The Japanese State of Health: A Political-Economic Perspective
William E. Steslicke
The Postwar “Health Miracle”
When compared with conditions at the end of World War II, the generally high standard of living enjoyed by contemporary Japanese seems amazing.1 Indeed, the recovery from the devastation of defeat and the subsequent rapid growth in the production of goods and services are often referred to as Japan’s “economic miracle.” The international attention and acclaim that Japan’s economic recovery and growth have received have, in fact, tended to overshadow other postwar Japanese accomplishments. Yet, to borrow a metaphor, a virtual “health miracle” has also taken place in postwar Japan. In terms of most commonly accepted indicators, the Japanese state of health at the beginning of the 1980s was among the highest in the world. In 1945 the estimated life expectancy at birth for Japanese males was 23.9 years and for females 37.5 years. By 1984 the average life expectancy for males had increased to 74.54 years and for females to 80.18 years (table 1). These figures were the highest in the world.
Japan’s economic and health “miracles” are not unrelated. As pointed out in the recent World Health Organization study, “Countries with a high gross national product have a low infant mortality rate and a high life expectancy, the opposite being the case for countries with a low GNP” (WHO 1981, 21–22). Although a number of other factors contribute to the state of health in various nations, clearly economic development provides the capacity for bringing other important factors into play. Still, it would be wrong to conclude that the relationship is simple and unilinear (Abel-Smith 1976, 138–197; Renaud 1975, 559–571). Improved health status and effective public health and medical care programs contribute to economic development, but economic development 25also gives rise to new health hazards. If the Japanese have enjoyed the benefits of economic development, the victims of Minamata disease, Yokkaichi asthma, “Itai-Itai” disease, and other ailments can testify to the pain that has accompanied the high-growth strategy of the postwar period. Admirers of the Japanese model tend to ignore this side of the balance sheet (Huddle and Reich 1975).
Table 1. Average Life Expectancy at Birth: Japan and Other Nations
England and Wales
England and Wales
Federal Republic of Germany
Federal Republic of Germany
Source: Kōsei Tōkei Kyōkai (1985, 79).
Note: Figures for Japan, 1984; Iceland, 1981–1982; Sweden, 1983; Holland, 1982; Norway, 1981–1982; United States, 1983; England, 1980–1982; France, 1982; Federal Republic of Germany, 1981–1983.
Neither “miracle,” therefore, is without blemish. Nor is it possible to certify the intervention of a divine hand in the economic and health sectors. Much more apparent in both cases is the intervention of the Japanese state and its only too mortal agents. While a precise measurement of cause and effect is impossible, the evidence strongly supports the proposition that a Japanese version of the “developmental state” was an essential component of high economic growth.2 The concept of a “developmental state” and the particular set of priorities adopted by its agents are also important to an appreciation of the state of health in contemporary Japan and the problems and issues of the present and foreseeable future (Steslicke 1982c). A brief review of the Japanese state of health as of 1980 in terms of some of the more widely used indicators is a necessary preface to further discussion.
The Japanese State of Health
To the extent that such things can be ascertained by national surveys, it appears that Japanese citizens place a very high priority on good health 26and medical care. Every three years since 1972 the Economic Planning Agency has conducted national surveys on living standards. These surveys utilize ten categories related to daily life: (1) education and culture, (2) employment and quality of working life, (3) family, (4) income and consumption, (5) justice and social welfare, (6) living environment, (7) medical care and health, (8) quality of community life, (9) security and protection of individuals, and (10) vacation and leisure. In response to the question, “Which areas are important to your life at present and in the future?” 35.3 percent of those selected for the 1981 survey indicated that medical care and health was their top priority. Roughly 84 percent included medical care and health among their top five priorities. Not only the mature and elderly, but all segments of the population placed a high priority on medical care and health (Economic Planning Agency 1981, 243).
Although it is difficult to assess the importance of attitudes on the actual distribution of health and illness in the population, the generally positive orientation to health and medical care in Japan is surely an important influence on the state of health as measured by the conventional objective indicators.3 Certainly, attitudes have an important bearing on the more qualitative aspects of health and medical care (Caudill 1976). Also, widespread expectations of a long and healthy life must be taken into account by those who seek to establish and implement national priorities. Not only was life expectancy at birth the highest in the world as of 1980, so too was life expectancy at age sixty for both men (18.27 years) and women (21.96 years).4 These expectations place new burdens on the health care system as well as on national resources in general. Given the imperatives of Japan’s rapidly aging society and the leveling off of economic growth, it may prove impossible to improve or even maintain the comparatively high state of health (Ogawa 1982; Tominaga 1983). Whether the positive orientation toward health and medical care will be sustained remains to be seen.
One of two persons born in 1980 could expect to live to age eighty; however, in that same year 722,792 persons died. The fluctuation in the death rate per 1,000 persons between 1955 and 1980 was slight (from 7.8 to 6.2 per 1,000 persons). However, the age distribution changed markedly. In 1955, of 690,000 deaths, 17.3 percent were fourteen years of age or below; in 1980 this ratio dropped to 2.9 percent. A corresponding decrease in the mortality rate in the age fifteen to sixty-four category from 38.6 percent to 27.5 percent was also recorded. By 1980, 69.6 percent 27 of the deaths were among persons of sixty-five years or older, as compared with 44.1 percent in 1955. The changing distribution reflects the demographic change that has taken place and the sharp decrease in infant mortality as well as in tuberculosis-related deaths in the age category fifteen to sixty-four.
In causes of death, the increase is quite remarkable in so-called adult diseases, particularly cancer, heart disease, and cirrhosis of the liver. Between 1960 and 1980, cerebrovascular and hypertensive disease as causes of death increased by 8.1 percent and 5.3 percent, respectively, but cancer increased by 72.4 percent, heart disease by 80.5 percent, and cirrhosis of the liver by 81.6 percent. The increase in the latter was especially sharp in the forty to fifty age category. There was a decrease in tuberculosis, gastroenteritis, gastric ulcer, nephritis, and pneumonia as causes of death over the same period. Table 2 shows the change in incidence of the causes of death between 1960 and 1980. Although the top three held fast during that period, the relative increase in cancer and heart disease has aroused considerable concern. In table 3, the leading causes of death in Japan in 1980 are compared with figures from four other major industrial nations. It is interesting that Japan compares quite favorably with these nations in terms of motor vehicle and other accidental deaths. Between 1960 and 1980, the rate per 100,000 of accidental deaths decreased from 41.7 in 1960 and 42.5 in 1970 to 13.7 in 1980. This means about 30,000 accidental deaths a year at present, of which over 13,000 are motor vehicle or traffic related. It has been estimated that in the postwar era one of every ten Japanese has been injured in a traffic accident. Obviously, given the spectacular increase in automobiles in recent times, the problem is chronic (Kubota 1980; Japan Institute of Labor 1982).
Work-related deaths and injuries are similarly chronic. In 1980, 3,009 persons were killed and 336,000 persons injured at work. The trend in work-related fatalities between 1965 and 1980 is shown in table 4. As indicated, there has been a steady decline since 1965, especially in the construction and manufacturing industries and, as a consequence of the reduction in scale of those industries, a corresponding decline in mining and forestry fatalities and injuries.
Finally, note should be taken of suicide as a cause of death (21.6 per 100,000 population in 1960, 15.3 in 1970, and 17.7 in 1980). A great deal has been written about the relatively high rate of suicide in contemporary Japan (see, for example, Iga et a!. 1978). What is not widely 28known, however, is the increased incidence among middle-aged males since the late 1960s. In the 1950s and 1960s, the age distribution of suicides described an “N” curve, with one peak at the twenty to twenty-four age group, the other at the high end of the age scale, with the thirty-five to forty-four age group providing the valley. The postwar high in the suicide rate (25.7 persons per 100,000) was reached in 1958. The rate then declined to a postwar low of 14.2 per 100,000 in 1967. There has been a gradual increase since then, mainly in the former valley of middle-aged males—thus changing the shape of the “N” curve. According to National Police Agency data for 1980 related to motives for suicide, within the age forty to forty-nine category, 35.1 percent apparently suffered from disease, but 20.4 percent were apparently troubled by economic problems (table 5).
Table 2. Leading Causes of Death in Japan, 1960–1980
|Cirrhosis of the liver|
|Cirrhosis of the liver
Source: Economic Planning Agency, Govt. of Japan (1981, 105).
Note: Figures in parentheses indicate death rate per 100,000 population.29
Table 3. Leading Causes of Death in Five Industrial Nations
|Cause of death||(1980)||(1977)||(1977)||(1976)||(1978)|
|Cirrhosis of the liver||14.2||14.3||3.7||32.9||27.6|
|Motor vehicle accidents||10.1||22.9||11.9||23.3||23.1|
Source: Economic Planning Agency, Govt. of Japan (1981, 107).
Note: Unit: number of deaths per 100,000 persons.
Table 4. Work-Related Fatalities in Japan, 1965–1980
|(Change in percentage)||%||%||%||%||%||%||%|
Source: Economic Planning Agency, Govt. of Japan (1981, 117). 30
Before shifting the focus of this review from mainly mortality-related statistics to an examination of morbidity indicators, it should once again be emphasized that definitive description of the national state of health is not the objective here.5 Rather, the more limited goal is to present such information as is readily available in support of the general impression that the state of health in Japan has a high international ranking. The most important source of data is the annual National Health Survey (Kokumin Kenkō Chōsa) conducted since 1953 by the Ministry of Health and Welfare (Kōseishō). In 1980 some 54,000 persons from 16,000 households selected as a stratified random sample were interviewed between September 15 and 17 in order to estimate the extent of injury, disease, and medical treatment in Japan. Some of the major findings follow.
Of the total number of households included in the sample, 25.9 percent reported one or more injured or diseased members (up from 25.8 percent in 1979) and 10.0 percent of those individuals interviewed reported personal injury or disease (also 10.0 percent in 1979). In terms of the morbidity or prevalence rate, estimated at 110.4 per 1,000 persons, it seems that one in every 9.1 Japanese was injured or ill in 1980. This figure has remained relatively stable for the past several years. As indicated in table 6, diseases of the circulatory system had the highest rate at 36.6. Within that category, the rate of hypertensive disease was 24.1 per 1,000 persons. Diseases of the respiratory system (15.5) and diseases of the digestive system (14.4) were the next two highest categories reported.
Table 5. Motive for Suicide in Japan, 1980
|Suffering from Diseases||Alcoholism-Mental Disorder||Home-Related Problems||Work-Related Problems||Economic Problems||Other|
|(male and female)|
Source: Economic Planning Agency, Govt. of Japan (1981, 109).31
Table 6. Yearly Change in Prevalence Rates by Category per 1,000 Persons
|Infectious and parasitic diseases||7.7||4.4||3.7||2.5||3.7||3.6||2.8||2.9||2.5|
|Endocrine, nutritional and metabolic diseases, and immunity disorders||0.7||1.2||2.0||2.6||3.1||3.5||3.3||4.9||5.4|
|Diseases of the blood and blood-forming organs||0.2||0.5||0.7||0.8||0.8||0.8||0.8||0.9||0.8|
|Diseases of the nervous system and sense organs||4.8||7.9||11.2||10.4||12.0||9.8||9.3||5.4||5.8|
|Diseases of the circulatory system||3.3||11.9||21.6||23.3||28.7||30.1||26.6||31.3||36.6|
|Diseases of the respiratory system||5.5||8.2||14.4||30.8||26.3||25.8||25.5||17.9||15.5|
|Diseases of the digestive system||6.5||13.8||17.9||15.4||16.2||16.4||16.5||15.9||14.4|
|Diseases of dental and dental sustentacular tissue||1.9||5.0||6.9||3.8||3.8||3.9||3.9||3.4||3.4|
|Diseases of the genitourinary system||0.8||1.6||1.8||2.3||2.4||2.6||2.9||2.4||2.4|
|Complications of pregnancy, childbirth, and the puerperium||0.2||0.2||0.1||0.1||0.2||0.1||0.1||0.2||0.2|
|Diseases of the skin and subcutaneous tissue||2.0||2.1||3.2||3.5||3.7||3.1||2.7||3.0||3.3|
|Diseases of the musculoskeletal system and connective tissue||1.5||3.6||5.6||6.3||6.5||7.6||7.3||11.9||10.7|
|Certain conditions originating in the perinatal period||0.0||0.1||—||0.0||0.0||0.0||0.0||—||0.0|
|Symptoms, signs, and ill-defined conditions||1.0||1.2||2.5||2.5||1.9||2.4||2.4||2.7||2.2|
|Injury and poisoning||2.3||4.2||6.2||7.4||8.8||7.4||8.5||7.6||8.5|
|Treatment with dental prosthetic device||0.4||0.5||0.6||0.1||0.1||0.2||0.1||0.2||0.0|
Source: Ministry of Health and Welfare (1981b, 5).
Note: The 9th International classiflcation for disease, injury, and cause of death has been adopted since 1979. For this reason the names of diseases and classifications may not necessarily coincide with those prior to 1978.32
Table 7. Prevalence Rates by Disease and Age Bracket
|Age Bracket||75 and||70 and|
|Infectious and parasitic diseases||2.5||4.6||2.6||0.3||2.1||1.7||3.3||2.5||5.3||2.9||3.8|
|Endocrine, nutritional and metabolic diseases, and immunity disorders||5.4||—||—||0.7||1.8||4.0||5.6||14.1||23.4||14.1||19.3|
|Diseases of the blood and blood-forming organs||0.8||—||—||0.1||0.2||0.9||1.0||1.9||2.9||2.9||2.2|
|Diseases of the nervous system and sense organs||5.8||4.8||4.1||1.7||2.4||3.8||4.2||10.4||18.4||28.8||23.7|
|Diseases of the circulatory system||36.6||0.5||0.3||0.7||2.9||13.2||40.4||106.7||173.7||241.9||224.2|
|Diseases of the respiratory system||15.5||48.6||24.9||7.1||10.1||8.8||8.3||12.0||18.1||21.2||20.2|
|Diseases of the digestive system||14.4||3.8||5.1||5.6||7.9||16.4||24.0||30.5||29.5||27.1||30.9|
|Diseases of dental and dental sustentacular tissue||3.4||1.9||4.1||2.2||3.2||4.2||4.0||3.7||3.5||0.6||1.6|
|Diseases of the genitourinary system||2.4||—||0.9||1.3||2.3||2.7||3.0||4.4||3.2||8.2||5.7|
|Complications of pregnancy, childbirth, and the puerperium||0.2||—||—||0.4||0.6||0.2||—||—||—||—||—|
|Diseases of the skin and subcutaneous tissue||3.3||9.7||4.7||2.5||2.3||2.7||1.5||3.1||2.0||5.3||3.8|
|Diseases of the musculoskeletal system and connective tissue||10.7||—||0.8||1.4||2.5||7.0||12.7||30.9||42.7||53.6||54.0|
|Certain conditions originating in the perinatal period||0.0||0.3||—||—||—||—||—||—||—||—||—|
|Symptoms, signs, and ill-defined conditions||2.2||1.6||1.9||1.2||1.4||1.8||3.3||1.5||2.0||14.1||8.5|
|Injury and poisoning||8.5||13.3||10.1||5.9||5.2||9.2||8.0||10.2||9.6||10.0||10.4|
|Treatment with dental prosthetic device||0.0||—||—||—||0.1||—||—||—||—||—||—|
Source: Ministry of Health and Welfare (1981a, 6).
Table 7 shows morbidity rates by disease and age bracket. Note that the general rate of 87.4 in the zero to four age group tapers off to a low of 30.2 in the fifteen to twenty-four age group, and then gradually increases to 437.3 in the seventy-five and above bracket. Persons under thirty-five years old reported the highest rate for diseases of the respiratory system; those between thirty-five and forty-four, digestive disorders; and persons forty-five and above, diseases of the circulatory system. The overall morbidity rate was higher for females (117.8) than for males (102.6) and higher in large cities (121.7) than in smaller communities, where the morbidity rates ranged from 103.4 to 112.0. Males reported the highest rates for injury and poisoning and females reported the highest rates for diseases of the circulatory system, musculoskeletal system and connective tissue, nervous system, and sense organs.
It is worth noting that, while seven of every ten persons reported that they were in good health, only 1.3 percent indicated that they had received no medical treatment during the year of the survey. Of those receiving some sort of treatment, 87.5 percent went to hospitals or clinics, 8.8 percent purchased drugs at pharmacies, and 1.4 percent relied on massage, acupuncture, moxibustion, and judo corrective exercises. Of the total, over 40 percent reported taking at least one type of medication during the month before the survey.
Concluding this review of the Japanese state of health, it should be noted that the majority of those included in the 1980 survey (61.9 percent) reported that they had not been confined to bed during the survey year, and 30.5 percent reported bed stays of from one to ten days. As might be expected, the older age groups reported more and longer bed stays, but the majority of persons in all age categories, including those of years seventy-five and older, reported no bed stays. Nevertheless, the institutionalization rate for the population sixty-five and older is quite high, having increased from 0.9 percent in 1955 to 5.6 percent in 1980 (Ikegami 1982, 2001). How to cope with this and other health and medical care problems related to the rapid aging of the population is an item high on the agenda for the health policymakers in contemporary Japan.
The Japanese State in Health
In the post-World War II era, public health and welfare activities of the Japanese “developmental state” have had an explicit constitutional basis. According to Article 25 of the Japanese constitution (adopted in 1947), all citizens are guaranteed “the right to maintain the minimum 35standards of wholesome and cultured living.” Article 25 also provides that “in all spheres of life, the state shall use its endeavors for the promotion and extension of social welfare and security, and of public health.” During the 1950s and 1960s, the Japanese state appeared reluctant to fill this constitutional prescription and within the club of advanced industrial and capitalist nations was generally perceived as a “welfare laggard” (Bennett and Levine 1976, 442). By the end of the 1970s, however, both the image and the reality of the Japanese welfare state changed considerably. Not only was the constitutional prescription being filled, but some critics claimed that Japan had become a “welfare superstate.” Others warned of the dangers of incipient “English Disease.” A close examination of the role of the Japanese state in the health sector fails to confirm the diagnosis—nor does it support either the “laggard” or the “superstate” assessment.
To understand the contemporary situation, it is important to know something about the historical context. As noted earlier, the achievements of the Japanese state in the health sector since 1945 seem substantial. Consider, for example, the following assessment of the health and welfare administration made by officials of the Public Health and Welfare Section, General Headquarters, Supreme Commander for the Allied Powers:
During the war increased industrialization and urbanization in the four main islands of Japan, plus the dominance of the military aims over all social welfare activities, had a pronounced influence on public health and welfare administration. Pressure of militarism brought greater emphasis on such emergency requirements as a rapid turn out of medical students, nurses and dentists. It also resulted in the cessation of many public health activities of benefit to the civilian population. The conversion of many factories, engaged in the manufacture of medical and sanitary supplies and equipment, to war material production, plus the lack of adequate professional people to serve the civilian population, resulted in a complete breakdown of all public health and welfare functions. From the national to the lowest level the entire administration of public health and welfare activities became disorganized. Lack of trained personnel, low salaries and incompetent officials, charged with crucial responsibilities for public health, seriously affected the efficiency of the entire organization. In addition, the Ministry of Welfare had not been permitted to assume its proper place in Japanese government and many of the activities generally associated with public health and welfare were the responsibilities of other Ministries. Upon the arrival of the Occupation Forces, Japanese public health and welfare activities were found to be in a very demoralized state. An 36unsound administration, plus the nation’s efforts to gear itself during the war, had completely broken down any semblance of health or welfare functions. (GHQ, SCAP, PHWS 1949a)
Assuming the relative accuracy of the SCAP evaluation, the rapid recovery and development of health and welfare administration and its subsequent contribution to the economic and health “miracles” is quite impressive. Although the Ministry of Health and Welfare (MHW) continues to share responsibility for health and welfare administration with other national and subnational agencies, it appears to have assumed the “proper place” in Japanese government that SCAP officials had in mind. It is an integral part of the extensive apparatus of state intervention in postwar Japanese society “for the promotion and extension of social welfare and security, and of public health” legitimated by Article 25.
In functional terms, Japanese national health administration may be divided into four main categories: (1) environmental protection, (2) industrial health administration, (3) school health administration, (4) general health administration. In each of these areas state intervention has led to the establishment of a complex administrative apparatus that is likely to grow in spite of the “administrative reform” policies adopted by recent prime ministers and cabinets. For example, state involvement in school health activities has increased in the postwar period. At the national level, the Ministry of Education, Science, and Culture is the state’s main administrative agent and its Physical Education Bureau bears the major responsibility for preventive health programs in schools. Critics contend that state commitment to disease prevention and health promotion is weakest in the school health programs under the ministry’s jurisdiction and that the school system must play a more important role in the future, not simply in promoting physical education and sports activities, but also in providing basic health education and fostering “good health habits” for school children (Sakuma 1978). Be that as it may, it should be noted that the high literacy rate and accumulated educational stock of the Japanese people as a result of the highly developed compulsory educational system has an important impact on the national state of health.
The story of the emergence of the Japanese version of the welfare state is fascinating but too complex to be told here.6 It should be noted in passing, however, that the relevant activities of political parties and the 37organized interest groups of business, labor, providers, insurers, and the like, the roles of the legislative and judicial branches of Japanese government and, within the executive branch, the Economic Planning Agency and the Social Security System Council of the Office of the Prime Minister as well as the Ministry of Finance were all important components of the state in health, historically and at present. The discussion here will be limited to the current activities of the major national administrative agency concerned with health, the Ministry of Health and Welfare.
General health administration at the national level is centered in the Ministry of Health and Welfare. Established as a result of pressure from the military in 1938 and reorganized under the aegis of SCAP during the Occupation, the MHW was organized into nine bureaus, two departments, and one separate agency, and was responsible for 9.1 percent of the overall national budget in 1980. The ministry is engaged primarily in four types of activities: public health and medical care; social welfare and public aid; social insurance; and education, research, and information gathering. It oversees the administrative and programmatic activities of prefectural and city, town and village governments in the public health-medical care area as well as overseeing the system of health centers. The ministry also plays an important role in health planning and policy development at the national and regional levels. In general, the MHW is the most visible and concrete manifestation of the Japanese state in public health and medical care, and ministry officials are responsible for integration and coordination of health and medical affairs with other state activities and priorities.
The Medical Care Complex
As used here, “medical care” refers to the organization and delivery of personal health services, that is, diagnosis, treatment, rehabilitation, and prevention of disease and injury in individual cases. The providers and consumers of personal health services, the financing mechanisms, and the agencies through which state authority is exercised comprise the “medical care complex.” Ostensibly, the bulk of personal health services are delivered through the private sector in contemporary Japan and financed through the system of comprehensive, compulsory health insurance. As previously indicated, however, the Japanese state is deeply involved in the organization and delivery of services, and the line between public and private sectors is not clearly drawn. State intervention 38 in the medical care sector has a firm constitutional, historical, and cultural basis (Steslicke 1982b), and although countervailing forces are present, it seems likely that the role of the state will grow in coming years. A brief examination of the basic components of the medical care complex will indicate why.7
Medical Care Consumers
It has been argued that the state of physical, mental, and social well-being in contemporary Japan is among the highest in the world, in keeping with its status as the world’s third major industrial power. However, economic development seems to generate as many health hazards as it eliminates. What is loosely referred to as “life-style” in the advanced industrial nations is sometimes seen as the key to health and illness, but is is not entirely clear whether this is a matter of individual choice or social determinants. There is also considerable disagreement as to whether the relatively affluent life-style in such nations is basically healthy or unhealthy or some combination of both. It is as easy in Japan as it is in the United States to stimulate a lively debate regarding lifestyle. What is clear in both countries, however, is that consumption of sophisticated, high-tech, professionalized medical services has become an intrinsic part of life for most of the population (Steslicke and Kimura 1985).
In 1981 more Japanese availed themselves of medical services than ever before. According to the annual patient survey conducted by the MHW, the rate increased from 4,805 per 100,000 persons receiving medical care on the survey date in I960 to 7,049 per 100,000 in 1975. This proportion remained relatively stable between 1975 and 1980 (decreasing slightly to 6,855 per 100,000 in 1980), and peaked at 7,266 per 100,000 in 1981. The changing pattern in the illness categories for which care was sought between 1955 and 1981 is shown in the accompanying graph. Note especially the rise in hypertensive disease, heart diseases, and mental disorders. These trends are also likely to continue throughout the foreseeable future. Therefore, medical care providers can expect a healthy market for their services, particularly among the middle-aged and elderly segments of the population. Whether or not medical care providers have the personnel, skills, facilities, and credibility to adequately supply the changing needs and demands for medical services is problematic. This is generally recognized within the medical care community and, in order to cope with future circumstances, numerous public and private investigations 39are being conducted into various aspects of health care training and performance.
Medical Care Providers
Since the establishment of the system of medical care based on Western medical science following the Meiji Restoration, the provision of medical services has been restricted to individuals and organizations designated by the state. This state-supported monopoly has a statutory basis and is administered by government officials at the national and prefectural levels. Within the medical care monopoly, the physician has been authorized to dominate the division of labor. The various kinds of individual medical care providers and the requirements for entry into the exclusive circle are indicated in table 8. According to the Medical Practitioner’s Law of July 30, 1948, as amended, only “duly licensed” individuals may use the title of “doctor” (ishi), and are authorized to “take charge of medical treatment and guidance of health, and contribute to the improvement and promotion of public health in order to secure the healthy life of the people” (Art. 1). In 1980 there were 156,235 “duly licensed” physicians, 53,502 dentists, and 487,169 nurses. (The distribution of these practitioners throughout the system is shown in table 9.)
Table 8. Types of Medical Care Providers and Licensure Requirements in Japan, 1980
In Japan, it is generally agreed that the most pressing personnel problem in the medical care sector is the acute shortage of nurses, including public health nurses. Of the latter, in 1980 the total number of 17,957 nurses represented 15.3 per 100,000 persons, that is, 6,519 persons for each public health nurse. There is no shortage in the total number of doctors, dentists, and pharmacists, but there is a very marked geographic maldistribution. There were 116,056 pharmacists in 1980, that is, 99.3 per 100,000 persons, or 1,009 persons per pharmacist (54.6 percent of pharmacists were females). The ratios of dentists and physicians were 45.8 and 133.6 per 100,000, respectively, or 2,184 persons per dentist and 748 persons per physician. Of the physician population, 148,815, or 95.3 percent, were engaged in clinical practice and, of that number, 65,114, or 41.7 percent, were owners of hospitals and clinics. This means that, in 1980, 83,701 physicians in clinical practice, or 53.6 percent of the total, were salaried employees. A total of 24,879, or 15.9 percent of physicians, were employed in medical school hospitals. Thus, the majority of Japanese doctors are salaried employees working in hospitals, clinics, and other institutions, both public and private.
Table 9. Doctors, Dentists, and Nurses in Japan, 1960–1980
|Engaged in institutions:|
Employers in hospitals
Employers in clinics
Employees in hospitals
Employees in clinics
Employees in medical school hospitals
|Engaged in non-institutions:|
Employees in medical schools
Engaged in others
Engaged in nurses’ schools
Engaged in health centers
Engaged in hospitals
Engaged in clinics
Engaged in schools
Source: Ichijo and Kiikuni (1982, 13) 43
Despite their position as salaried employees, the practice of medicine remains highly regarded and well rewarded in contemporary Japan. There has been a rapid increase in medical school admissions in recent years, and it is estimated that the total number of physicians will increase by 50 percent in the next twenty years. By the year 2000 there would thus be 210 doctors and 81 dentists per 100,000 population. If the present pattern of geographical maldistribution persists, the already keen competition for customers will intensify. In recent years there have been a number of well-publicized scandals involving physicians and medical schools that have contributed to a growing sense of disenchantment with the medical establishment. Moreover, in their everyday relation with patients, many physicians have tended to reinforce the negative images popularized in the mass media. As a result, the medical mystique is losing a good deal of power and influence at both the individual and collective levels. Laypersons, both patients and public policymakers, no longer accept without question the notion that “doctor knows best.” Clearly, the status and role of the physician in Japanese society is changing. Not only physicians, but all medical care providers are likely to encounter alterations in many phases of their work during the coming decades.
Medical Care Institutions
The dominant role of the physician in the provision of medical care is reinforced by the Medical Service Law of July 30, 1948, the basic governing statute for organization and delivery of medical services in Japan. The law distinguishes between “hospitals” and “clinics” by numbers of beds, the former having twenty or more beds and the latter nineteen or fewer. A “general hospital” is a facility of one hundred or more beds that also meets certain other specifications. According to the law, a hospital or clinic must be managed by a physician regardless of its ownership. 44
Table 10. Number of Hospitals and Clinics in Japan, 1965–1980
Source: Ichijo and Kiikuni (1982, 10).
Table 11. Number of Beds by Type of Hospital and Beds per 10,000 Population, 1965–1980
|Per 10,000 persons|
Source: Ichijo and Kiikuni (1982, 10). 45
Table 10 gives the number of hospitals and clinics in Japan from 1965 to 1980. The number of beds in those hospitals and the beds per 10,000 persons over the same time span are shown in table 11 and the distribution of hospitals by type of ownership is indicated in table 12. It should be noted that when the 287,000 clinic beds are added to the 1,319,406 hospital beds in 1980, the bed-to-population ratio of 13.7 per 1,000 was 2.2 times as large as that of the United States.
For present purposes, but at the risk of considerable oversimplification, the following observations regarding medical care organization and delivery in contemporary Japan may be made. (1) Although there is a substantial “public sector” involvement in medical care, the bulk of medical services are delivered through the “private sector” (about 79 percent of the hospitals and 60 percent of the hospital beds and more than 90 percent of Japan’s 77,000 clinics are privately owned and operated). (2) The delivery of services is highly competitive, with hospitals and clinics, both public and private, offering very similar services, resulting in considerable overlapping, redundancy, and excess capacity. (3) Since there are really no acute care hospitals as such and few special long-term care facilities, acute, chronic, short-term, long-term, inpatient, and outpatient care tends to be delivered in the same institutions for young and old alike, with a resulting average length of stay in hospitals of 38.3 days in 1980 as compared with 8 days in the United States (Goldsmith 1984, 119). (4) The closed-staff system means that every clinic and hospital is exclusive with respect to its patients and tries to offer “all-in-one” medical services. (5) Even though all Japanese physicians are specialists, most actually are engaged in general practice. (6) The quality of medical care is quite erratic, ranging from excellent to inferior, sometimes within the same facility. (7) The coordination and continuity of services from primary care to specialized care to rehabilitation and prevention are seriously deficient, and regional medical care planning is hampered by basic legal and structural constraints. (8) Since physicians are permitted both to dispense and prescribe drugs, overutilization of medicine has been a serious health hazard as well as a financial problem for consumers. (9) The trend toward high-technology medical care is well advanced, and the more or less traditional doctor-patient relationship has become severely strained as a consequence. (10) The combination of predominately private, fee-for-service, physician-centered medical care with compulsory, universal health insurance offering free choice of provider for insurees has created a serious financial crisis that currently seems to require substantial state intervention. This last component of the medical care complex merits more detailed examination.
Table 12. Distribution of Hospitals in Japan by Type of Ownership, 1980
|Category of Hospitals|
Source: Ichijo and Kiikuni (1982, 11). 46
Medical Care Financing
Perhaps the single most important feature of the medical care complex is the system of health insurance that has covered the entire population since 1961 (Steslicke 1982a). Based on the Health Insurance Law of 1922, the first of its kind in Asia, the system has grown incrementally to include other employment-based schemes for seamen, day laborers, teachers, and government workers. Citizens not covered by one of the employment-based schemes are entitled to coverage under the National Health Insurance Law of 1958, which requires that every city, town, or village in Japan offer health insurance to its residents and collect a special tax from those who are covered. Insurees are expected to share the costs of benefits with the community insurer and the national treasury.
The major features of the health insurance system are outlined in table 13. It is not necessary to go into the details of the various plans here except to note that there is a disparity in the level of benefits and cost sharing between the employment-based and community-based plans. Within the former category, members of society-managed plans tend to be much better off than members of government-managed schemes, many of which are chronically in the red. It is a complex system that reflects the politics of labor-management relations and the dual economy of modern Japan rather than the ideal of medical care planners for a more rational, efficient, and unified system. Efforts to reform the system in any fundamental way have been frustrated by the veto power exercised by the Japan Medical Association and other influential interest groups (Steslicke 1982b). 47
Table 13. Outline of Medical Care Insurance System in Japan, 1982
From the standpoint of the individual citizen, the system offers relatively free access to medical services on an inpatient as well as on an outpatient basis without the fear that financial crisis will follow medical crisis. A much greater measure of medical security is available to the average Japanese citizen than to an American counterpart. From the standpoint of the provider, there is assurance not only that fees for service will be covered, but also that customers will be encouraged to enter the market for services quite freely. Providers are highly critical of many aspects of the system, even though they benefit from its operation. Mainly, they cry for increased payment under the unit-point system and for greater freedom within the national fee schedules that place many restrictions on treatment practices. Still, neither providers nor consumers are as disturbed as are insurers and payers at the rise in overall medical expenditures during the past decade.
In Japan, as in the United States and a number of other advanced industrial nations, cost containment has become the paramount concern in the medical care sector. Perhaps of somewhat less urgency in Japan than elsewhere, the situation is nevertheless serious. A summary of the basic facts is contained in table 14. By 1980 the rapid growth of medical care costs reached almost 12,000 billion yen, an estimated 4.98 percent of the GNP and 6.18 percent of national income. Because actual medical care expenditures may be underestimated by as much as 15 percent, according to some economists, it is of small comfort that the Japanese figures remain lower than in the United States and a number of other industrial nations. As indicated in a recent report from Japan: “During the period of high economic growth it was possible for the expanding economy to absorb the increase in medical care costs and they were not a matter for concern. However, following the oil shock, and even when the economy reverted to stable growth, medical care costs continued to rise at a faster pace than economic growth” (JICWELS 1983, 10). In short, it is not simply the rapid increase in medical costs but also the economic circumstances in which the increase has taken place that is troublesome.
How is the burden of medical costs distributed in contemporary Japan? In 1980 the national treasury’s share was 30.5 percent, local government’s share was 2.9 percent, and the insurance system’s share was 54.5 percent, for a total of 88.2 percent. The remaining 11.8 percent was the direct patients’ share of the burden. Whether or not a redistribution of shares is desirable or even possible is controversial. The question is highly political and is being debated in that arena. A partial answer has been incorporated into the recently passed Health and Medical Care Services for the Elderly Law (Rōjin Hoken-Hō). Increasing the patient’s share may be the trend of the future, but resistance may prove quite fierce. Under the circumstances, providers can expect increasing pressure to join the battle, largely at their own expense. Thus, rationalization of medical care costs is likely to produce among various components of the medical care complex a struggle that will force a change in the strategy of state intervention developed during the happier days of high economic growth. Government officials at the national level are eagerly preparing themselves to serve as the agents of a new strategy of state intervention. 49
Table 14. Medical Care Costs in Japan, 1955–1980
|Medical Care Costs|
|Percentage increase over preceding year||Per-capita Costs yen||Medical Care Costs as Percentage||GNP billion yen||National Income billion yen|
|Year||Billion yen||of GNP||of NI|
Source: Ichijo and Kiikuni (1982, 18) 50
Medical Care and Government
As stated earlier, the Japanese state has been involved in health care since the early 1870s, and government has been a basic component of the medical care complex at both national and regional levels. The specific form, content, and magnitude of government involvement have, of course, changed over time (Steslicke 1972). Since its establishment in 1938, the Ministry of Health and Welfare has been the major national government agency responsible for medical care policy and administration.
Within the MHW, four bureaus are most closely concerned with medical care policy and administration. They are the Health Policy Bureau, the Pharmaceutical Affairs Bureau, the Health Service Bureau, and the Health Insurance Bureau. Many of the career officials assigned to the four bureaus are graduates of medical and other health-related schools and bring some measure of scientific or technical expertise to their bureaucratic positions, though the majority of MHW officials have followed the more conventional path to career service and are graduates of the law departments of Tokyo University or other national universities. Although difficult to document, it is clear that ideological and programmatic differences do exist within the MHW and that officials have competing interests and loyalties, as well as differing postretirement aspirations. There is also a surprising degree of fragmentation and lack of coordination between bureaus. Still, in a basic structural sense, MHW officials share a common interest in promoting the role of the ministry in the overall governmental process and in enhancing their own stature as managers of state intervention in the medical care system. They may not be in a very good position to set basic priorities for the nation, but they do seek to articulate those priorities within the medical care complex.
The Health Care Industry
The medical care complex is expected to contribute to the general well-being of the Japanese population while at the same time providing psychic and material rewards to service providers. However, the medical care complex is also part of a much larger and expanding health care industry. While the medical care complex is legally organized on a not-for-profit basis, other components of the health care industry are expected to provide a return to investors and to contribute to general economic health and well-being. This is especially true of producers of pharmaceutical 51and medical/dental instruments and supplies. In Japan, as in other advanced capitalist societies, the production and distribution of goods and services related to health has become big business, not only for domestic consumption, but also for foreign export. A brief examination of these two subsectors of the health care industry is illustrative.
In 1980 the total value of finished pharmaceutical products was estimated at 3,482,177 million yen, a new high that was a 14.5 percent increase over 1979 production. Since 1979 production had increased by only 8.9 percent over 1978, the return to double-digit growth was welcomed within the industry, even though it was far less than the record growth of 20.6 percent of 1976 (13.7 percent for 1977 and 1978). As in 1979, the major products were antibiotics (23.4 percent of the total) followed by cardiovascular products (see table 15). Although total growth in 1980 was mainly attributed to the rapid growth of the major pharmacotherapeutic categories listed in table 15, it is interesting to note that production of Chinese medicines also increased by 23 percent, even though their market share was a mere 1 percent of the total.
The overwhelming dominance in the production and sale of prescription drugs over nonprescription drugs was secured by a 16.3 percent increase in production in 1980. Nonprescription drugs increased in output by 4.9 percent, but their market share fell from 15.8 percent in 1979 to 14.5 percent in 1980. The share of prescription drugs in the total drug market was 85.5 percent in 1980. As indicated in table 16, sales of the sixteen major pharmaceutical companies totaled 1,684,183 million yen for fiscal years ending in 1980 or 1981, a 10 percent increase over the 1979–1980 period. Profits of 77,282 million yen were higher by 8 percent in spite of the 19,900 million yen paid by Takeda and Tanabe Seiyaku as compensation to victims of SMON (subacute myelo-opthalmo-neuropathy, an iatrogenic disease resulting from a drug prescribed for various gastrointestinal problems. Subsidiaries and Japanese affiliates of foreign drug companies also did well in 1980. Those with sales of 30 billion yen or more included Ciba-Geigy (Japan) Ltd., the Sandoz group, Hoechst Japan Ltd., and No. 1 Pfizer Taito Company. 52
Table 15. Pharmaceutical Production by Pharmacotherapeutic Category in 1979 and 1980
|Total Production||1980 Change from 1979||Ratio to Total|
|Rank in 1980||Category||1979
|3||Miscellaneous agents affecting metabolism||315,601||363,950||48,349||15.3||10.4||10.5|
|4||Agents affecting central nervous system||304,503||344,197||39,694||13.0||10.0||9.9|
|5||Agents affecting digestive organs||240,960||256,830||15,870||6.6||7.9||7.4|
|7||Agents for epidermis||189,942||197,984||8,042||4.2||6.2||5.7|
|11||Nutrients, tonics, and alternatives||82,684||85,704||3,020||3.7||2.7||2.5|
|12||Agents relating to blood and body fluids||71,577||82,690||11,113||15.5||2.4||2.4|
|13||Agents affecting peripheral nervous system||81,944||80,272||–1,672||–2.0||2.7||2.3|
|14||Agents affecting respiratory organs||67,257||79,960||12,703||18.9||2.2||2.3|
|15||Agents affecting sensory organs||41,070||45,005||3,929||9.6||1.4||1.3|
|17||Agents for urogenital and anal organs||28,567||34,573||6,006||21.0||0.9||1.0|
|21||Agents for public health||20,126||19,918||–208||–1.0||0.7||0.6|
|22||Agents for dispensing use||13,849||14,995||1,146||8.3||0.5||0.4|
|23||Agents for treatment and diagnosis of tissue cells||8,481||12,390||3,909||46.1||0.3||0.4|
|24||Agents for artificial dialysis||6,097||7,137||1,040||17.1||0.2||0.2|
|25||Agents against parasites||1,866||1,884||18||1.0||0.1||0.1|
|26||Agents activating cellular function||2,068||1,750||–318||–15.4||0.1||0.1|
Source: Japan Medical Gazette (Dec. 20, 1981, 4).53
Table 16. Sales and Net Profits of 16 Major Pharmaceutical Companies in Japan, 1979 and 1980
In more recent times, several major facts stand out. First, until the early 1960s, the industry concentrated on domestic production and sales of products that had been developed abroad; by 1980, it was estimated that about 40 percent of the drugs produced domestically were developed by the Japanese. Also, in 1980, drug exports reached a high of 93,901 million yen, an increase of 12.5 percent over 1979. Although this figure was only about 2.5 percent of total production and a mere 0.3 percent of total Japanese exports, the internationalization process is well underway, and Japan has become part of the “multinationalization” of the pharmaceutical industry. Imports were also up by 19.9 percent in 1980 (0.8 percent of total Japanese imports) and exceeded exports by over 168,000 million yen. A second important fact for the industry is that the health insurance system that stimulated growth and development in the 1960s and 1970s is now forcing substantial reorganization of the way the pharmaceutical industry does business in Japan. A downward revision of an average of 18.6 percent in the health insurance standard prices by the Ministry of Health and Welfare in 1981—with more downward revisions in the offing—was one of those “shocks” that seem to hit so often in Japan. A third fact affecting the industry is the emergence of biotechnology and corresponding new frontiers for exploration and international competition during the 1980s. Much is expected of the industry in this arena by investors, medical care providers, consumers, and the agents of the Japanese developmental state (Kasagi 1982, 112).
Although of much more recent vintage as a recognized subsector of the health care industry, ME (a designation often used in Japan) is also seen as an attractive investment opportunity for the 1980s. ME is used in three different ways at present (Konagaya 1982, 100). The narrowest usage means “medical electronics,” including electronic machinery, apparatus, and equipment such as X ray, CT (computer tomographic) devices, ultrasonic diagnostic devices, automatic biochemical analysis equipment, urinal dialysis devices, and nuclear diagnostic devices. ME is also used more broadly to mean “medical engineering,” thereby including a wider range of medical and dental instruments and supplies. The third and broadest definition of ME used by the MHW in its annual statistical reports embraces the full range of medical equipment as categorized in table 17. As indicated, 1980 production totaled 720,184 million yen, an all-time high and an increase of 27 percent over 1979 production. It is not surprising that “devices for hospitals and clinics” tops the list and represents 25.7 percent of the total. “Diagnostic instruments and apparatus” (11.6 percent) and “related goods for radioactivity” (11.6 percent) are second and third, with the latter showing a spectacular increase of 85.1 percent over 1979. The bulk of production in that category is of X ray photographic film. ME production and sales figures demonstrate that high technology medicine has arrived in Japan. 55
Table 17. Production of Medical Equipment in Japan, 1979 and 1980
|Category||Value (¥1 mil)||% to total||Value (¥1 mil)||% to total||% change from ’79|
|Devices for hospitals and clinics||151,729||26.8||185,044||25.7||22.0|
|Steel products for medical use||4,009||0.7||4,634||0.6||15.6|
|Diagnostic instruments and apparatus||64,259||11.3||83,802||11.6||30.4|
|Operating instruments and apparatus||28,077||5.0||39,131||5.4||39.4|
|Devices for medical treatment||38,692||6.8||60,623||8.4||56.7|
|Laboratory instruments and apparatus||2,629||0.5||2,474||0.3||–5.9|
|Instruments and apparatus for dental consulting room||28,729||5.1||32,034||4.4||11.5|
|Instruments and apparatus for dental consulting||5,685||1.0||6,421||0.9||12.9|
|Related goods for radioactivity||44,884||7.9||83,069||11.5||85.1|
|Surgical goods, orthopedic goods, and related products||12,842||2.3||13,589||1.9||5.8|
|Simplified therapeutic instruments||57,590||10.2||70,237||9.8||22.0|
|Birth control products||7,277||1.3||7,908||1.1||8.7|
Source: Japan Medical Gazette (Dec. 20, 1981, 2).
This development is even more striking when viewed in terms of the narrow definition of ME (medical electronics) used in Ministry of International Trade and Industry (MITI) statistics, which report total ME production for 1980 to be roughly 250,000 million yen, a 20 percent plus increase over 1979. This branch of the industry, which is less than twenty years old, consists of about twenty fiercely competitive Japanese firms, mainly large electric and electronic manufacturers such as Hitachi and Toshiba that produce ME as a sideline, plus a few foreign participants in the field.
The 1980s were also a kind of crossroads for this branch of the ME industry. After ten years of boom, the medical care complex has become saturated with its products. This circumstance has intensified competition and has led to the underpricing of many products, thus encouraging 56grossly inappropriate utilization. During the latter half of 1980, a series of exposés of overuse, misuse, and abuse of ME products in various hospitals and clinics caused grave concern even among medical care providers themselves. Also, the 18.6 percent decrease in the standard price of drugs of June 1981 and other MHW efforts at rationalization of medical care costs have had a sobering effect on medical care providers who had gotten into the habit of reinvesting income derived from drugs and ME back into new ME equipment. Nevertheless, the ME boom is unlikely to collapse in the foreseeable future, and internationalization of the industry will probably continue at a rapid pace.
Health and Medical Care Policy in the 1980s
The Japanese developmental state played a major role in promoting economic recovery and growth in the postwar era, thereby contributing to the generally high levels of health and well-being of the population at the beginning of the 1980s. Direct state intervention in public health and medical care has also contributed to economic recovery and growth, and government has become a basic component of the contemporary medical care complex. What government does or does not do has an important bearing on the organization, financing, and delivery of medical care as well as on the general state of health. Although national policymakers are preoccupied with various pressing issues related to defense, trade, and the changing domestic and international economies, it has become impossible for them to ignore the signs and symptoms of distress in the medical care sector. Articulation of the health policy agenda for the future has become an urgent but controversial matter.
The controversy has intensified the ongoing struggle for power and prestige in the medical care complex between various interested groups and individuals. There are about forty national associations representing providers, insurers, business, and labor that are active in the medical care policy arena. Although none of these associations directly and unequivocally represent medical care consumers as such, most claim to represent the public interest.
Officials of the major associations interact both formally and informally with each other as well as with elected and appointed government and political party officials. It is a relatively stable network of full-time professionals who see each other in Diet committee meetings, advisory council sessions, public and private study groups, task forces, seminars 57and social gatherings, and other institutionalized channels for communication and decision making. Informally the network has a decided “old boy” character. Moreover, in keeping with Japanese tradition, the amakudari (descent from heaven) practice is followed, whereby top bureaucrats are moved into lucrative retirement jobs, and current MHW officials, for example, find themselves dealing with former associates and superiors who have become Dietmen or group officials. It is a network in which there are few strangers and in which the battle lines are well known and respected. As in other policy arenas, a number of active and retired academicians have become regulars who sometimes exercise considerable influence; however, their main role is to provide expert information and advice and help to legitimize the innumerable “deals” of which medical care policy has been composed.
This more or less “normal” policy-making process emerged from the bitter struggles of the late 1950s and early 1960s, when the Japan Medical Association, led by Dr. Takemi Taro, strongly contested implementation of the government’s universal health insurance program (Steslicke 1973). Negotiations involving high-level cabinet and Liberal Democratic party officials and the various contending interest groups led to a compromise agreement that averted the threatened general resignation from health insurance practice by JMA members. For the next two decades MHW officials, in cooperation with key Liberal Democratic party Dietmen and staff, assumed responsibility for maintaining the uneasy truce by accommodating and balancing the interests and demands of the various contending forces. While their broad objective was to promote the national priorities articulated in the series of economic and social plans and other basic policy pronouncements (mainly economic productivity and social stability), the more immediate objective was to manage the conflicts and contradictions within the medical care complex.
The most troublesome aspect of this for state managers has been the health insurance system. In order to keep the system working for providers, insurers, and consumers of medical care, it was necessary to arrange a series of compromises. When the deals were made, whether formally or informally, representatives of the leading national associations participated in the process of negotiations, consultations, conferences, and bargaining sessions that became quite routinized and ritualized. The process closely resembled the “limited pluralism” characterizing many other public-policy arenas in Japan during the 1960s and 1970s (Fukui 1972, 1977). 58
By the late 1970s it became clear that the broader economic and social context of health and medical care was changing (Economic Planning Agency 1979, 1). Under the circumstances, the problems within the medical care complex that were so well managed and contained during the preceding era of recovery and high growth became more troublesome. In order to cope with the realities of the new era, policymakers have been forced to abandon the essentially passive and accommodationist approach to state intervention and to adopt a more active, developmental strategy. Given the persistence of the limited-pluralism pattern in the medical care policy arena, wherein even marginal, incremental reforms are not easily induced, more basic structural changes should prove extremely difficult; yet, such changes may be necessary. Policymakers will also be forced to contend with the growing sense of entitlement to accessible, high quality, and affordable medical care within the populace, especially among the elderly.
This bottom-up expression of concern for health is shared by national policymakers. The emphasis at the top, however, is not so much on personal health as on fiscal health. Fiscal reconstruction and administrative reform are top priorities on the domestic policy agenda, and the national health insurance system has been targeted as a major source of budgetary distress requiring remedial action. These priorities are strongly supported within the corporate establishment. Demands by leading business associations for reform of the nation’s health insurance system, so as to contain costs and discourage overutilization of medical services, will increase the sense of urgency within the government. Management also is demanding increased cost sharing by workers for their own and their dependents’ health insurance and medical care (Steslicke 1984).
The Japan Medical Association has advocated a more fundamental reorganization of the health insurance system in the direction of a single, unified, community-based system along the lines of the National Health Insurance Law. The JMA has maintained its strong support for private practice, fee-for-service medical care and has resisted all government efforts to experiment with capitation reimbursement methods. Under Dr. Takemi’s leadership, the JMA called for “denationalization” of health insurance and the institution of a privately managed system of “bio-insurance.” Dr. Takemi retired as JMA president in 1982 and died in 1983.8 It is not clear to what extent the current JMA leadership will actively support its inherited positions or develop a more compliant stance vis-à-vis the ongoing reform efforts directed by MHW officials. 59
Perhaps the major accomplishment of the reform effort thus far was the enactment of the Health Care for the Aged Law in August of 1982. Skeptics have dismissed as more symbolic than tangible the changes the new legislation introduced in the system of health and medical care for Japan’s rapidly aging population (Campbell 1984, 1979). Supporters of the law prefer to see it as the “first step” in the direction of a more comprehensive reorganization and reorientation of health and medical services in Japan that will emphasize disease prevention and health promotion as well as high-technology, cure-oriented medical intervention (JICWELS 1983‚ 18). Implementation of the complex new system provided for in the law is, therefore, one of the top priorities on the MHW agenda. The long-term rationalization of medical costs is contingent upon some degree of success in that effort.
What the state does or does not do in the health and medical care arena and how the public policy agenda is formulated and implemented in the coming years is of enormous interest and concern in Japan. However, it should also be of considerable interest in the United States and other industrial nations. After all, the state of health is not a purely domestic concern within particular nations—especially for those who must compete in the international marketplace for goods and services in order to survive. A nation’s state of health and the way in which health and medical care services are organized and delivered has a significant bearing on productive capacity and costs. Japanese leaders would very much like to maintain the relative advantage the nation has had in that respect during the past few decades by dealing with current medical care problems before they get out of control. Although they are placing emphasis on “the vitality of the private sector” (minkan katsuryoku) as a way of coping with such problems, they will continue to rely on state intervention in the health care system as in the past.
1. Consider, for example, the following description as a frame of reference.
At the time of Japan’s surrender in August 1945, the nation was confronted with the awesome costs of the war. Combined military and civilian casualties totalled about 1,800,000 dead; civilians alone accounted for 668,000 killed, wounded or missing; roughly twenty-five percent of the national wealth had been destroyed or lost; some forty percent of the built-up area of the sixty-six major cities subjected to air attacks had been leveled to the ground; about twenty percent of the nation’s residential housing and almost twenty-five percent 60 of all her buildings were obliterated; thirty percent of her industrial capacity, eighty percent of her shipping, and forty-seven percent of her thermal power-generating capacity were destroyed; forty-six percent of her prewar territory had been lost, some of it only temporarily, however. Other more intangible costs were harder to calculate: the long-term economic significance of the loss of Empire; the political consequences of being reduced to the status of a second-or-third-class power; the effects of being cut off from established trading partners; the consequences of facing world suspicion and opposition to any revival of Japan’s prewar eminence in Eastern Asia. Japan’s immediate prospects were ominous and alarming. What had become of the country? How was it to be reconstructed and rehabilitated? (Ward 1967, 17–18)
Ohtani (1971, 7–107) gives a brief description of the state of health and the health care system in the immediate postwar period. For a more detailed account of that period, see GHQ, SCAP, PHWS 1949a, 1949b.
2. Chalmers Johnson (1982, 305–306) writes:
The effectiveness of the Japanese state in the economic realm is to be explained in the first instance by its priorities. For more than 50 years the Japanese state has given its first priority to economic development. This does not mean that the state has always been effective in achieving its priorities throughout this period, but the consistency and continuity of its top priority generated a learning process that made the state much more effective during the second half of the period than the first…. A state attempting to match the economic achievements of Japan must adopt the same priorities as Japan. It must first of all be a developmental state—and only then a regulatory state, a welfare state, an equality state, or whatever other kind of functional state a society may wish to adopt. This commitment to development does not, of course, guarantee any particular degree of success; it is merely prerequisite.
3. By “state of health” I mean to suggest somatic, psychic, and social aspects of national “health” (well-being) in a broad international and historical perspective. However, the actual description is a crude and eclectic review of mortality and morbidity data that is not intended to be definitive. It is more or less in keeping with the following observation. As defined in the constitution of the World Health Organization:
“health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Unfortunately, health status cannot be adequately measured in such terms anywhere in the world. It is still common, indeed necessary, to measure and compare health primarily in terms of the incidence and prevalence of diseases or infirmities, variations in causes of death, and according to levels and trends in mortality. For the most part the available data on health status for the less developed countries range from the extremely weak to the non-existent. Information on morbidity and cause of 61death is often only accurate within very broad ranges of error for the more developed countries. Similarly, both time-series data and statistics from different countries are frequently not fully comparable. Consequently, health status differentials can only be discussed in broad terms. (WHO 1980, 37)
See also Goldsmith (1972, 212–221) and Jazairi (1976). For a Japanese approach, see Research Committee, Council of National Living (1975, 87–136).
4. According to the WHO report:
Life expectancy at birth, despite its limitations, has time and again been proved to be the most important single measure of the level of health of a population, particularly when viewed from the broader perspective of socioeconomic development strategy. A study made by the United Nations Research Institute for Social Development has found that life expectancy was closely correlated with the “general development index” devised by the Institute, and much more substantially so than any other available health status indicators. Even in developed countries the correlation between gross national product per capita, used as a proxy indicator of economic development, and life expectancy at birth is still highly significant. (WHO 1980, 238)
5. A more complete description would include what Henrik L. Blum (1981, 15–16) proposes as “twelve measurable aspects of the state of health,” that is, (1) life span, (2) disease or infirmity, (3) discomfort or illness, (4) disability or incapacity, (5) participation in health care, (6) health behavior, (7) ecologic behavior, (8) social behavior, (9) interpersonal relationships, (10) reserve or positive health, (11) external satisfaction, and (12) internal satisfaction.
6. Some useful accounts of the development of the health and medical care components of the Japanese welfare state include: Kōseishō 1953, 1955, I960, 1980; Nakano 1976; Ohtani 1971; Kawakami 1977; Saguchi 1960, 1985; Lock 1980; and Steslicke (1972).
7. Among the many annual publications in Japanese that offer statistical and other descriptive information and documents related to health and medical care, the following are especially convenient and useful: Kenkō Hoken Kumiai Rengōkai (1982), Kōsei Tōkei Kyōkai (1983a, 1983b, 1985), and Kōseishō (1983).
8. Dr. Takemi was quite prolific and a collection of some of his writings is now available in English (see Takemi 1982).
Abel-Smith, B. 1976. Value for money in health services. London: William Heinemann.
Bennett, J. W., and S. B. Levine. 1976. Industrialization and social deprivation. In Japanese industrialization and its social consequences, ed. H. Patrick. Berkeley and Los Angeles: Univ. of California Press.
Blum, H. L. 1981. Planning for health. New York: Human Science Press. 62
Campbell, J. C. 1979. The old people boom and Japanese policy making. Journal of Japanese Studies 5:321–357.
——. 1984. Problems, solutions, and non-solutions, and free medical care for the elderly in Japan. Pacific Affairs 57:53–64.
Caudill, W. 1976. The cultural and interpersonal context of everyday health and illness in Japan and America. In Asian medical systems, ed. C. Leslie. Berkeley and Los Angeles: Univ. of California Press.
Economic Planning Agency, Govt. of Japan. 1979. New economic and social seven-year plan. Tokyo: Ministry of Finance.
——. 1981. In search of a good quality of life. Tokyo: Ministry of Finance.
Environment Agency, Govt. of Japan. 1982. Quality of the environment in Japan 1981. Tokyo: Health Welfare and Environment Problems Research Society.
Fukui, H. 1972. Economic planning in postwar Japan. Asian Survey 12:327–348.
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