income, and family compositionof each respondent, and the present and past medical careexperience of the respondent and the respondent’s family
members.
To increase the reliability of the analysis results,
questions concerning respondents’ reasons for unwillingness
to pay were included to distinguish and handle negative
responses. After confirming the basic statistics of the dataset, typical amounts that respondents were willing to pay
were estimated based on the open question method. To
clarify factors impacting the amount people would be
willing to pay, regression analysis of the respondents’attributes was performed.
3）Results
The results of a t-test demonstrated that there was no
statistically significant difference in the mean values people
were willing to pay between the two surveys. Mean values
people were willing to pay were 3,677（95% confidence
interval, 3,409 to 3,944）yen for general internal medicalcare, 3,185（2,920 to 3,450）yen for pediatric care, 2,803＊（2,599 to 3,006）yen for obstetrics care, and 3,515（3,289 to

Explanatory Variable

parametert-valuep-ValueSex（male vs female）
Child（＋vs−）Household members
currently receiving outpatient care（＋vs−）
Age（year）10−19
20−29
40−49
50−59
60−69
70−79
80−overHousehold income−3.00 million yen
3.01〜4.00million yen
5.01〜6.00million yen
6.01〜8.00million yen
8.01〜10.00million yen
10.01〜14.00million yen
14.01〜18.00million yen
18.01〜25.00million yen
25.01million yen −Constant

−99.1
−3.4

−0.37
−0.01

0.71
0.99

666

2.35

0.02

2440
90.3
−407
111
1410
1210
−177

3.92
0.20
−0.98
0.24
2.95
1.31
−0.07

0.00
0.84
0.33
0.81
0.00
0.19
0.94

−243

−0.44

0.66

−176
286
577
1020
1890
2220
4070
5130
2470

−0.31
0.50
1.13
1.90
3.29
2.78
3.66
2.62
4.70

0.76
0.62
0.26
0.06
0.00
0.01
0.00
0.01
0.00

exemption standard Age: thirties, Householdincome: 4.01〜
5.00million yen

3,741）yen for emergency medical care.
Table 2 ．Pediatric care

The study of the impact of respondents’ attributes on theamounts they were willing to pay for each of these services
revealed that:（1）for general internal medical care, the amounts
teenagers and people in their sixties were willing to pay
were positively significant, the amounts people earning 8
million yen or more per year were willing to pay were also
positively significant, and household members who werecurrently receiving out-patient care also had a positive
impact on the amounts people were willing to pay（Table 1）;（2）for pediatric care, the amounts people in their forties
and males were willing to pay were negatively significant,the amounts people earning from 10 million yen to 18
million yen per year were willing to pay were positively
significant, and there was a positive impact on the amounts
people were willing to pay when there was a child in thefamily（Table 2）;（3）for obstetrics care, the amounts teenagers werewilling to pay were positively significant, amounts people intheir forties were willing to pay were negatively significant,the amounts people earning from 10 million yen to 25
million yen per year were willing to pay were positively
significant, and household members currently receiving out-＊

Explanatory Variable

parametert -value

p-ValueSex（male vs female）
Child（＋vs−）Household members
currently receivingout−patient care（＋vs−）
Age（year） 10−19
20−29
40−49
50−59
60−69
70−79
80−overHousehold income−3.00 million yen
3.01〜4.00million yen
5.01〜6.00million yen
6.01〜8.00million yen
8.01〜10.00million yen
10.01〜14.00million yen
14.01〜18.00million yen
18.01〜25.00million yen
25.01million yen −Constant

−779
746

−2.88
2.25

0.00
0.02

417

1.48

0.14

968
−51
−1340
−24
242
−318
−987

1.55
−0.11
−3.22
−0.05
0.51
−0.34
−0.40

0.12
0.91
0.00
0.96
0.61
0.73
0.69

393

0.71

0.48

−58
112
619
558
1280
2360
1880
572
2850

−0.10
0.20
1.21
1.04
2.22
2.96
1.69
0.29
5.43

0.92
0.85
0.23
0.30
0.03
0.00
0.09
0.77
0.00

exemption standard Age: thirties, Householdincome: 4.01〜
5.00million yen

patient care also had a positive impact on the amounts

28

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

Toshiro KUMAKAWA

people were willing to pay（Table 3）;（4）for emergency medical care, the amounts teenagers
and people in their sixties were willing to pay wereTable 3 ．Obstetrics carepositively significant, and the amounts people earning from
8 million yen to 25 million yen per year were willing to pay
were positively significant（Table 4）.
4）Conclusion
The survey hinted at the possibility that amounts that
regional residents were willing to pay for the establishmentof this provision system varied according to the functions of
medical care institutions. It was also assumed that because
those utilizing obstetrics and pediatrics services inparticular were limited to specified age groups, thewillingness of other age groups to pay for these services
was low.
Regarding general internal medical care institutions that
could be used widely by anyone, evaluations varied by age
group,; high evaluations were given by the elderly whowere at a high risk of falling ill, and currently receiving
medical care was also a significant factor.
Regarding annual household income, a clear difference
was confirmed with 8 and 10 million yen as the boundaryline, and a high probability of using an actual medical careinstitution and income had a great effect on the regional＊

residents’ evaluations of the construction of the medical

Explanatory Variable

parametert -value

p-ValueSex（male vs female）
Child（＋vs−）Household members
currently receivingout−patient care（＋vs−）
Age（year）10−19
20−29
40−49
50−59
60−69
70−79
80−overHousehold income−3.00 million yen
3.01〜4.00million yen
5.01〜6.00million yen
6.01〜8.00million yen
8.01〜10.00million yen
10.01〜14.00million yen
14.01〜18.00million yen
18.01〜25.00million yen
25.01million yen −Constant

−219
276

−1.07
1.09

0.29
0.28

412

1.92

0.06

2130
361
−1160
−357
422
483
−968

4.50
1.05
−3.69
−1.02
1.16
0.69
−0.51

0.00
0.30
0.00
0.31
0.25
0.49
0.61

−222

−0.53

0.60

−363
−159
644
709
956
1640
1710
1660
2350

−0.84
−0.37
1.66
1.74
2.18
2.71
2.02
1.12
5.88

0.40
0.71
0.10
0.08
0.03
0.01
0.04
0.26
0.00

exemption standard Age: thirties, Householdincome: 4.01〜
5.00million yen

care provision system.
Table 4 ．Emergency medical care

The public’s evaluation of the reconstruction of medicalcare provision systems varies between people in different

Explanatory Variable

parametert-valuep-Valueage groups. Differences in incomes also have a clear impact

Sex（male vs female）
Child（＋vs−）Household members
currently receivingout−patient care（＋vs−）
Age（year）10−19
20−29
40−49
50−59
60−69
70−79
80−overHousehold income−3.00 million yen
3.01〜4.00million yen
5.01〜6.00million yen
6.01〜8.00million yen
8.01〜10.00million yen
10.01〜14.00million yen
14.01〜18.00million yen
18.01〜25.00million yen
25.01million yen −Constant

−260
−88

−1.14
−0.31

0.25
0.75

327

1.37

0.17

1920
579
−543
333
1110
340
−434

3.65
1.51
−1.55
0.86
2.77
0.44
−0.21

0.00
0.13
0.12
0.39
0.01
0.66
0.84

−71.2

−0.15

0.88

−21.5
362
435
1210
1790
3080
3460
1460
2510

−0.04
0.75
1.01
2.67
3.69
4.58
3.69
0.89
5.68

0.96
0.45
0.31
0.01
0.00
0.00
0.00
0.37
0.00

on evaluations, so it is necessary to give full consideration
to generational and income differences in regions when
considering the reconstruction of medical care provisionsystems.

References
１）Wood S, Trice A. Measurement of recreation benefits.
Land Economics 1958；34：195-207.
２）Rosen S. Hedonic prices and implicit markets: productdifferentiation in pure competition. Journal of Political
Economy 1974；82（1）：34-55.
３）Rowe R, D’Arge RC, Brookshire DS. An Experiment ontheeconomics

value

of

visibility.

JournalofEnvironment Economics and Management 1980；7：119.
４）Hidano N. The Economic valuation of the environment
and public policy. Massachusetts; Edward Elgar
Publishing；2002.
５）Uzawa H. Economic analysis of social common capital.
New York: Cambridge University Press；2005.

＊

exemption standard Age: thirties, Householdincome: 4.01〜
5.00million yen

６）Boardman AE, Greenberg DH, Vining AR, Weimer DL.

J. Natl. Inst. Public Health, 59（1）: 201029

Benefit Evaluation of the Health Care System as Social Common Capital

Cost-benefit analysis: concepts and practice（Third

system: ISO 26000 and socially responsible investment.

Edition）. New Jersey: Upper Saddle River；2006.

J Natl Inst Public Health 2009；58（3）：283-93.

７）Kumakawa T. Restructuring Japanese health care８）Kumakawa T, Sugahara T, Sato E, Hiratsuka Y.

system and health promotion system in the future -Evaluation of existence value of regional medical caremechanical system and complexity adaptive system -.

provision system by the contingent valuation Method.

HEP 2009；36（4）：365-71.

In: Proceedings of the 41st APACPH Conference; 2009８）Kumakawa T. Social responsibility in healthcare

Dec 3-6; Taipei, Taiwan. p.175.

医療および医療を取り巻く環境の変化により，ヘルスケアシステムの目的，その構成要素，それらの相互関係は大きく変化する．経済構造・人口構造・社会構造の変化や医学・医療技術の急速な進歩は，疾病構造を大きく変容させてきた．わが国を例に取れば，第二次世界大戦直後までは急性疾患・感染症型社会が形成され，その後の高度経済成長を背景に慢性疾患・生活習慣病型社会が形成され，今日ではそれらが混合した社会が形成されつつある．
２１世紀の日本社会はグローバル化，IT化，NPO/NGOなどの市民活動の活発化，個人の価値観の多様化，行き過ぎた株
主資本主義の是正，５５年体制の終焉，少子高齢化，国家財政の危機などの社会環境の変化の中で大転換期にさしかかってい る．こ の よ う な 困 難 な 状 況 は 世 界 各 国 が 抱 え て お り，そ の 問 題 解 決 の 突 破 口 と し て， Sustainability
Responsibility

SocialSocial common capital のコンセプトが世界各国で見直されている．２１世紀のヘルスケアシステムの再構

築においてもこの点が重要なポイントになる．
一般に非市場財，すなわち社会的共通資本の構成要因の価値は，利用価値と非利用価値に大別され，前者は競争的消費と非競争的消費に分類される．これまでの社会的共通資本としてのヘルスケアシステムの価値評価は主に直接的利用価値に重点が置かれており，その結果に基づいて政策や資源配分が決定されてきた．しかしながら２１世紀においては，急激な社会環境の変化を反映する患者ニーズに確実に答えてゆくヘルスケアシステムを再構築するためには，住民との合意のもとに優先順位を決め，限られた資源を配分する必要がある．そのためにはヘルスケアシステムの直接的利用価値のみならず他の価値についても正確に測定することが重要であり，その代表的な測定方法である旅行費用法，ヘドニック・アプロー
チ， 仮想市場評価法に対して理解を深める必要がある．
キーワード：

便益分析，ヘルスケアシステム，サステナビリティー，社会的責任，社会的共通資本，トラベルコスト法，
ヘドニック・アプローチ，仮想市場評価法
熊川寿郎

30

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

国立保健医療科学院経営科学部