Overview of Health and Medical Care System in Japan JICA Tokyo International Center December 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. 1
Outline Health/Medical Services Laws --- 3 Health Services ---------------- 4-14 Medical Services ------------- 15-18 Health Insurance System --- 19-22 2 2
Health/ Medical Services Laws Laws 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) 3 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. 3
Health Service System Ministry of Health, Labour and Welfare National Policies/Programs Budget Catchments areas for secondary medical care:365 (March 2006) 47 Prefectual Governments*, 139 Large Municipal Governments* Regional Health Medical plan Budget 535(April 2006) Provision of Preventive Health Services (Promotion, sanitation, medical pharmaceutical affairs, statistics, risk management) Technical support Public Health Centers (Hoken-jo) Municipal Governments* (city, town, village) Municipal Health Centers (Hoken-center) 1820(April 2006) Provision of Health /Welfare Services Budget 2692(April 2006) Health services for the aged Immunization MCH checkup Community People * Local governments Source:NIPH(2005) 4 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 (Hokencenter) 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. 4
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 level service system National Government Policy, Laws and budget Local Government People in the community Source:JICA(2001) 5 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 allocation The 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. 5
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) 6 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. 6
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) 7 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. 7
Public Health Center (2) Types of services Law enforcement Number (April 2006) Director Staff Specialized or focused (psychiatric, intractable diseases, infectious diseases such as tuberculosis, HIV) Supervision and audit of health and medical care facilities/ restaurants Total 535 Prefecture (396), major cities (139) Basically medical doctor (or non-md with certain qualification) All kinds of health professionals (doctors, dentists, pharmacists, public health nurses, veterinarians, nutritionists, X-ray technicians, food inspectors, statisticians and bacteriologists) Source:JPHA(2004) 8 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. 8
Public Health Center (3) 9 This is the office at one of Public Health Center (SUGINAMI Ward, TOKYO) 9
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) 10 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. 10
Municipal Health Center(2) Types of services Law enforcement Number (April 2006) Director Staff 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.) None 2692 (Cities, towns, villages) No requirement Predominantly public health nurses and dieticians Source:JPHA(2004) 11 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 MHCs entrust 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. 11
Municipal Health Center(3) 12 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... MHCs provide 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. 12
Maternal and Child Health Services Pregnancy Birth Registration at City hall Pregnancy Registration at City hall MCH hand book Mass screening Examination at Clinics/hospitals Delivery Parents class Home visit service Baby s Health Check-ups Baby s Immunization at hospitals/clinics/mhcs *Blue ink: related to the public health services *MHCs (Municipal Health Centers) Source:JICA(2006) 13 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 (MCH handbook) 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 checkups 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. 13
Health Services provi der 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) Community Based public health /School health/occupational health Local governments (prefectual, municipal) /Schools/Employer/Insurer Infant examination 18 month examination 3 years old examination Preschool examinatio ns and health guidance Health checkups at school entry and at regular intervals Health check-ups for pregnant women and new mothers, 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) Occupational health and safety Workplace health programs 14 Source:JICA(2004) 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. 14
Definition of Medical 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) 15 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. 15
Number of Medical Institutions by Founder As of October 2004 3% 17% National Gov. 1% 5% National Gov. 80% Local Gov. and Other Private 94% Local Gov. and Other Private Number of Hospitals National Governments:304 Local Government and Other: 1,506 Private: 7,267 Total: 9,077 Number of Clinics National Governments: 620 Local Government and Other: 4,895 Private: 91,536 Total: 97,051 Source:IMCJ(2005) 16 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. 16
Formulated by Medical Care Plans 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) 17 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. 17
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) Number of medical institutions by beds 2500 2000 Institutions 1500 1000 500 0 50-99 150-199 300-399 500-599 Bed category 700-799 900-18 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. 18
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) 19 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. 19
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) 20 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, and National 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. 20
Health Insurance System(3) Proportion of insurers SIA(28.1%) HIS(23.9%) MAA(7.7%) Municipal NHI(36.2%) NHI societies(3.1%) Indigent(1.0%) Employees Health Insurance (SIA, HIS, MAA) covers 60% of the population. (March 2004) 21 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 21
Medical Service Concept Chart of Insured Medical Care Medical institutions (hospital/clinic) Reimbursement of medical fee Insured person (patient) Payment of partial cost-sharing amount Claim of medical fee Examination and payment organization Claim of examined amount Payment of premium Insurer Reimburse ment of requested amount Payment fund / National Health Insurance Group Association Source:IMCJ(2005) 22 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. 22
23 -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 23