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Overview of Health and Medical Care System in Japan

JICA Tokyo International CenterDecember 2006

The health status in Japan has drastically improved since the end of the World War II in 1945.Expected life expectancy at birth increased from 50.06 and 53.96 years in 1947 (men and women respectively) to 78.53 and 85.49 in 2005.Maternal mortality ratio (per 100,000 live birth) has been improved from 130.6 in 1960 to 4.4 in 2004.Infant mortality rate (per 1,000 live birth) has changed from 76.7 in 1947 to 2.8 in 2004.

The transition and the history of health and medical program in Japan is described in other book published by JICA, ‘Japan’s Experiences in Public Health and Medical Systems’, March 2005, (JICA Report Number: IIC/JR/04-068), however, there has not been a document describing the present system in Japan.

So this presentation shows the system of health and medical services in Japan to introduce the main points of present situation.

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Outline

•Health/Medical Services Laws --- 3 •Health Services ---------------- 4-14•Medical Services ------------- 15-18•Health Insurance System --- 19-22

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Health/ Medical Services LawsLaws regulate medical services to guarantee the equal and proper supply.

Institutional aspect - Medical service Law, etc Professional activity - Medical Practitioners Law, etc Drug and medical

device control - Pharmaceutical Affairs Law

Laws for some medical practices and health services Psychiatric disease - Mental Health Law Infectious diseases - Infectious Diseases

Prevention Law Tuberculosis Control - Tuberculosis Control Law Immunization - Immunization Law Insurance - Health Insurance Law Community health - Regional Health Law etc…

Source: JICA(2001)

The beginning of the legal system in Japan dates back to 1874 when the ‘Comprehensive Medical Code’was promulgated. The law system has been established with new development and several revisions according to the trend and situation of health in Japan and the world.

Every activity done by public and private organizations in the field of health and medicine should be based on laws. All programs, roles of health/medical institutions, roles of health/medical personnel, rules of health insurance etc… are written in general and specific laws. The national government is responsible for formulation of these laws.

There are laws regulating medical services to guarantee the equal and proper supply to the public and also laws to regulate the activities in specific medical and health activities.

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Health Service SystemMinistry of Health, Labour and Welfare

47 Prefectual Governments*,

139 Large Municipal Governments*

Public Health Centers(Hoken-jo)

Municipal Governments* (city, town, village)

Municipal Health Centers(Hoken-center)

Community People

・National Policies/Programs

・Budget

・Regional Health Medical plan

・BudgetCatchments areas for secondary medical care:365 (March 2006)

・Provision of Health /Welfare Services

・Budget

・Health services for the aged

・Immunization

・MCH checkup

2692(April 2006）

・Provision of Preventive Health Services (Promotion, sanitation, medical pharmaceutical affairs, statistics, risk management)

・Technical support

535(April 2006)

1820(April 2006）

* Local governments

Source:NIPH(2005)

This figure shows the structure of health service system in Japan.The Ministry of Health, Labour and Welfare is responsible for the system in

national level.On the other side, local governments, which is the general name for prefectural

governments, large municipal governments, and municipal governments are responsible for formulation of an effective health service program to the people in their community.

Prefectural and large municipal governments divide their administrative boundaries into several health districts. A public health center (Hoken-jo) is established in each one of those districts. Moreover, under the supervision and guidance of a public health center, there are municipal health centers (Hoken-center) which provide direct health services to community people.

This structure is the basic but there are some exceptions as shown in dotted line in the figure.

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Ministry of Health Labour, and Welfare

Role: To make policies and programs for establishment and maintenance of various systems for health, medical care and welfare services.

National Government

Policy, Laws and budget

Local Government

People in the community

National level service system

Source:JICA(2001)

The main function of the Ministry of Health, Labour, and Welfare (MHLW) is to make policies and programs for establishment and maintenance of various systems for health, medical care and welfare services.

Policies for health and medical care are handed down to local governments and medical institution.

Budget allocationThe total budget of MHLW in 2006 is 20.9 trillion Japanese Yen (190 billion US

dollars :US$1=110 Yen) and 26.3% of total budget of the nation.

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Local Governments

Role : Establishment of effective health service system in cooperation with health/medical service agencies (public and municipal health centers, hospitals)

National Government

Local Government

Rules and Budget

Management of health service and medical care service

People in the community

Source:JICA(2001)

The main function of the Local Governments (prefectural governments/municipal governments) is to bring an effective health service to people in their community in collaboration with health service agencies (public/municipal health center), and medical service agencies (hospitals/clinics/midwifery practice) .

In Japan, there are 47 prefectures and approximately 1800 municipalities in 2006.

Each Prefectural Government or Municipal Government plans and practices its own Health and Medical care programs based on the national policies and programs designated by MHLW.

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Public Health Center (1)Role: to plan, supervise and evaluate health

programs at responsible area.Fields of activities:

health education, demography and health statistics, improvement of nutrition and food hygiene, safe water supply and waste management, promotion of public medical services, maternal and child health, oral hygiene, and control of disease including sexually transmitted infections and tuberculosis control.

Source:NIPH(2005),HWSA(2005)

Prefectural and Municipal Governments divide their administrative boundaries into several health districts.

A public health center (PHC:Hoken-jo) is established in each one of districts.Fields of PHC services are in below it does not include medical services;

1.Disseminating and improving knowledge and concepts about health;2.Collecting vital statistics;3.Improving nutrition and assuring sanitation of food and beverage;4.Sanitation of housing, water supply, sewage, waste disposal, cleaning, and other environmental factors;5.Medical and pharmaceutical affairs;6.Improving and promoting public medical services;7.Maternal and child health and the health of the elderly;8.Dental health;9.Mental health;10.The health of individuals who require long-term care for the diseases for which no effective method of treatment has been established or other special diseases;11.Preventing HIV infection/AIDS, tuberculosis, venereal diseases, communicable diseases, and other diseases;12.Testing and laboratory studies on health matters;13.Other matters related to improving and promoting the health of local residents.

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Public Health Center (2)

All kinds of health professionals (doctors, dentists, pharmacists, public health nurses, veterinarians, nutritionists, X-ray technicians, food inspectors, statisticians and bacteriologists)

Staff

Basically medical doctor (or non-MD with certain qualification)

Director

Total 535Prefecture (396), major cities (139)

Number(April 2006)

Supervision and audit of health and medical care facilities/ restaurants

Law enforcement

Specialized or focused (psychiatric, intractable diseases, infectious diseases such as tuberculosis, HIV)

Types of services

Source:JPHA(2004)

This table shows the summary of PHC.Compared with Municipal Health Center shown later, services in PHC is more

specialized and focused.In addition, a public health center has variety of roles as its activities. The field

of its activities includes food hygiene and supervision of restaurants. However, they do not provide any medical care services.

All kinds of health professionals are working for these purposes, such as doctors, public health nurses, pharmacists, etc.

After the Regional Health Act was enacted, the act was intended to delegate much of the personal services provided by PHCs to MHCs (Municipal Health Centers). The number of PHCs is 535 in April 2006, and there used to be 848 PHCs as of March 1994.

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Public Health Center (3)

This is the office at one of Public Health Center (SUGINAMI Ward, TOKYO)

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Municipal Health Center(1)•Role: to provide health services directly to

the residents at the municipal (cities, towns, villages) level.

•Activities: more closely related with daily life than those public health centers do, such as health counseling, health advice, health checkups, and so on.

•Target population is selected based on resident registration and services are announced by newsletters and mails.

Source:JPHA(2004)

Municipal health centers (MHCs: Hoken Center) provide direct services to community people under the supervision and guidance of public health centers.

They do not provide any medical care services, but health care services such as health check ups, counseling and some immunization.MHCs are open to public, however, some services are selectively offered to recipients according to the resident registration of local government. MHCs inform the recipients of the date and contents of the services by mail or newsletter e.g. poliomyelitis group immunization, 3 months new born baby health check up.

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Municipal Health Center(2)

Predominantly public health nurses and dieticians

Staff

No requirement Director

2692 (Cities, towns, villages)Number (April 2006)

None Law enforcement

General and community oriented (well baby clinic, immunization, health screening, disabled elderly, disease detection, issue of “Maternal and Child Health Handbook”, health check of 18-month-old infants, health education, water supply services, garbage collection and waste or night soil treatment, etc.)

Types of services

Source:JPHA(2004)

This table shows the summary of Municipal Health Center (MHC).

MHCs are established under municipal government or public health center to provide comprehensive and community oriented health services such as health promotion, health check-ups and immunization to community people by public health nurses and dieticians in cooperation with medical institutions where MHCsentrust for implementation of the service.

The number of MHCs has increased from 2364 in April 2001 to 2692 in April 2006. It is because the Regional Health Act was enacted to delegate much of the personal services provided by Public Health Centers to MHCs.

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Municipal Health Center(3)

This picture is at the counter in the one of Municipal Health Centers (MHC) ( OGIKUBO, SUGINAMI Ward, TOKYO).

Community people like mothers can visit a center to have consultation of Maternal and Child Health services and information on immunization etc... MHCsprovide the first contact for community people to receive health services. However, MHCs don’t provide any medical services and those who want medical care have to go to hospitals or clinics.

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Maternal andChild Health Services

Pregnancy Registration at

City hall

Pregnancy

MCH hand book

Examination at Clinics/hospitals

DeliveryBirth

Registration at City hall

Mass screening

Home visit service

Baby’s Health Check-ups

Baby’s Immunization

Parents’class

at hospitals/clinics/MHCs

*Blue ink: related to the public health services*MHCs (Municipal Health Centers)

Source:JICA(2006)

This is how health service is provided in maternal and child health services - A case when a woman noticed her pregnancy, she will have several steps before and after giving a birth.

1. Go to the nearest city hall (or municipal health center: MHC) for pregnancy registration and receive Maternal and Child Health handbook (MCHhandbook) and briefing by a public health nurse.

2. Go to clinics, hospitals or midwifery practices for examination. These medical institutions are entrusted by local governments and two vouchers for free maternity examination are privileged by local governments.

3. Take some parents’classes (health education to parents) which are organized by MHCs, hospitals, clinics, or midwifery practices.

4. Deliver at hospitals, clinics, or midwifery practices and a new-born baby has mass screening within a week after birth.

5. Go to city hall for birth registration.6. Provided home visit service by a public health nurse or midwife depending on

MHC’s decision or parents’need.7. Take baby for health check-ups at hospitals, clinics or MHCs. Several check-

ups are provided in free of charge by local governments.8. Take baby for immunization at MHCs/hospital/clinic. Most immunization is

provided in free of charge by local governments.

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Health Services in the Life Cycle

0 1 2 3 4 5 6 - 12 - 15 - 18 –24 - 30 - 35 - 40 - 45 - 50 - 55 –60 -65-(Years of age)

provider

Com

mu

nity B

ased public h

ealth

/School h

ealth/O

ccupation

al health

Local governm

ents (prefectu

al, m

un

icipal) /Schools/Em

ployer/Insu

rer

3years old examin

ation

18mon

th exam

ination

Infan

t examin

ation

Health check-ups for pregnant women and new mothers, and health guidance

Preschool examinations and health guidance

Women’s health checks and nutritional guidance

Public health programs for the elderly, health education, health consultation, health check-ups, occupational therapy, home visit counseling

Regular tuberculosis screening

Rural health maintenance guidance program (health education, health checks, health guidance and consultation)

Health check-ups at school entry and at regular intervals

Source:JICA(2004)

Occupational health and safety

Workplace health programs

This slide illustrates the service in whole life cycle of a person. The Japanese public health and medical system is a comprehensive system that aims to assist people, to deal with all problems that might cause anxiety, including diseases, injury, disability, unemployment, old age and the need for case over the entire lifecycle from birth to death. Such a system requires public health and medical services, including prevention, diagnosis, treatment and rehabilitation, within reach of where people live.

Lifestyle-related diseases such as diabetes mellitus, heart diseases, etc… now form a major health challenge in Japan, so the emphasis in prevention has moved from early detection and treatment of disease as secondary prevention, into prevention of disease and health promotion as primary prevention.

The main preventive activities can be divided into school health upon school entry, occupational health upon entry into the workforce, and community-based health, which are providing health education, health checks, and health guidance to target population or students, workers, and community people respectively. School health programs are run by the Ministry of Education, in collaboration with the Ministry of Health, Labour and Welfare.

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Definition ofMedical Institutions

•Hospitals: Established by doctors or dentists, with inpatient beds (20 or more) to provide medical services.

•Clinics: Medical institutions without beds or with less than 20 beds.

•Midwifery practices: Medical institutions for delivery and care related to delivery by a midwife, with less than 10 beds.

Source:JICA(2001)

This slide starts to explain about medical care service system in Japan. There are three category in the medical institution such as hospitals, clinics, and midwifery practices, dental clinics, medical institutions for the aged etc. Medical institutions are under registration and supervision of local government.

Here are definition of major institutions;Hospitals: Hospitals must have a standard number of doctors, nurses and other

medical professionals (a doctor for every 16 patients –minimum 3 doctors, a nurse for every 4 patients, and so on). The number of beds is 20 or more. They must also meet facility and medical equipment requirements, regarding such places as examination rooms, operating rooms, laboratories, sterilizing facilities, kitchens, etc… The hospital may deal with both outpatients and inpatients.

Clinics: The clinics are defined as medical institutions which have less than 20 beds and can accommodate each patient only within 48 hours, except in cases with an unavoidable delay on the advice of physician. Approximately 70% of clinics are without beds, and are typically staffed by a doctor, a registered nurse, an auxiliary worker and in some cases, technician.

Midwifery practices: Because of the increase in the number of deliveries in hospitals, the utilization of midwifery home is decreasing. The total number of midwifery practices has dropped to 722 in December 2004.

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Number of Medical Institutions by Founder

3%

17%

80%

NationalGov.

Local Gov.and Other

Private

1%

94%

5%National Gov.

Local Gov.and Other

Pr ivate

Number of HospitalsNational Governments：304Local Government

and Other: 1,506Private: 7,267Total: 9,077

Number of ClinicsNational Governments： 620Local Government

and Other: 4,895Private: 91,536Total: 97,051

Source:IMCJ(2005)

As of October 2004

In Japan, most Hospital and Clinic are private institutions.As Charts show, about 80% of Hospitals and 94%of clinics are private.

In Japan, people can choose either public or private and hospitals or clinics to have medical services. Any public/municipal health centers don’t provide medical care services in Japan. Furthermore, there are no difference of fee for a certain treatment or a certain medicine whichever public or private and clinic or hospital.

Even though any medical institutions can be selected by clients, if one wants to have consultation at some large-scale hospital like Medical university hospital, a letter of introduction may be required. If one does not have any letter, it could be charged “the first visit fee”.

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Medical Care PlansFormulated by Local (prefectural) governments for: •appropriate allocation of medical

resources•share of functions and cooperation

among healthcare related institutions •promotion of the systematic

improvement of high-quality community healthcare

Source：JICA(2003),HWSA(2005)

Regulated by medical laws, medical care plans should be formulated by local governments for efficient allocation of medical recourses, cooperation among stakeholders, effective service healthcare.

There are nine items in below that medical care programs must include.(1)Designation of secondary medical care areas: 365 areas in March 2006.(2)Designation of tertiary medical care areas for each prefecture basically (total 52 areas in 47 prefectures).(3)Standard number of hospital beds: hospital beds for general purposes, rehabilitation, mental disorder, infectious diseases, and tuberculosis.(4)Goals for the improvement of hospitals supporting community health care and institutions that provide medical services in relation to other functions.(5)Colaboration and business tie-ups among hospitals, clinics, pharmacies and other health/medical care related institutions.(6)Emergency medical services: systems for providing pediatric emergency care and pre-hospital care.(7)Medical services in remote areas as needed.(8)Securing sufficient physicians, dentists, pharmacists, nurses and other health care personnel.(9)Other essential matters to ensure maintenance of system for the provision of medical services.

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Access to Medical Services •Universal access to any type of medical institutions.•Substantial portion of medical care is provided by the

primary care physician (at a clinic).•Tendency to go to a big hospital because of its excellent

facilities and personnel. Source:JPHA(2004)

0

500

1000

1500

2000

2500

Insti

tuti

ons

50-99

150-199

300-399

500-599

700-799

900-

Bed category

Number of medical institutions by beds

As is described in the explanation of medical institutions, people can choose either public or private and hospitals or clinics to have medical services.

As is shown in the figure, most medical institutions are small scale. Most of the people choose a clinic nearby, however, there is a tendency to be fond of hospitals since large scale hospitals started to offer attractive and state of the art services to clients.

To compete with big hospitals, private clinics offer distinguished service for diagnosis and treatment, such as X-ray displays, endoscopy, and even physiotherapy.

This type of all-in-one service is very convenient for the patient, but is a very expensive system because of the duplication of functions in several institutions from primary level to tertiary level.

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Health Insurance System(1)

•In 1961, the “Universal National Health Insurance System”was established. And it applies to the entire population of the nation.

•Whole cost was used to be covered in the past. But now mostly 70% is covered and patients are required to pay a certain amount (30%)

Source:JICA(2003),HWSA(2005)

In Japan, everyone is obliged to carry some kind of health insurance, and Japan achieved ‘Universal National Health Insurance system’in 1961 in order to provide efficient and effective medicine to citizens. Each medical treatment and prescribed drug has its fixed price. So fee for a certain treatment or a certain medicine is uniform whichever clinic or hospital.

All medical cost used to be covered by health insurance in the past but due to the increase of national medical expenditure, most Japanese has to pay 30% of all amount of fee with 70% share by health insurance.

The benefit of Japan’s health insurance system is comprehensive and universal: one can safely assume that all medical services including dental care and outpatient medication are covered to all nation regardless of the insurance system. However, maternal health and medical services such as health checkups and maternity care including delivery are not covered by any insurance, although all pregnant women had some health insurance. Because it is regarded that pregnancy and normal delivery are not illness nor diseases. But if there is an abnormality such as placenta previa, threatened abortion, the condition is regarded as unhealthy and treatment such as caesarian section is covered by health insurance.

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Health Insurance System(2)

•The Employee’s Health Insurance (EHI) - Health Insurance Societies (HIS)- the Social Insurance Agency (SIA)- Mutual Aid Association (MAA)

•The National Health Insurance (NHI)- municipal governments- NHI societies

Source:JPHA(2004)

There are two major pillars for health insurance in Japan.They are: The Employees’Health Insurance that covers employed workers and their

dependent family members.The National Health Insurance that covers non-employed population.

Health Insurance societies or HIS are established in major corporations.Social Insurance Agencies or SIA cover employees and medium to small sized

corporations.Mutual Aid Associations or MAA cover civil servants such as national and local

government employees, private school personnel, andNational Health Insurance or NHI is established by municipal governments or

some occupational association (NHI societies) such as doctors, dentists, lawyers and self-employed construction workers.

These health insurance cover dependents as well as themselves.

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Health Insurance System(3)

Employees Health Insurance (SIA, HIS, MAA) covers 60%of the population. (March 2004)

SIA(28.1%)

HIS(23.9%)

MAA(7.7%)

MunicipalNHI(36.2%)

NHIsocieties(3.1%)

Indigent(1.0%)

Proportion of insurers

Source:JPHA(2004)

Employee’s Health Insurance or EHI has about 60 % of coverage: 59.7%=SIA+HIS+MAA

National Health Insurance or NHI covers about 40% of the total population: 39.3%=Municipal NHI+NHI Societies

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Concept Chart of Insured Medical Care

Insured person (patient)

Insurer

Examination and payment organization

Medical institutions (hospital/clinic)

Payment of partial cost-sharing amount

Payment of premiumMedical Service

Reimbursement of medical fee

Claim of medical fee

Payment fund / National Health Insurance Group Association

Claim of examined amount

Reimbursement of requested amount

Source:IMCJ(2005)

This figures shows reimbursement system by health insurance. The reimbursement is basically free-for-service and the government sets the

national uniform fee as well as the price list of all drugs covered by insurance. Hospitals and clinics will submit claims for direct reimbursement to the insurers.

Practically, insurers do not handle the claims, instead they maintain examination and payment organization for claims processing. All hospitals and clinics will submit all the claims to the examination and payment organization established in each of 47 prefectural level. Examination and payment organization are authorized to audit the claims to verify the content of the claims, after then the reimbursement will be paid to each hospital or clinic. Claims must be submitted every calendar month. The total number of such claims is well over one billion per year.

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-Reference-①Japan International Cooperation Agency (JICA)(2001) ‘National Health Administration in Japan ～Textbook-Seminar in national Health Development for Senior Officers F.Y.2001’②National Institute of Public Health (NIPH)(2005) ”Brief outline of Public Health in Japan (Dr.Hyoi Nobuyuki)”’Health Systems Management 2005’③Japan Public Health Association (JPHA)(2004) ‘Public Health of Japan 2004’④JICA(2006)”Infant Checkup & Infectious Diseases Control in Japan (Dr.Hirayama Munehiro)”’Asian MCHW Workshop 2005’⑤JICA(2004) ‘Japan’s Experiences in Public Health and Medical Systems’⑥JICA(2003) ‘Illustrated Trends in Japan’s Public Health 2002’⑦Health and Welfare Statistics Association(HWSA)(2006) ‘Kokumin Eisei no Doko (Trends of Public Health) ’(in Japanese) ⑧International Medical Center of Japan (IMCJ)(2005) ”MCH system in Japan (Dr.Chinda Eiki)”’The Seminar on Maternal and Child Health for French-Speaking African Countries 2006’