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24

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

Country Men         Country Women
Japan 74.54   Japan 80.18
Iceland 73.91   Sweden 79.61
Sweden 73.62   Iceland 79.45
Holland 72.70   Norway 79.41
Norway 72.64   Holland 79.40
United States 71.60   France 78.85

England and Wales

71.09   United States 78.80
France 70.73  

England and Wales

77.11

Federal Republic of Germany

70.46  

Federal Republic of Germany

77.09

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

Rank 1960 1970 1980
1 Cerebrovascular disease
(160.7)
Cerebrovascular disease
(175.8)
Cerebrovascular disease
(139.7)
2 Cancer
(100.4)
Cancer
(116.3)
Cancer
(139.2)
3 Heart disease
(73.2)
Heart disease
(86.7)
Heart disease
(106.3)
4 Senility
(58.0)
Accidents
(42.5)
Pneumonia
(33.8)
5 Pneumonia
(49.3)
Senility
(38.1)
Senility
(27.7)
6 Accidents
(41.7)
Pneumonia
(34.1)
Hypertensive disease
(25.1)
7 Tuberculosis
(34.2)
Hypertensive disease
(17.7)
Suicides
(17.7)
8 Suicides
(21.6)
Tuberculosis
(15.4)
Cirrhosis of the liver
(14.2)
9 Gastro-enteritis
(21.6)
Suicides
(15.3)
Accidents
(13.7)
10 Infant mortality
(18.5)
Cirrhosis of the liver
(12.5)
Nephritis
(8.8)

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

          West
  Japan U.S.A. U.K. France Germany
Cause of death (1980) (1977) (1977) (1976) (1978)
Heart disease 106.3 327.2    379.1    200.2    335.1
Cancer 139.2 178.7    254.9    225.4    252.9
Cerebrovascular disease 139.7    84.1    149.3    141.0    166.0
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
Other accidents    15.0    24.8      17.4      48.6      26.1
Suicides    17.7    13.3        8.0      15.8      22.2
Total causes 622.0 877.9 1,172.5 1,051.6 1,179.3

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

Year Industry types Con­struc­tion Manu­facture Trans­porta­tion Minery Forestry Others Total
(Actual number) person person person person person person person
1965 2,251 1,161 674 960 319 681 6,045
1970 2,430 1,400 674 474 248 822 6,048
1975 1,582 856 375 224 153 535 3,725
1976 1,451 669 371 170 136 548 3,345
1977 1,464 709 344 180 131 474 3,302
1978 1,583 650 303 135 135 520 3,326
1979 1,404 594 331 149 115 484 3,077
1980 1,374 589 313 105 117 511 3,009
(Percentage) % % % % % % %
1965 37.2 19.2 11.1 15.9 5.3 11.3 100.0
1970 40.2 23.2 11.1 7.8 4.1 13.6 100.0
1975 42.5 23.0 10.1 6.0 4.1 14.3 100.0
1980 45.6 19.6 10.4 3.5 3.9 17.0 100.0
(Change in percentage) % % % % % % %
1970/1965 8.0 20.6 0.0 ∆50.6 ∆22.3 20.7 0.0
1975/1970 ∆34.9 ∆38.9 ∆44.4 ∆52.7 ∆38.3 ∆34.9 ∆38.4
1980/1975 ∆13.1 ∆31.2 ∆16.5 ∆53.1 ∆23.5 ∆4.5 ∆19.2

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
All ages 44.3% 16.6% 10.6% 4.4% 8.6% 15.5%
(male and female)  
Ages 40–49 35.1% 15.1% 10.2% 7.3% 20.4% 11.9%
(male)  

Source: Economic Planning Agency, Govt. of Japan (1981, 109).31

Table 6. Yearly Change in Prevalence Rates by Category per 1,000 Persons

  Year      
Disease 1955 1965 1970 1975 1976 1977 1978 1979 1980
Infectious and parasitic diseases 7.7 4.4 3.7 2.5 3.7 3.6 2.8 2.9 2.5
Neoplasms 0.5 0.9 0.8 0.9 0.8 0.9 0.9 0.8 0.9
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
Mental disorders 0.4 1.1 1.1 0.9 1.1 1.0 1.0 1.2 0.9
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
Hypertensive diseases 1.3 8.0 14.6 15.6 19.5 20.1 17.5 20.8 24.1
Diseases of the respiratory system 5.5 8.2 14.4 30.8 26.3 25.8 25.5 17.9 15.5
Acute nasopharingitis 9.6 25.3 20.9 20.2 20.0 13.5 9.6
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
Congenital anomalies 0.1 0.2 0.3 0.2 0.2 0.3 0.1 0.2 0.3
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
Total 37.9 63.6 93.6 109.9 116.4 115.7 110.9 109.4 110.4

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
Disease Total 0–4 5–14 15–24 25–34 35–44 45–54 55–64 65–74 above above
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
Neoplasms 0.9 0.5 0.2 0.1 0.1 0.6 2.2 0.4 3.2 5.3 4.4
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
Mental disorders 0.9 0.9 1.5 1.0 1.4 0.8 1.2 0.6 1.6
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
Hypertensive diseases 24.1 0.1 0.6 9.2 30.3 70.8 113.5 150.1 141.5
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
Acute nasopharingitis 9.6 42.9 13.5 5.1 7.4 5.5 4.1 2.6 6.7 9.4 8.2
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
Congenital anomalies 0.3 0.8 0.4 0.1 0.2 0.6 0.6 1.2 0.9
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
Total 110.4 87.4 56.0 30.2 43.4 74.3 121.8 229.9 336.0 437.3 413.6

Source: Ministry of Health and Welfare (1981a, 6).

3334

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.)

40

Table 8. Types of Medical Care Providers and Licensure Requirements in Japan, 1980

42

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

Practitioners 1960 1965 1970 1975 1980
Physicians
    Engaged in institutions:
        

Employers in hospitals

2,449 2,608 3,597 3,250 3,468
 

Employers in clinics

47,849 52,609 57,170 59,904 61,646
 

Employees in hospitals

25,896 28,038 32,461 38,085 50,075
 

Employees in clinics

10,450 9,011 8,469 8,630 8,747
 

Employees in medical school hospitals

9,394 9,749 11,517 16,101 24,879
    Engaged in non-institutions:  
 

Employees in medical schools

2,137 2,165 2,086 2,973 3,644
 

Administrative

2,632 2,260 1,895 2,067 2,099
 

Engaged in others

2,324 2,929 1,795 1,469 1,657
  Total 103,131 109,369 118,990 132,479 156,235
Dentists 33,177 35,558 37,859 43,586 53,602
Nurses          

    Engaged in nurses’ schools

881 1,167 2,086 4,223 5,498

    Engaged in health centers

325 317 357 430 493

    Engaged in hospitals

144,575 189,021 213,880 279,316 377,746

    Engaged in clinics

29,846 45,477 52,919 72,274 96,347

    Engaged in schools

2,454 2,613 872 739 631

    Dispatched nurses

6,370 5,488 974 948 518
    Others 1,141 1,128 2,484 3,674 5,936
  Total 185,592 245,211 273,572 361,604 487,169

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

Institutions 1965 1970 1975 1980
Hospitals
    General 5,922 6,869 7,235 8,003
  Mental 725 896 929 977
  Tuberculosis 340 160 87 39
  Leprosy 14 14 16 16
  Infectious 46 35 27 20
  Total 7,047 7,974 8,294 9,005
Clinics
  With beds 27,332 29,841 29,104 28,956
  Without beds 37,192 39,156 44,010 48,655
  Total 64,524 68,997 73,114 77,611
Dental clinics 28,602 29,911 32,565 38,834

Source: Ichijo and Kiikuni (1982, 10).

Table 11. Number of Beds by Type of Hospital and Beds per 10,000 Population, 1965–1980

Beds 1965 1970 1975 1980
In hospitals
    General 442,536 601,978 721,858 895,494
    Mental 172,950 247,265 278,123 308,554
    Tuberculosis 220,757 176,949 129,055 84,905
    Leprosy 13,230 13,217 14,020 12,235
    Infectious 24,179 23,144 21,042 18,218
Total 873,652 1,062,553 1,164,098 1,319,406
Per 10,000 persons
    General 45.0 58.1 64.5 76.6
    Mental 17.6 23.8 24.8 26.4
    Tuberculosis 22.5 17.1 11.5 7.3
    Leprosy 1.3 1.3 1.3 1.1
    Infectious 2.5 2.2 1.9 1.6
Total 88.9 102.5 104.0 113.0

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    
Ownership   General Mental Tuber­culosis Leprosy Infectious disease   Total
National   437 3 0 13 0   453
Prefectural   259 37 6 0 1   303
Municipal   740 11 2 0 19   772
Other public   292 2 0 0 0   294
Social insurance   139 0 1 0 0   140
Private   6,136 924 30 3 0   7,093
Total   8,003 977 39 16 20   9,055

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

48

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
1956 258.3 8.2 2,862 2.60 3.16 9,950.9 8,173.4
1958 323.0 11.5 3,511 2.74 3.36 11,785.0 9,616.1
1959 362.5 12.2 3,899 2.66 3.29 13,608.0 11,023.3
1960 409.5 13.0 4,384 2.53 3.09 16,207.0 13,269.1
1961 513.0 25.3 5,441 2.58 3.26 19,852.8 15,755.1
1962 613.2 19.5 6,443 2.83 3.46 21,659.5 17,729.8
1963 754.1 23.0 7,843 2.95 3.66 25,592.1 20,627.1
1964 938.9 24.5 9,661 3.17 4.01 29,661.9 23,390.4
1965 1,122.4 19.5 11,421 3.35 4.22 33,550.2 26,606.6
1966 1,300.2 15.8 13,126 3.30 4.18 39,452.0 31,106.6
1967 1,511.6 16.3 15,080 3.27 4.11 46,175.6 36,778.2
1968 1,801.6 19.2 17,766 3.29 4.18 54,689.2 43,126.0
1969 2,078.0 15.3 20,244 3.20 4.09 64,850.8 50,859.1
1970 2,496.2 20.1 24,032 3.32 4.10 75,091.6 60,875.4
1971 2,725.0 9.2 25,949 3.29 4.14 82,725.8 65,845.6
1972 3,399.4 24.7 31,672 3.53 4.38 96,424.0 77,602.1
1973 3,949.6 16.2 36,332 3.39 4.13 116,636.3 95,526.0
1974 5,378.6 36.2 48,875 3.90 4.80 138,044.6 112,081.6
1975 6,477.9 20.4 57,781 4.27 5.26 151,797.0 123,184.3
1976 7,668.4 18.4 67,810 4.50 5.54 172,900.1 138,446.8
1977 8,568.6 11.7 75,100 4.54 5.61 188,804.3 152,690.2
1978 10,004.2 16.8 86,900 4.84 6.00 206,762.5 166,854.9
1979 10,951.0 9.5 94,300 4.93 6.13 222,043.1 178,712.5
1980 11,980.5 9.4 102,300 4.98 6.18 240,647.0 193,811.7
1981 12,870.9 7.4 109,200 5.07 6.36 253,811.2 202,429.6

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
(¥1 mil)
1980 
(¥1 mil)
  Value
(¥1 mil)
Rate
(%)
  1979
(%)
1980
(%)
1 Antibiotics   658,009 814,320   156,311 23.8   21.6 23.4
2 Cardiovasculars   309,332 377,757   68,425 22.1   10.2 10.8
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
6 Vitamins   210,813 216,249   5,436 2.6   6.9 6.2
7 Agents for epidermis   189,942 197,984   8,042 4.2   6.2 5.7
8 Biologicals   91,533 114,396   22,863 25.0   3.0 3.3
9 Antineoplastics   93,782 107,351   13,569 14.5   3.1 3.1
10 Hormones   82,986 89,315   6,329 7.6   2.7 2.6
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
16 Antiallergics   30,744 35,985   5,241 17.0   1.0 1.0
17 Agents for urogenital and anal organs   28,567 34,573   6,006 21.0   0.9 1.0
18 Chinese medicines   27,432 33,749   6,317 23.0   0.9 1.0
19 Diagnostics   28,059 30,164   2,105 7.5   0.9 0.9
20 Chemotherapeutics   29,940 29,487   –453 –1.5   1.0 0.8
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
  All others   3,076 4,165   1,089 35.4   0.1 0.1
  Total   3,042,302 3,482,177   439,875 14.5   100.0 100.0

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

54

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

    1979   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
Sutures   2,087 0.4   2.392 0.3 14.6
Surgical goods, orthopedic goods, and related products   12,842 2.3   13,589 1.9 5.8
Ophtholmic goods   44,548 7.9   48,899 6.8 9.8
Hearing aids   4,491 0.8   5,280 0.7 17.6
Simplified therapeutic instruments   57,590 10.2   70,237 9.8 22.0
Dental materials   63,983 11.3   68,810 9.6 7.5
Birth control products   7,277 1.3   7,908 1.1 8.7
Others   5,412 1.0   5,838 0.8 7.9
Total   566,922 100.0   720,184 100.0 27.0

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.

Notes

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).

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Additional Information

ISBN
9780824880774
MARC Record
OCLC
1055462902
Launched on MUSE
2018-09-19
Language
English
Open Access
Yes
Creative Commons
CC-BY-NC-ND
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