Health and Global Policy Institute (HGPI)
Cardiovascular Disease Control Promotion Project

Developing and Expanding Cardiovascular Disease
Control Plans in Each Prefecture

Challenges and Good Examples for Cardiovascular Disease Control

Addendum

May 2024

Contents
Introduction: Background to the creation of this addendum and its objectives……………………… 2
Efforts required of each stakeholder for equity and further progress in CVD control measures
01

Internal and external collaboration at government agencies…………………………………… 3

02

Effectively using awareness-raising materials…………………………………………………… 6

03

Integrated Centers for Stroke and Heart Disease Support……………………………………… 904

The lack of data and establishing data analysis systems ……………………………………… 12

Introduction………………………………………………………………………………………………… 16
Good examples and key points for future discussion identified during Phase 2 of the
Cardiovascular Disease Control Promotion Project01

Formulating plans tailored to actual conditions in each prefecture andplan evaluation………………………………………………………………………………………… 17

02

Building an integrated support system centered on “Model Projects for
Integrated Centers for Stroke and Heart Disease Support”……………………………………… 21

03

Promoting Patient and Public Involvement (PPI) in the processes forformulating and implementing CVD countermeasures…………………………………………… 25

Acknowledgments………………………………………………………………………………………… 28
Regarding the independent nature of these recommendations……………………………………… 28
Health and Global Policy Institute: Guidelines on Grants and Contributions………………………… 28

特定非営利活動法人 日本医療政策機構〒100-0004 東京都千代田区大手町 1-9-2 大手町フィナンシャルシティ グランキューブ 3 階Global Business Hub Tokyo
Tel: 03-4243-7156 Fax: 03-4243-7378 E-mail: info@hgpi.org
本レポートの著作権は、日本医療政策機構が保有します。

Developing and Expanding Cardiovascular Disease
Control Plans in Each Prefecture

Challenges and Good Examples for Cardiovascular Disease Control
Addendum

Introduction: Background to the creation of this addendum and its
objectives
In Japan, cardiovascular diseases (CVDs) like stroke and heart disease are leading causes ofdeath and the most common conditions that require long-term care. To advance all varietiesof CVD control measures, Japan enacted the “Basic Act on Countermeasures for Stroke, Heart
Disease and Other CVDs to Extend Healthy Life Expectancies” (or the “Basic Act on CVD
Measures”) in December 2018. Later, the Japanese National Plan for Promotion of Measures
Against Cerebrovascular and Cardiovascular Disease was formulated in accordance with that Act
and approved by Cabinet Decision in October 2020. Under the National Plan, each prefectural
government formulated a Prefectural Plan for the Promotion of CVD Countermeasures (referred toas “Prefectural Plans” below) and is now advancing efforts to promote CVD control.
While Japan has laid the groundwork to further advance CVD control measures, the Basic Act andthe Basic Plan only outline general principles and goals. Expectations are now growing for thenational Government and prefectural governments to make concrete progress on these measuresand expand them in the future.
Given this context, in the latter half of 2021, Health and Global Policy Institute (HGPI) launched
the three-year Cardiovascular Disease Control Promotion Project to provide strong backing to theformulation of Prefectural Plans. Looking back on the first two years of this project, in its first year, we
set a direction and compiled perspectives for considering CVD control in policy recommendations,and in its second year, we gathered knowledge and identified methodologies for implementing
CVD control in prefectures in accordance with those perspectives. In response to the Second Phaseof the Basic Plan, which came into effect after a revision in April 2023, in the second year of ouractivities, this project worked to identify issues that must be addressed for the formulation of phase
two Prefectural Plans, with our main focus on measures at prefectural governments.
As of the time of writing, in April 2024, all prefectures are now in the final stages of reviewing theirrespective plans. At this stage, they will clarify the roles of each stakeholder and proceed with theactual introduction of countermeasures. Given these circumstances, to drive concrete progress in
CVD control, activities for year three of the HGPI CVD Control Promotion Project have included
sharing approaches, perspectives, and implementation strategies and methodologies we haveaccumulated thus far through opinion exchanges with prefectural officials and council members. In
the course of those discussions, government officials and collaborators from academia provided us
with new knowledge that was not fully captured in the recommendations presented in our project’s
second year. For this reason, we compiled this addendum describing each stakeholders’ roles in the
future implementation of CVD control measures.
It is our sincere hope that these recommendations can once again be shared with and utilized by all
related parties to contribute to steady future progress in CVD control.

2Addendum

Efforts required of each stakeholder for equity and further
progress in CVD control measures

01

Internal and external collaboration at government
02
03
04
agencies

Current circumstances
Oftentimes, many parts of Prefectural Plans have been prepared by compiling related items
extracted from multiple administrative plans. There are also some prefectures where theformulation of Prefectural Plans has been assigned to different divisions than those that are
responsible for implementing control measures.

Challenges● There are times when information from third-party experts from academia meant forPrefectural Plans is not received in the ideal manner because prefectural governments split
responsibility among multiple divisions. There are also other inefficiencies, such as when
government staff submit redundant inquiries.
● Some prefectures have placed multiple divisions in charge of the formulation process forPrefectural Plans. This hinders the smooth execution of various tasks, from monitoring the
progress of plans to implementing them.
● Some prefectures have formed comprehensive agreements with the private sector, butdifferences in how these parties perceive the roles of each stakeholder sometimes emerge
during the implementation of Prefectural Plans.
● Personnel transfers occur frequently at some prefectural governments. Despite theirimportance for human resource development and corruption prevention, personnel
transfers can sometimes hinder continuous multi-agency collaboration.

Examples● In one prefectural government, jurisdiction for CVD control was transferred from theMedical Policy Division to other divisions like the Health Promotion Division so discussions
could be completed internally at that division. This established a system for smooth internal
collaboration, such as by allowing staff to consolidate communication with outside experts.
● One prefectural government has implemented longer transfer periods during personnel
transfers. This creates more time for transferred personnel to help incoming staff members
get up to speed on discussions and or to hand off other duties.
● In some prefectures, councils involved in CVD plans are holding joint meetings with othercouncils, such as those responsible for medical plans.

3Addendum

Initiatives required from each stakeholder
Government (Ministry of Health, Labour and Welfare)● The Ministry of Health, Labour and Welfare (MHLW) should issue official notices toencourage internal cooperation to advance CVD control. It should also evaluate progress
on Prefectural Plans using certain criteria to encourage internal cooperation andautonomous efforts to promote plans within each prefectural government. The Japanese
National Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular
Disease suggests establishing logic models, and many Prefectural Plans have outlined
evaluation indicators based on logic models. After evaluating Prefectural Plans, the MHLW
should consider providing additional subsidies from the Project to Promote Special CVD
Countermeasures (which currently has a subsidy rate of 50%). One example of policy thatprovides a point of reference for evaluating initiatives based on clearly-defined evaluation
indicators are incentive grants for initiatives in long-term care prevention.

Government (Prefectures)● One option may be to reassign control measures in each disease to the most suitabledivision. This will combine all discussions on both the creation of plans as well as thosefor disease control measures, including preventive measures and the establishment ofemergency care provision systems.
● Another option to consider may be to consolidate each sections’ interviews with experts.
● It will also be important to utilize resources outside the government when advancing
measures for CVD control. Criteria for collaborative agreements should be developed in
anticipation of working with patient groups and other civil society organizations, as well aswith the private sector.
● Regarding council membership, in addition to specialists in CVD treatment, councils
should also include experts in public administration and public policy so feasible plans andmeasures can be developed.
● Encouraging involvement from patients and citizen council members in councils and relatedgroups during preliminary meetings and other early stages will create an environment
where discussion topics that require collaboration from each section can be identified fromthe perspectives of those who use administrative services.
● Citizen understanding should be promoted to help community members in the prefecture
understand and utilize Prefectural Plans. This might include presenting information withvisual aids in Prefectural Plan documents.

4Addendum

Academia and healthcare providers● The government performs a wide range of functions, so members of academia andhealthcare providers must understand the necessary functions of each section within
prefectural governments.
It● will also be important for members of academia and healthcare providers to continueemphasizing the need to promote initiatives for internal collaboration within thegovernment.

Industry● When forming comprehensive partnership agreements between the private sector andprefectural governments, spell out the value they can provide to prefectural governments
and citizens, then vigorously advance collaboration with prefectural governments whilereferring to examples in other fields.
● Stakeholders sometimes expect too much of other stakeholders, so joint activities should
be advanced after forming comprehensive cooperation agreements that clarify each party’s
responsibilities.
● Private sector activities can be expanded across multiple prefectures, so industry must be
willing to share examples of initiatives aimed at collaboration across prefectures.

Patients, affected parties, and citizens● Conveying the voices of patients and affected parties in a concrete manner at council
meetings or in the form of public comments or written requests will make the needfor cross-cutting, collaborative responses inside and outside of government agencies
apparent and can drive progress. Patients and affected parties must be proactive aboutcommunicating their needs from their perspectives.

5Addendum

01

02

Effectively
materials
03 using awareness-raising04

Current circumstances
Currently, Model Projects for Integrated Centers for Stroke and Heart Disease Support(hereinafter referred to as “Integrated Support Centers”) and prefectural governments areworking together to make many evidence-based, high-quality materials to raise awarenessabout CVD. A number of other materials to raise awareness for CVD have been developed
as part of initiatives undertaken for health promotion plans and of other frameworks. Privatecompanies are also actively participating in the development of these materials throughindustry-government-academia agreements.

Issues● The awareness-raising materials that have been developed are buried deep withingovernment websites. This may make it difficult for the general public to access accurate
information on CVDs.
● Different prefectures and health institutions are developing awareness-raising materials
with similar content.
● Integrated Support Centers must raise awareness for a wide range of topics, but a numberof items are unclear, such as the necessary range for prevention activities from primary
to tertiary prevention. This can result in inefficient project operations. For example,
prefectures and health institutions that wish to establish Integrated Support Centers may
require time to investigate what to include in awareness-raising activities.
● When developing awareness-raising materials, each prefecture must use accurate andreliable information based on scientific evidence. However, the newest findings, guidelines,
and other information are scattered, making it difficult for them to ensure that theirinformation is accurate.

Examples● Centered around Tochigi Prefecture, six prefectures (Tochigi Prefecture, Ibaraki Prefecture,
Mie Prefecture, Kyoto Prefecture, Fukuoka Prefecture, and Kumamoto Prefecture) worked
together to prepare materials for raising awareness.
● The MHLW has consolidated awareness-raising materials and has published them online.

6Addendum

Initiatives required from each stakeholder
Government (MHLW)● The MHLW should encourage efficient and effective operations at prefectural governments
when they are preparing awareness-raising materials.
● To disseminate awareness-raising materials published on the MHLW website, the MHLW
should make more active use of tools such as social networks and expand efforts to inform
people of their existence, including by cooperating with the mass media.
● When publishing awareness-raising materials, to ensure users have easy access to the rightinformation, websites should be designed to enable the systematic provision of informationand in a manner that takes user objectives into account. In addition to summarizing
awareness-raising materials from each body that produces them, providing information
along the patient journey (across prevention, examination, treatment, maintenance, andend-of-life) will make those materials more meaningful for patients and other affectedparties as well as for the parties that provide them, such as health professionals and local
governments.
● Creating links to and from materials from each prefecture and existing CVD control-relatedmaterials on the MHLW website will enhance policy synergy.
● The MHLW should cooperate with academia to support efforts to develop awarenessraising materials at prefectural governments and Integrated Support Centers by
establishing a portal site that serves as a centralized source of the latest research findings,
guidelines, and other information, and by producing materials on national policies that canserve as model materials for other parties.

Government (Prefectures)● While taking real-world conditions in each region into account, awareness-raising materials
should be produced through joint efforts among prefectures with common issues to makemore efficient use of CVD control measure budgets.
● As another option for making more efficient use of CVD control measure budgets,
prefectural governments should also consider using existing materials prepared by otherprefectures.
● Where feasible, it will also be important to assess the effectiveness of awareness-raising
activities. These effects can sometimes be measured without conducting new surveys. For
example, existing databases can be used to obtain accurate figures for items like medical
examination uptake and prescription volumes for therapeutics.
Another
option is to make proactive use of awareness-raising materials produced by parties●
such as private companies after carefully reviewing their content.

7Addendum

Academia and healthcare providers● Members of academia and healthcare providers should provide advice based on expert
insight when awareness-raising materials are being produced and, once those materials arecompleted and are being distributed, actively distribute them at all health institutions.
● To enable each health institution to make full and active use of awareness-raising materials,
the opinions of related institutions should be actively solicited from the earliest stages of
their production. This can also contribute to activities that will establish integrated systems
for raising CVD awareness in communities.

Industry● To take part in producing materials, industry should utilize its experience in diseaseawareness, including its efforts in other diseases, and actively participate in comprehensive
industry-government-academia collaboration or other suitable collaboration arrangements.
● Industry has a vast amount of know-how in areas like data analysis and can help awarenessraising measures achieve maximum impact by handling items like data analysis for
effectiveness assessments.
● When distributing awareness-raising materials, industry should make the most of its
network of health institutions to ensure efficient distribution.

Patients, affected parties, and citizens● Patients, affected parties, and citizens should help the government produce better
materials by providing active and constructive feedback based on their uniqueperspectives.
● Patients and affected parties should make full use of their own networks to ensure that themessage reaches those for whom it is intended, but who cannot be reached by private
facilities or the government.

8Addendum

02

03

Integrated Centers for Stroke and Heart Disease Support
04(Integrated Support Centers)

Current circumstances
In their first fiscal year of operation, Integrated Support Centers established by healthinstitutions are considered “Model Projects for Integrated Centers for Stroke and Heart
Disease Support” and are provided with direct subsidies of around 18 million yen from thenational Government. In subsequent fiscal years, they are considered “Special CVD Control
Projects,” which is a program targeting prefectural governments and has a subsidy rate of
50%. After completing the first fiscal year of operation, continued operations of these Centers
are handed off to prefectural governments, who manage them according to circumstances in
the prefecture, such as by outsourcing or subsidizing operations.

Challenges● The existence of Integrated Support Centers is not well-known among patients andaffected parties.
● Personnel costs account for a high percentage of total operating costs at Integrated
Support Centers. It is difficult to place full-time physicians at these centers or take othersteps to reinforce consultation support systems with current budgets.
● When establishing consultation counters, there is no physical space for new counters.
Oftentimes, new counters are created by renovating a distant portion of the building,hindering patient access.
Starting
in their second year of operations, prefectures must obtain funding to continue●
Integrated Support Center projects. This sometimes makes it unclear if they can becontinued. If they lack sufficient financial resources, prefectures and health institutions
that want to launch Integrated Support Center projects are unable to do so. Furthermore,
a Japanese Circulation Association survey found that after the first year, there is great
variance in budget size among prefectures.
● Evaluation indicators for Integrated Support Centers have yet to be defined and details
such as the number of consultations has yet to be disclosed, so each facility is conducting
assessments with different indicators.
● After being designated as model projects, Integrated Support Centers are launchedaround September or October at the earliest. This makes it difficult for prefectural
governments and health institutions to make evaluations for the next fiscal year’s budget
request.
● The relationships between health institutions and prefectures for providing consultation
support within Integrated Support Center projects are sometimes unclear, and all
prefectures have not yet determined whether they should be conducted as commissioned
projects or subsidized projects.

9Addendum

Examples● Before applying to establish an Integrated Support Center, the health institution thatwill operate it established methods of maintaining operations by securing a budget for
fiscal years after the first and without basing expectations on the presence of government
assistance.
● Confusion can occur regarding the entity operating an Integrated Support Center model
project when it is handed off to the prefecture in its second year of operations andoperations are outsourced. In one example, the prefecture and health institution consulted
with each other in advance and will maintain the same title throughout the initiative.
● Full-time prefectural government staff are being dispatched to some Integrated Support
Centers being operated as commissioned projects in certain municipalities. Issues related
to CVD are wide-ranging in nature and these full-time staff members are taking thelead in establishing and operating working groups to examine each issue individually.
Assigning these functions to Integrated Support Centers allows them to fulfill central roles
in promoting CVD control measures that are tailored to conditions in every region of theprefecture.
● In an effort led by the Japan Stroke Society, a Manual on Consultation Support Services for
Stroke has been developed and efforts to ensure high-quality consultation support havenow begun.

Initiatives required from each stakeholder
Government (MHLW)● One objective of Integrated Support Centers is to expand patient support systems
together with prefectural governments, but there are disparities in operations among
prefectures. For example, the state of cooperation between each Integrated Support
Center and its respective prefecture is sometimes unclear, or the division of roles among
Integrated Support Centers and other health institutions is sometimes undecided. When ahealth institution establishes an Integrated Support Center, they are not explicitly required
to structure their treatment systems so they can serve as a base hospital, but in practice,they are required to fulfill the role of a base hospital. To achieve equity in domestic CVD
countermeasures, past initiatives from Integrated Support Centers should be summarized,
their roles should be reiterated in clear terms, and their operational systems should bestandardized.
● To operate Integrated Support Center projects in a continuous manner, it will be necessary
to assess these initiatives in each prefecture. However, strict evaluation indicators have yet
to be set, so evaluation depends on the discretion of each prefecture. Working together
with academic societies, methods used to evaluate Integrated Support Center projects
should be unified. This will help achieve equity in consultation support services as well as
help prefectures that are launching new Integrated Support Center projects achieve more
concrete coordination with the health institutions that will operate them.

10Addendum
追補版

Government (Prefectures)● Difficulty in securing budgets makes it less likely that health institutions will implement
or reinforce Integrated Support Center projects. This means it is important to holdrepeated discussions from a medium- to long-term perspective after forming cooperative
arrangements with health institutions. These discussions should include how to coverpersonnel costs at Integrated Support Centers after the first fiscal year of operation.
Whilesecuring budgets from the national Government’s program for special projects●
for CVD control, discussions should be held on how to best operate Integrated Support
Centers to strengthen their ability to support patients. There should also be a clear divisionof roles between prefectural governments and the facilities that will introduce Integrated
Support Centers.
● To broadly inform people of and encourage them to use Integrated Support Centers,
effective referral and notification methods should be developed.

Academia and healthcare providers● In addition to providing consultation support services at their own facilities to improvehealthcare provision systems in each prefecture, Integrated Support Centers should also
serve as hubs for regional measures for CVD control.
● In the area of heart disease, it is important that health institutions and academic societies
work together to produce and revise consultation support manuals to ensure these services
are consistent.
● While consulting with each academic society and the MHLW, evaluation items for
Integrated Support Center projects should be standardized. Doing so will ensure evenquality among health institutions currently operating Integrated Support Center projects aswell as make it possible to establish a system to assist prefectures that have yet to launchsuch projects in their preparations to do so.

Industry● Industry should make full use of their networks in Japan and overseas to elevatecollaboration by supporting efforts from health institutions and prefectural governments.
This may include sharing initiatives among prefectures and case studies on consultation
services offered overseas.

Patients, affected parties, and citizens● Patients, affected parties, and citizens should make active use of Integrated Support
Centers and provide feedback. In cases where Centers are being operated undercommission from the prefecture, these parties should submit proposals on specific waysof improving these services to the prefectural government. This will help maintain andimprove Integrated Support Center services.
● Patients, affected parties, and citizens should actively encourage others to utilize Integrated
Support Centers through networks that connect patients and other affected parties.

11Addendum

03

04

The lack of data and establishing data analysis systems

Current circumstances
The Basic Act on CVD Measures stipulates that “a nationwide system for collecting andproviding information on cases related to CVDs shall be established,” but a CVD databasehas yet to be created. Discussions are currently being held on the need to keep pace withhealthcare DX throughout the country and to examine various aspects of operating a CVD
database, such as how to minimize workloads associated with data entry.
One proposal for evaluating Prefectural Plans offered at the Council for the Promotion of CVD
Control is to use evaluation indicators that, to a certain degree, offer complete coverage forthe prefecture. Tools being used as aggregate data for plan evaluation include the “Healthcare
Plan Preparation Support Data Book” (hereinafter the “Data Book”) and the “Regional
Medical Vision Preparation and Evaluation Support Tool,” which is based on scientific research
conducted through the MHLW Grants System.

Challenges● When evaluating Prefectural Plans, it is sometimes necessary to include all relevant cases
within the prefecture. However, the Data Book is based on the National Database of Health
Insurance Claims and Specific Health Checkups of Japan (NDB), which masks cases forwhich there are few examples and may lack the information necessary for plan evaluation.
● Evaluating CVD measures often requires information that cannot be obtained from healthinsurance claims data. This includes, for example, the number of patients with acute
myocardial infarction; the number of cases of acute myocardial infarction where the timefrom onset to medical examination was four hours or less; the percentage of patients withischemic heart disease whose time from hospital arrival to balloon dilation was 90 minutes
or less; and the Return-to-Work (RTW) rate for patients with CVD.
● The Data Books often contain data from the fiscal year prior to evaluation, so in prefectures
where medical resources are limited, information on when specific medical procedures
performed at specific health institutions start and end can become a direct issue thatemerges when examining a prefecture’s healthcare provision system. This requires
aggregating and evaluating data in real-time.
● Registration initiatives from related academic societies (such as the Japan Circulation
Society’s “Annual Survey of Clinical Practice” and “CVD Clinical Practice Survey”) covermost of the data discussed above, but their coverage is not complete.

Examples● Recognizing the lack of data to grasp current circumstances surrounding CVD andformulate measures, one prefecture is investigating and planning a new retrospective study.
● One prefecture will evaluate its plan using existing data from registration projects related
to CVDs conducted by local universities and medical associations.

12Addendum

Initiatives required from each stakeholder
Government (MHLW)● Communicating progress on the CVD database project and publicizing the direction of
epidemiologic surveys will be important. Many prefectures are considering conducting
new surveys to grasp local conditions during the processes of revising Prefectural Plans
and when planning initiatives based on those Plans. In the context of advancing efforts
for healthcare DX, disclosing the MHLW’s approach to data acquisition in existing CVD
countermeasures could become a source of information that helps prefectural governments
implement their own measures autonomously, starting with deciding whether or not to
conduct surveys.
● To enable each prefecture to evaluate its Prefectural Plan independently and over time, aplatform should be established that calculates age-adjusted mortality rates and other data
for each prefecture and that serves as a source of comprehensive information on CVDs
for patients, affected parties, their families, and citizens. One policy example of such aplatform is the National Cancer Center’s Cancer Information Service.

Government (Prefectures)● From the perspective of progressing healthcare DX, efforts to consolidate epidemiologicaland medical information through the national medical information network are currently
underway. In addition, data with near-complete coverage is available through registration
projects which are mainly operated by various academic societies. While it will be
important to formulate policies that accurately reﬂect current conditions in their respective
prefectures based on detailed surveys, municipalities may have limited manpower, so it
may be better for them to focus on formulating policies for numerous other issues related
to CVD.
● Another option may be to work with municipalities to evaluate measures and projects bygathering and analyzing electronic medical claims data from sources like National Health
Insurance and Diagnosis Procedure Combination (DPC) data.
● Many municipalities do not possess the necessary expertise to conduct data analysis,so they often evaluate their systems for providing care for CVD based on existing data
while using the Data Book, NBD Open Data, and other resources. However, making
effective use of databases and other tools can make it possible to establish support
systems that accurately reflect circumstances in their communities. This means it will be
important for prefectures that have taken part in projects like the “Project for Supporting
the Establishment of Data Analysis Teams for Regional Healthcare Provision Systems” toapply their know-how outside of the formulation of medical plans to establish systems fordata analysis. For prefectures that have not carried out such projects, it will be importantto establish systems that support the creation of a data analysis infrastructure throughindustry-government-academia collaboration.
● When launching new studies or creating databases, prefectural governments should
investigate methods of operating them that look to linking them to the nationwide
medical information platform with a view to the medium- to long-term on items like thesustainability of such projects.

13Addendum

Academia and healthcare providers● Members of academia should utilize their experience in database research and other fields
to cooperate with prefectural governments in data analysis and in formulating policies thatare tailored to actual conditions in each region.

Industry● Many private sector companies have implemented data analysis systems in recent years,
so in prefectures that lack the human resources or know-how for data analysis, the private
sector should support efforts to establish data analysis systems so measures for CVD
control can be appropriately formulated.

Patients, affected parties, and citizens● Patients, affected parties, and citizens should take an interest in policies related to CVD
control and use public comments and other opportunities to have their voices heard. They
should emphasize the importance of creating evidence-based healthcare policies that are
based on the perspectives of the people affected by those policies.

14

Developing and Expanding Cardiovascular Disease
Control Plans in Each Prefecture

Challenges and Good Examples for Cardiovascular Disease Control

Introduction
In Japan, cardiovascular diseases (CVDs) like stroke and heart disease are leading causes of deathand the most common conditions that require long-term care. One characteristic of CVDs is thatthe number of patients increases with age, making them a major problem for Japan and otherdeveloped countries where populations are aging. Given this backdrop, to advance all varieties ofmeasures for CVD control, the “Basic Act on Countermeasures for Stroke, Heart Disease and Other
CVDs to Extend Healthy Life Expectancies” (or the “Basic Act on CVD Measures”) was enacted in
December 2018 and came into effect in December 2019. Based on this law, the Japanese National
Plan for Promotion of Measures Against Cerebrovascular and Cardiovascular Disease was approved
by Cabinet Decision in October 2020. In accordance with the National Plan, each prefectural
government formulated a Prefectural Plan for the Promotion of CVD Countermeasures and is now
advancing efforts to promote CVD control. Furthermore, the National Plan was revised in April 2023,
and prefectures must revise their CVD control plans in the near future.
A broad variety of initiatives must be taken in the area of CVD control. These include establishingeffective systems for sharing patient treatment data and personal health records (PHRs); promoting
the health data policies and suitable outcome assessments needed for those systems; implementing
prevention measures that look forward to the needs of the next generation; advancing efforts forearly detection and risk detection; promoting cooperation among healthcare institutions; anddeveloping a healthcare provision system that provides seamless care from the acute stage to thechronic stage. In the midst of such efforts, good examples are beginning to emerge from eachprefecture, particularly those related to cultivating cooperation among local stakeholders. Many
prefectural officials in charge of CVD countermeasures have voiced the strong desire for chances
to refer to how other local governments are implementing their plans to learn about items likeformulating CVD control promotion plans, securing budgets, and obtaining subsidies.
Meanwhile, when implementing CVD countermeasures, there are a number of factors that result ingreat variance in challenges and necessary measures among regions. For example, the peak size ofthe senior population differs in each region. Geographical and cultural differences among regions
also mean that there is varying prevalence of diseases among regions. When formulating andimplementing plans that are tailored to real-world conditions in each region, it will be essential foreach region to refer to good examples from other regions to identify similarities and differences andeffectively apply what they learn.

16Given these circumstances surrounding CVD countermeasures, HGPI’s Cardiovascular Disease
Control Promotion Project activities for FY2022 included creating an opportunity for sharing anddiscussing best practices and lessons learned at an event titled the “Kyushu-Shikoku Summit
on Promoting Measures for CVD Control” held in October 2022. At the Summit, which aimed topromote collaboration among prefectures and examine concrete measures for implementing
CVD control plans, administrative officials involved in creating and implementing measures for
CVD control in the Kyushu and Shikoku regions cross-referenced measures by discussing current
circumstances, pointing out noteworthy issues, and sharing best practices. We then summarized
those discussions in, “Current Issues and Prospects for Advancing Cardiovascular Disease
Control Promotion Plans in Each Prefecture.” In April 2023, we hosted another summit to review
the discussion points raised at the Kyushu-Shikoku Summit called the “Nationwide Summit for
Promoting CVD Control.” This Nationwide Summit was attended by administrative officials fromall prefectures in Japan and involved multi-stakeholders whose cooperation will be necessary
when implementing CVD countermeasures in the future, such as people living with CVDs, patientadvocate leaders, and representatives of industry, Government, academia, and civil society.
Based on discussions held at the Kyushu-Shikoku Summit and Nationwide Summit, this documentcompiles good examples and issues from three perspectives on initiatives in each prefecture,
namely: (1) formulating plans tailored to actual conditions in each prefecture and evaluating them;(2) building an integrated support system centered on “Model Projects for Integrated Centers for
Stroke and Heart Disease Support;” and (3) promoting Patient and Public Involvement (PPI) in theprocesses for formulating and implementing CVD countermeasures. It also crystallizes common
points and discusses necessary future initiatives for each perspective.

17

Good examples and key points for future discussion identified
during Phase 2 of the Cardiovascular Disease Control
Promotion Project01

Formulating plans tailored to actual conditions in each
02plan evaluation 03
prefecture and

The “Basic Act on Countermeasures for Stroke, Heart Disease and Other CVDs to Extend
Healthy Life Expectancies” was enacted in 2018 and obligated prefectural governments
to formulate and implement plans to promote CVD countermeasures. In response,
each prefectural government formulated a Prefectural Plan for the Promotion of CVD
Countermeasures in 2021 and 2022, and CVD countermeasures which are tailored to the realworld conditions in each region are now in the process of being implemented. As Medical
Care Plans are set to be revised in 2024, many prefectures are currently evaluating andrevisiting their Prefectural Plans for the Promotion of CVD Countermeasures so they can berevised together. Given these circumstances, the following is a summary of good examples
of initiatives and solutions for the formulation and evaluation of Prefectural Plans for the
Promotion of CVD Countermeasures from each prefecture. We have also summarized points
that prefectural governments should keep in mind for advancing Prefectural Plans for the
Promotion of CVD Countermeasures in an effective manner.

Good examples● Implementing and evaluating new projects introduced in Prefectural Plans for the
Promotion of CVD Countermeasures was difficult because there was little time between
formulation and evaluation. Given the lack of time, one prefecture started by utilizing
existing projects to advance measures and generate results while planning new initiatives
at the same time.
● Because there was little time until evaluation, in their plan’s first phase, one prefecture
focused on establishing face-to-face relationships and developing systems to facilitatesmooth planning and implementation of future measures.
● One prefecture had been using a logic model since the formulation of the seventh revisionof the Medical Care Plan and has been involving healthcare institutions and university
hospitals in discussions and efforts to build consensus. Based on those experiences,the prefectural government was able to smoothly formulate a Prefectural Plan for the
Promotion of CVD Countermeasures that is compatible with real-world conditions in clinicalsettings and that is based on a logic model.
● To ensure revisions made to Prefectural Plans for the Promotion of CVD Countermeasures
were congruent with its Medical Care Plan, positions such as “Medical Coordination
Supervisor” were created to coordinate cross-departmental efforts with an overhead viewin each prefecture. This allowed those responsible for formulating plans to focus on theirown duties.

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● To facilitate collaboration among government, academia, and healthcare, in addition tocollaborating with healthcare specialists like physicians on the Council for the Promotionof CVD Measures, one prefecture made it easier to communicate and collaborate witheach stakeholder by working with coordinating departments (such as administrative or
general affairs departments) at healthcare institutions participating in the model project for
Integrated Centers.
● One prefecture held several liaison meetings per year to share challenges in communities.
They were attended by personnel at the assistant chief level of each section as well as the
project leader at the public health center.
● Working with a private company, one prefecture conducted a public awareness programon CVD countermeasures that included releasing a publicity video and other referencematerials.

Challenges● Many aspects of the measures and evaluation targets in Plans for the Promotion of CVD
Countermeasures overlap with those of other administrative plans (such as Medical
Care Plans, Health Promotion Plans, Prefectural Insured Long-Term Care Service Plans,
and Disability Welfare Plans). While the Ministry of Health, Labour and Welfare (MHLW)
issued a notification that allowed these plans to be formulated in an integrated manner(Administrative Communication “Regarding the Integrated Formulation of Medical Care
Plans and Other Plans,” March 31, 2023), doing so requires many meetings to be held anda great amount of coordination across departments to take place, so formulating plans in
an integrated manner is time-consuming.
● Because there was a short amount of time between when prefectures started formulatingplans (in 2021 or 2022) to their revision (the end of 2023), progress on individual measures
has not been made. It is also difficult to conduct plan assessments or the surveys needed
to conduct plan assessments.
The
periods for reviewing many administrative plans related to medicine, welfare, and●health will overlap in FY2024. This is likely to result in insufficient manpower for reviewingplans for CVD control and other individual diseases.
● Although one prefecture created a basic logic model while referring to recommendations
from academic societies and other organizations, it does not give sufficient consideration
to CVD countermeasures that are based on consultations with stakeholders, which is theoriginal objective. That logic model is now only presented in reference materials.
● Due to the nature of CVDs, Plans for the Promotion of CVD Countermeasures are closely
related to Medical Care Plans and other plans, especially in terms of prevention andawareness-building. However, in several prefectures, different departments are responsible
for each plan and efforts to manage progress in a coordinated manner are not progressing.
● Prefectural Councils for the Promotion of CVD Measures have different members thanPrefectural Councils for Acute Myocardial Infarction and Stroke described in Prefectural
Medical Care Plans. This can sometimes make it difficult to reconcile differences in opinion
even within a prefecture.
● In the operation of study groups, it is difficult to increase efficiency for the administrative
duties that accompany each study group. This is due to factors like the difficulty of
coordinating schedules for plan formulation meetings or the use of slightly different
formats in reference materials.

19Key points and future initiatives
We found three points in common related to formulating Prefectural Plans for the
Promotion of CVD Countermeasures: (1) securing human resources, establishingmanagement positions, and building systems for cross-departmental collaboration
at prefectural governments; (2) building systems for collaboration with external
stakeholders; and (3) planning methodologies.

Securing human resources, establishing management positions, andbuilding systems for cross-departmental collaboration at prefectural
governments
At some prefectural governments, staff numbers are falling while workloads increase. This
makes the formulation of administrative plans a major burden. In the Basic Policy on Economic
and Fiscal Management and Reform 2022 approved by Cabinet Decision in 2022, the section
titled, “A new division of duties between the national Government and local governments”
mentions that laws and regulations should keep the formulation of new plans to the bareminimum. It also states, “As long as there are no particular obstructions, then plans, etc.
should in principle be integrated with plans, etc. that have already been completed or be
developed jointly with other organizations.” In a March 2023 notification titled, “Regarding
the Integrated Formulation of Medical Care Plans and Other Plans,” the MHLW also
encouraged efforts to formulate Medical Care Plans and other plans in an integrated manner.
While progress is being made in the effort to lighten the burden of plan formulation, it has
also become clear that efforts to integrate plans face many practical barriers, such as when
jurisdiction for each plan belongs to a different department.
Many people – including both those who serve in administrative settings and community
members – would like to see the burden of plan formulation-related tasks lightened so more
effort can be devoted to services for citizens. In addition to standardizing the details of formats
used for each plan and coordinating formulation schedules, another necessary initiative will beto establish management positions (as described in the previous section, “Good examples”).

Building systems for collaboration with external stakeholders
The administration plays a key role in both policy-making and in policy implementation.
However, in an era when social issues that require a response are growing increasingly diverse,
collaborating with stakeholders outside of the government has become an essential partof carrying out policies. In particular, policy fields that demand a high level of specialized
knowledge for implementation (such as health, medicine, and welfare) also require
collaboration with professional associations, universities and other academic and research
institutions, and the people who are the beneficiaries of the policies in question, such as
patients and other affected parties.

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Furthermore, one goal in the movement toward New Public Management (NPM) is to improve
efficiency in administrative operations with an emphasis on public-private partnership-based
initiatives in all policy areas. In practical terms, utilizing private sector resources and engaging
in public-private collaboration have become essential for a Government that is faced with anever-increasing number of projects to implement and that lacks the option of expanding its
manpower. In the field of health policy, we can look forward to seeing the creation of higher
quality, more effective administrative services through the proactive utilization of private
sector ideas and know-how in areas like system development and information collaboration,
particularly for efforts to build awareness among and provide information to citizens.

Planning methodologies
One item being advanced under Prefectural Plans for the Promotion of CVD Countermeasures
is the use of logic models to systematize plan formulation and evaluation. Logic models
were invented in the U.S. in the 1970s and have since been adopted to promote EvidenceBased Policy Making (EBPM) around the world. In recent years, EBPM has been incorporated
into policy decision-making at many ministries and agencies in Japan, as well. In the field ofhealthcare, EBMP is being utilized in Medical Care Plans and in the Basic Plan to Promote
Cancer Control Programs.
In the area of CVD control, a civil society organization called the Regional Health PLAN
Evaluation Network (RH-PLANET) provides one example of a basic logic model. The Japanese
Circulation Society and the Japan Stroke Society have created and presented detailed logic
models in each field, and many prefectures are now developing their own logic models
based on their recommendations. However, many of the target outcomes included in these
prefectural logic models overlap with those of other related plans. There are also gaps
between prefectural project output and outcomes designated by academic societies andother organizations. In many cases, the development of logic models has become an objective
in and of itself, and the logic models that are developed are only being utilized as additionalreference materials. In other words, some of the logic models being created are not in linewith the intended purpose of utilizing them in policy making.
While it will be important to continue promoting the use of logic models nationwide, given
current circumstances, we must also point out that it will also be important to ensure theburden of developing logic models should not fall too heavily upon the prefectures that havebeen obligated with formulating plans. The development of logic models is not the goal;
rather, they are a method for advancing plan formulation in an effective and efficient manner.
In light of this fact, in the early formulation stages, it is safe to say that it will be necessary toallow for some discrepancy among individual project outputs and ideal outcomes, to avoid
setting too many evaluation indicators, and to consider limiting what items logic models areused for or making selective use of logic models when formulating plans. There are also highexpectations for prefectures to prevent these efforts from ending at the discussion table bycollaborating with local healthcare institutions, universities and other research institutions,professional associations, and patient advocacy organizations; and to focus on building
consensus early on in the plan formulation process, particularly when setting outcomes.

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01

02

Building an integrated support system centered on“Model Projects for Integrated Centers for Stroke and03
Heart Disease
Support” (hereinafter “integrated support
center projects”)

Under the Japanese National Plan for Promotion of Measures Against Cerebrovascular andCardiovascular Disease, integrated support centers are supposed to help establish systems
to deliver care for stroke, myocardial infarction, and other CVDs (duties which were originallyoutlined in prefectural Medical Care Plans) as well as to provide a broad variety of information
on topics like palliative care, employment support, and items that require consideration
during childhood and young adulthood. This means it will be important for integrated support
centers to collaborate with prefectures and play central roles in providing information in amanner that reﬂects past initiatives made at each facility as well as to enhance patient support
systems for their entire region. In FY2022, the first year of “Model Projects for Integrated
Centers for Stroke and Heart Disease Support,” integrated support center projects werecarried out in ten prefectures and at twelve facilities. Fifteen new prefectures and sixteen
new facilities were selected for model projects in FY2023, and they are currently preparing
to launch their initiatives. When there were no existing examples to refer to in FY2022, eachfacility and prefecture established a model project framework through mutual cooperation
among facilities, centered on academic societies. This helped lay a foundation for their future
activities. Expectations are high for the experience and knowledge accumulated over thecourse of these model projects to be utilized when other prefectures and facilities establish
new integrated support centers in the future. To this end, the Japanese Circulation Society
and other organizations are now working to compile case studies, mainly from healthcare
institutions. The MHLW also plans to establish a platform that will share best practices
for reference. Centered on joint action and initiatives from prefectural governments andhealthcare facilities when implementing integrated support center projects, the following
section summarizes good examples, challenges, and key points for achieving equity inintegrated support center projects.

Good examples● Discussions on formulating Prefectural Plans for the Promotion of CVD Countermeasuresand efforts to advance model projects are serving as a foundation for collaboration among
government, academia, and the health sector. In addition to prefectural governments anduniversity hospitals and other central healthcare institutions, this collaboration also includes
local medical associations.
● To reach out to both citizens and healthcare professionals and inform them of thesignificance of integrated support centers, one integrated support center is providing
lectures that are open to the public as well as workshops for healthcare professionals.
● One center is working to expand its consultation service user base by publicizing theavailability of the service online and in newspapers, leaflets, digital advertisements inapplications, and other forms of media.
● Officials from one prefectural government are participating in project management
meetings at the integrated support center every month, facilitating cooperation andleading to more active communication with healthcare institutions.

22

● One integrated support center is being operated without a significant expansion in
manpower by having staff members including nurses, social workers, and clerical staff
hold concurrent positions at existing cancer consultation services and other consultation
services.
● Because time was short between the establishment of the integrated support center andits evaluation, one center was not assessed by number of consultations for its first-year
evaluation. Rather, the prefecture conducted a qualitative evaluation that focused onenhancing consultation support services and gathering users’ voices.
● In one prefecture, multiple healthcare institutions applied to take part in the model project.
Facilities were selected based on an equal evaluation that included comparing facilities
using the plans they submitted as well as by providing opportunities for them to givepresentations.
One
prefecture built awareness toward the importance of collaboration among facilities●
other than those selected to conduct integrated support center projects. With support
from the facility taking part in the model project, which served as an “Integrated Stroke andHeart Disease Support Desk,” a list of contact information for related facilities was created
and a consultation desk was established to promote the creation of an integrated CVD
healthcare provision system in the prefecture.

Challenges● Each prefecture must secure a budget on its own if it is to continue operating integrated
support centers after the model project period ends, but making arrangements withfinancial departments has been difficult.
● Integrated support center projects are supposed to be operated jointly with prefectural
governments, but the roles of administrative bodies are unclear and each region issearching for methods to collaborate.
● Integrated support center projects are positioned to be able to provide an extremely broad
range of functions, making it difficult to achieve a shared understanding of the direction ofthese projects within healthcare institutions as well as among prefectures and healthcare
institutions.
● Problems related to securing human resources resulted in cases where the introduction of
integrated support center projects was delayed or in which applications to participate in
the model project were denied.
● Too little collaboration among central healthcare institutions and prefectural governments
has resulted in cases where applications to launch model projects were rejected or did notproceed in a smooth manner once approved.
● In regions with many small- to medium-scale healthcare institutions, little progress has
been made in providing support for patients who have completed acute care and aretransitioning to chronic care. Expectations are high for integrated support centers to help
support smoother transitions to chronic care.

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Key points and future initiatives
We identified four common points among integrated support centers that are currently
being operated as model projects: (1) clarifying the functions of integrated support
centers; (2) promoting collaboration among Government, civil society, academia, andmedicine; (3) building systems for continuous operations; and (4) fostering mutual
collaboration among major hospitals.

Clarifying the functions of integrated support center projects
With the goal of enhancing patient support throughout each prefecture, ongoing integrated
support center projects are being utilized to provide a broad variety of support. This includes
transitional support from the acute phase to the chronic phase, psychological support, andemployment support. However, a number of drawbacks have emerged due to the scope ofthese operations. For example, some have said that undefined support targets have resulted
in a lack of focus in project operations at healthcare institutions where there is no sharedunderstanding toward the direction of the model project. While seemingly contradictory to
the concept of “integrated,” overcoming this issue requires maintaining the view that thebroad range of support defined in the model project is ideal and comparing the prefecture’s
priorities with the resources at the facilities where the integrated support center will beestablished is to identify which services should be the focus of the integrated support center.
For example, centers can provide consultation services to the general public; play central roles
in integrated community care, including in cooperation among healthcare institutions; and,for difficult cases only, provide specialized services. Identifying the priority of the integrated
support center and setting a direction beforehand is likely to foster common understanding,promote multidisciplinary cooperation within facilities, and encourage cooperation among
healthcare institutions.

Promoting collaboration among government, civil society, academia,
and medicine
To successfully build an integrated healthcare provision system for CVDs through integrated
support center projects, it is vital for there to be collaboration among each stakeholder,
including healthcare institutions in communities in addition to the institutions that implement
integrated support center projects. However, upon reviewing feedback from people serving at
the centers, there were cases in which stakeholders did not possess a common understandingof the functions and objectives of integrated support centers, meaning community-wide
support systems were not established. First, consensus and common understanding must be
fostered among institutions and prefectural officials conducting integrated support center
projects and other relevant stakeholders, such as cooperating healthcare institutions, as wellas among patients and other affected parties, who are the primary users. Given that efforts toseparate hospital care beds by function will progress in the future, expectations are high for
healthcare institutions taking part in model projects to cooperate with healthcare institutions
experiencing manpower shortages, such as small- and medium-sized institutions, and play
central roles in supporting patients during the transition from the acute phase to the chronic
phase. In addition to providing medical and long-term care, there are also high expectations
for the creation of systems that provide continuous support for patients and other affectedparties who are vulnerable to isolation by building connections among patients and otheraffected parties through activities like providing information and holding patient gatherings.

24Building systems for continuous operations
While integrated support centers will be established in each prefecture in the future, in orderfor them to function as an infrastructure for CVD control, it will be essential to build a systemthat allows them to operate in a sustainable manner. However, the national Government
only provides financial support for operational expenses for a single fiscal year. While partial
support from the national Government will continue after that year, prefectural governments
and facilities will have to secure budgets on their own. Securing budgets in prefectures will
require persuading financial departments, which means the projects must generate as many
results as possible over very short timeframes. In addition to quantitative evaluation indicatorssuch as the number of times consultation support is provided, it will be necessary to include
indicators that are based on qualitative assessments, as well. While it depends on establishingintegrated support center projects in each prefecture, it may also be possible to assign staff onother projects to concurrent roles to provide consultation support programs. Another option
is to improve consultation support systems to the greatest extent possible within existing
systems. For example, specialists at healthcare institutions designated as core cancer hospitals
could be appointed to concurrent roles as consultation support providers for the areas where
their expertise overlaps. These specialists might include counselors like nurses or medicalsocial workers as well as certified psychologists, clinical psychologists, or clerical staff. Anotheroption might be to establish a framework for developing specialist human resources like heart
failure treatment counselors. It will also be necessary to create a framework for encouraging
creativity and ingenuity in building sustainable systems, such as by establishing additional
support for the aforementioned initiatives.

Fostering mutual collaboration among major hospitals
As a general rule, integrated support center projects are being implemented at an extremely
limited number of facilities in each prefecture – in most cases, only one. This means that whena single large-scale healthcare institution applies to launch an integrated support center
project, the number of people who can lead the project after it is adopted is limited. Many said
that this allows efforts to establish integrated support centers to proceed relatively smoothly,such as when communicating with prefectural governments. Meanwhile, when multiple
healthcare institutions applied to launch a project, one prefecture created a fairer selection
process by providing opportunities for them to give presentations in addition to document
screening. When utilizing such a process, it is also important for prefectural governments tolead efforts to encourage role-sharing and cooperation by building better understanding fromthe institutions that were not selected and by having them participate in regional networks
after projects are launched. Expectations are high for the successful establishment of systems
that enable collaboration among multiple large-scale healthcare institutions when integrated
support center projects are implemented in major metropolitan areas in the future. Flexible
collaboration that leverages the unique strengths of each healthcare institution will also benecessary. For example, this might include dividing roles among facilities for heart diseaseand cerebrovascular diseases. It will also be important to maintain an awareness that creating
systems that are truly significant for patients and other affected parties is of the utmost
importance, and that establishing an integrated healthcare provision system will requiredevoted efforts from every related party.

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03

02

Promoting Patient and Public Involvement (PPI) in
the processes for formulating and implementing CVD
countermeasures

In recent years, patients and other affected parties who are the recipients of medical andlong-term care services have become increasingly involved in the policy formulation process,particularly in the fields of cancer and dementia. As for CVD control, Articles 20 and 21 of
the Basic Act on CVD Measures stipulate that Councils for the Promotion of CVD Measuresestablished at the national and prefectural levels must involve patients and other affectedparties. These parties are now participating on councils in many prefectures, where theopinions they express drive discussions from the perspectives of those most affected andare later reﬂected in policies and measures. However, there is great information asymmetry
between these parties and healthcare providers, who are generally specialists in medicine.
This lack of specialized knowledge prevents adequate discussions from being held. To further
promote CVD countermeasures from the perspectives of those most affected, the following
section compiles key points for the future that are based on good examples and issues fromeach prefecture and that are related to collecting and reflecting the voices of patients andother affected parties.

Good examples● Involvement from patients and other affected parties on Prefectural Councils for the
Promotion of CVD Measures made it possible for meetings to cover points that only
those most affected would notice. This led to the formulation of plans that placed greater
emphasis on the perspectives of those most affected.
● Patients and other affected parties were not accustomed to speaking up at Council
meetings and other meetings. To help them fully express their opinions and participate,detailed explanations and consultations were provided in advance.
Inaddition to getting patients and other affected parties involved in the Prefectural Council●
for the Promotion of CVD Measures, one prefecture is working to implement patient- andpatient advocate-centered measures by collaborating with an awareness-raising initiative.
● One useful method of reflecting the opinions of patients and other affected parties inan effective manner is to issue an open call for applications for patient council members.
Efforts to build awareness toward the council were undertaken with physicians and othercouncil members and successfully increased the number of applications.

26

Challenges● While it would be desirable to have patients and other affected parties who took part in
the plan formulation process also be involved in other initiatives like public awarenessprograms, in some cases, this is difficult due to the need to make arrangements aroundtheir work schedules and daily lives.
CVD
countermeasures target a broad variety of diseases and patient populations, which●makes it difficult to crystallize opinions that are representative of those most affected andreﬂect them in plans. For example, people in different stages of treatment have different
needs. Furthermore, issues vary by region. It also can be difficult to identify patientadvocacy organizations, and many of the affected parties are not members of patientadvocacy organizations.
● While issuing an open call for applications increased the total number of applications,setting selection criteria was difficult.

Key points and future initiatives
We found three key, common points regarding the promotion of PPI: (1) identifying
people living with CVDs and other affected parties and encouraging their involvement;(2) providing support and consideration to facilitate participation in discussion forums;and (3) securing diverse methods of involvement and opinion gathering.

Identifying people living with CVDs and other affected parties andencouraging their involvement
Before Prefectural Plans for the Promotion of CVD Countermeasures can be formulated andpromoted, it is first necessary to recruit patients and other affected parties who are the targetof those plans so they can be involved. Many Prefectural Councils for the Promotion of CVD
Measures already have patient advocate council members, many of whom were recruited byphysicians who are also council members. Ideally, it would be most effective if each region
had patient advocacy organizations that could participate in council meetings and serve
as a resource for gathering opinions. In the modern era, however, people can access theinformation they need over the internet without joining a patient advocacy organization. Thisis said to be a factor that is causing membership and formation rates for patient advocacy
organizations to decline. Furthermore, many CVDs are acute diseases, so it is more difficult toform patient advocacy associations compared to chronic diseases, which people live with forlong periods of time.
Given this backdrop, more diverse methods of recruiting people for PPI should be considered.
Some prefectures have already started using open recruitment to find members of the generalpublic who can serve as patient advocate council members. While using open recruitment isa fair method of recruiting council members, the number of applications can be inﬂuenced
by the amount of publicity these efforts are given as well as the methods used. It can also be
difficult to determine selection criteria.

27

Providing support and consideration to facilitate participation in
discussion forums
Various discussions on topics like healthcare provision systems and academic research arebeing held at Prefectural Councils for the Promotion of CVD Measures. For council members
to be able to participate in discussions and provide appropriate comments, they must be
familiar with specialized knowledge from each field. However, compared to specialists who
have been serving in their fields for many years, it is difficult for patient advocate council
members to acquire adequate knowledge to participate in these discussions. To help address
this, some prefectures are providing support for patient advocate council members so they
can fully participate in discussion forums, such as by holding briefings for them before council
meetings. However, some of the personnel responsible for council operations have said
that it was difficult for patient advocate council members to fully participate, even after suchopportunities were provided. While some civil society organizations are making progressin training patient advocate council members, such efforts will also require public support.
Moving forward, expectations are high for each prefecture to undertake various efforts to
support patient advocate council member training, and it is desirable that they share such
efforts with each other to improve the quality of PPI. In addition to efforts from patients andother affected parties as well as prefectural governments, it will also be important to promote
more significant PPI through efforts from all council members. For example, this might include
asking other council members to use language that is easy to understand for patient advocate
council members in attendance.

Securing diverse methods of involvement and opinion gathering
Participation in the policy formulation process is not necessarily limited to council meetingsand other discussion forums. The “Guidelines for Formulating Prefectural CVD Control
Promotion Plans” also point out the need to provide various methods for PPI, saying, “Efforts
should be devoted to reflect the opinions of patients and community members by holding
town meetings, conducting hearings and surveys among patients and community members,
and by gathering public comments.” CVD countermeasures target an extremely broad rangeof diseases and patients, so crystallizing opinions that are representative of those mostaffected is likely to be difficult in the short amount of time available for consensus-building
at council meetings. As these opinions might not fully represent the opinions of those mostaffected, such discussions should be supplemented with increased diversity.
When formulating their Prefectural Plans for the Promotion of CVD Countermeasures, many
prefectural governments also gathered public comments, which is a representative example ofone method for people to participate in the policy-making process outside of joining council
meetings. A few advanced prefectures also held town meetings. When utilizing measures likethese, there is a great amount of knowledge that can be learned by referring to when they
were used in other fields such as cancer and dementia. In the future, it will also be important
to gradually expand initiatives to introduce various methods of gathering opinions. Quality islikely to improve as know-how is accumulated.
HGPI has conducted a project on the theme of achieving patient-centered health policy. For more
information on topics related to PPI in the policy formulation process, such as initiatives in otherdisease areas and enhancing support for councils, please refer our recommendations titled, “Further
Promoting Patient and Public Involvement in the Policy-Making Process: Steps for Achieving
Healthcare Policies That Are Truly Centered on Patients and Citizens” (presented on July 1, 2022).

28

Acknowledgments
The recommendations in this report were crystallized from discussions held withrepresentatives of industry, Government, academia, and civil society who participated in the“Kyushu-Shikoku Summit on Promoting Measures for CVD Control” and the “Nationwide
Summit for Promoting CVD Control,” which were held as part of the HGPI) Cardiovascular
Disease Control Promotion Project. Additionally, we have extracted information based on
individual interviews conducted after the publication of the main text in September 2023.
We express our deepest gratitude to the experts and administrative officials responsible
for advancing CVD countermeasures in each prefecture who spoke at these events and therepresentatives from industry, government, academia, and civil society who provided feedback
for the creation of the addendum edition.

Regarding the independent nature of these recommendations
This report is based on discussions at meetings HGPI held for this project and has been
compiled in HGPI’s capacity as an independent health policy think-tank. It does not, inany capacity, represent the opinions of any participating expert, speaker, related party, ororganization to which those parties are affiliated. This report is copyright 2023 Health andGlobal Policy Institute.

Introducing Health and Global Policy Institute (HGPI)
Health and Global Policy Institute (HGPI) is a non-profit, independent, non-partisan healthpolicy think tank established in 2004. In its capacity as a neutral think-tank, HGPI involves
stakeholders from wide-ranging fields of expertise to provide policy options to the public tosuccessfully create citizen-focused healthcare policies. Looking to the future, HGPI produces
novel ideas and values from a standpoint that offers a wide perspective. It aims to realizea healthy and fair society while holding fast to its independence to avoid being bound to
the specific interests of political parties and other organizations. HGPI will continue working
actively to generate policy options that will be effective in Japan and around the world andthat will contribute to resolving global health challenges. HGPI’s activities have received global
recognition. HGPI was ranked second in the “Domestic Health Policy Think Tanks” category
and third in the “Global Health Policy Think Tanks” category in the Global Go To Think Tank
Index Report presented by the University of Pennsylvania (as of January 2021, the most recent
report).

Author: The Health and Global Policy Institute (HGPI) Cardiovascular Disease Control
Promotion Project (in no particular order)
Shunichiro Kurita(Senior Manager, HGPI)
Shotaro Tsukamoto(Senior Associate, HGPI)Ryoji Noritake(CEO, Board Member, HGPI)

29

MEMO

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