Globalisation of the Healthcare Services Sector

2018 EROPA Conference, Bali, Indonesia September 16-20 Public Administration in Managing Global Megatrends: People, Public Services, Institutions, and Ethics Theme B Public Services: Challenges and Strategies for Delivering Better Public Services Globalisation of the Healthcare Services Sector Employing Foreign Physicians in National Strategic Special Zones in Japan Yumi HINOHARA Lecturer Faculty of Social Welfare, Iwate Prefectural University, JAPAN y_hinoha@iwate-pu.ac.jp 1

Contents 1. Introduction Purpose and Background, Theoretical Framework, Present Status of Healthcare Services in Japan 2. Approach towards the Recruitment of a Sufficient Number of Doctors Case study in Japan, UK and Singapore 3. Measures for Globalising Healthcare Services in Japan Certification System for Medical Institutions Providing Healthcare Services to Foreign Patients Medical Practice by Foreign Doctors in the National Strategic Special Zone 4. Discussion 5. Conclusion 2

Introduction: Purpose and Background Purpose of This Presentation -to discuss the expansion and diversification of healthcare service demands as a challenge of public service -to examine the issues and prospects of healthcare services provide for foreign patients in Japan Background -due to the existence of a so-called nationality requirement, the National Health Insurance Act was only applicable to Japanese nationals until 1986 - now the nationality requirement was eliminated, and Japan modified its system to include foreign residents Is this enough? -to respond to the healthcare needs of foreign residents, it is also important to develop a healthcare service system which considers linguistic, cultural and religious differences How about in Japan? -Japan imposes strict regulations on healthcare services provided by foreign doctors and essentially does not allow foreign nationals to provide healthcare services, except in cases with a bilateral agreement -the provisions of articles 2 and 17 of the Medical Practitioners Act, Japan only permits those with a Japanese medical licence to domestically practice as doctors 3

A Concept of Citizenship Introduction: Theoretical Framework -a seminal study of citizenship theory by the British sociologist T.H. Marshall in 1950 -his theory was modelled on Britain and strongly linked to the concept of a nation state this theory did not include a guarantee of citizenship to foreigners Healthcare Right as Citizenship -healthcare services as a fundamental mechanism of the welfare state -protection of the right to live specified in Article 25 of the Constitution of Japan which regards the protection of citizens right to live as a public responsibility 4

A Concept of Denizenship -established by Swedish political scientist Tomas Hammar -as a status existing somewhere between citizens and foreigners, on the basis of his concern over the status and the rights of people living in foreign countries not as citizens but as residents i.e. their political rights Denizenship and Healthcare Right Introduction: Theoretical Framework -both nationals and foreign residents living in a country need the same Healthcare services -the concept of guaranteeing rights based on a residence status akin to denizenship needs to be incorporated into provision of actual medical welfare services and other public service Denizenship as a Right to Health Services through Interpreters -under the Civil Rights Act of 1964, No person in the United States shall, on the ground of race, colour, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any programme or activity receiving Federal financial assistance -this act also covers the prohibition of discrimination through language access to medical interpretation services is guaranteed to patients who do not speak English 5

Introduction: Present Status of Healthcare Services in Japan The Elderly Population in Japan -elderly population in Japan accounted for 7% of total population in 1970, increase to 14% in 1994, the figure reached 27.3% in 2016 -the highest rate of ageing in the world in terms of proportion of the population aged over 65 years What Is the 2025 Problem? -by 2025, when the baby-boomer generation reaches 75 years of age Increase in Healthcare Needs Current and Future Trends of Ageing in Japan -the demand for medical care and social security in Japan will further expand and labour shortage in healthcare and nursing will become a serious problem in a super-aged society Source: Cabinet Office (2017: 5) 6

Introduction: Present Status of Healthcare Services in Japan Diversification of Healthcare Needs -people s lifestyles, disease patterns and complex healthcare needs, resulting from an increase in foreign patients Trends in the Number of Foreign Residents in Japan Trends in the Number of Foreign Residents in Japan and their Proportion to Japan s Total Population the total number of foreign residents increased 7.5% compared to the end of the previous year -the number of foreign nationals staying in the country as technical trainees and highly skilled workers has been growing in recent years -foreign residents are also increasing in proportion to the total population Source: Ministry of Foreign Affairs (2017: 234) 7

Approach towards the Recruitment of a Sufficient Number of Doctors:Japan Means for Quantitative Expansion of Healthcare Services (Ito, 2006:257-248) 1increase the number of medical students2promoting retention rates and return after leave 3overseas recruitment How about in Japan? -the number of doctors has been managed with regard to social conditions including potential future outcomes, through public intervention in the number of medical schools and their capacities -the country foremost among super-aged societies, the Cabinet decided to increase the number of medical school students under the Basic Policy for Economic and Financial Reform 2008 -the policy to increase the number of medical students will also continue to be implemented in 2019 Trends in the Admission Capacity of Medical Schools since 1981 Source: Increase in the Number of Medical Students by Ministry of Education, Culture, Sports, Science and Technology (2017) 8

Approach towards the Recruitment of a Sufficient Number of Doctors :UK Means for Quantitative Expansion of Healthcare Services - the first step taken to increase the number of doctors was to expand the domestic training of doctors in the country -overseas recruitment Acceptance of Foreign Doctors in the UK -history of foreign doctors from former British colonies and joined the Commonwealth of Nations after achieving independence -26% of the doctors working in the NHS are foreigner, 12% of the doctors are of the Asian origin, 10% are European Union(EU) member countries other than Britain and 4% are African nationals and other nationalities Origins of doctors working in the UK and their proportions Source: Baker (2018:12) 9

Approach towards the Recruitment of a Sufficient Number of Doctors :Singapore Means for Quantitative Expansion of Healthcare Services - the first step taken to increase the number of doctors was to expand the domestic training of doctors in the country -overseas recruitment -outsourcing of the training of doctors Outsourcing of the Training of Doctors in Singapore -only three medical schools in Singapore -those trained abroad account for about half of the total number of doctors in public hospitals and a third in private hospitals -doctors who trained abroad are not necessarily foreigners, many of them are Singaporean citizens -largely relying on foreign countries for the training of doctors an efficient means to provide a stable supply of healthcare services in such small country Number of Registered Doctors by Location of Training, Employment Sector and Resident Status Registration Type Pubic Sector Private Sector Local Trained Singapore Citizens 4,013 2,926 Foreign Trained Singapore Citizens 1,145 752 Local Trained Singapore Permanent Residents 234 191 Foreign Trained Singapore Permanent Residents 1,005 374 Local Trained Non-Residents 111 10 Foreign Trained Non-Residents 2,054 191 Total 8,562 4,444 Source: Singapore Medical Council(2015: 11) 10

Measures for Globalising Healthcare Services in Japan: Certification System for Medical Institutions Providing Healthcare Services to Foreign Patients Outline of the System: Japan Medical Service Accreditation for International Patients(JMIP) -adopted as support system of Ministry of Health, Labour and Welfare in 2012, operating under the Japan Medical Education Foundation -the criteria for accreditation include provision of multilingual healthcare services using medical interpreters, arrangement of international medical coordinators and installation of prayer rooms The JMIP s Assessment Process 1the Japan Medical Education Foundation which operates the JMIP provides an accredited investigator to prepare a written assessment 2field survey of the medical institution 3based on the results of the survey visits, the final decision is made by the Accreditation Review Board, which consists of a panel of experts 11

Measures for Globalising Healthcare Services in Japan:Certification System for Medical Institutions Providing Healthcare Services to Foreign Patients Assessment Criteria Are 1framework for the provision of services i.e. systems to treat foreign patients in-hospital departments and methods of notifying them about the details of medical expenses and payment methods 2patient service i.e. pertains to the status of interpretation and translation services and preparation of the hospital environment in consideration of the religions and customs of foreign patients 3management of health provision i.e. the methods of communication with foreign patients, gaining informed consent in medical examinations, testing and nursing care 4organizational structure and management i.e. the roles and safety management of departments that treat foreign patients 5approach towards improvement i.e. the education and training of in-hospital staff who provide healthcare services to foreign patients, as well as the methods of surveying the opinions of foreign patients 12

Measures for Globalising Healthcare Services in Japan:Certification System for Medical Institutions Providing Healthcare Services to Foreign Patients Locations of Japan Medical Service Accreditation for International Patients (JMIP)-certified Medical Institutions across the Country (as of June 2018) Component Ratio of Foreign Residents (by Prefecture) (as of June End 2017) Source: Created by author by using JMIP website. URL: http://jmip.jme.or.jp/search.php Source: Ministry of Justice (2017) 13

Measures for Globalising Healthcare Services in Japan:Medical Practice by Foreign Doctors in the National Strategic Special Zone Definition of the National Strategic Special Zone -based on the Act on National Strategic Zones enacted on 2013, the special economic zones were subject to a regulatory reform system for deregulation and tax incentives, mainly to enhance the international competitiveness of Japanese industries Purpose of the National Strategic Special Zone -the National Strategic Special Zones constitute part of the growth strategy for encouraging private investment, aiming to surmount strict regulations -part of pillar of the reform of Abe s second Cabinet, which developed the growth strategy of Abenomics 14

Measures for Globalising Healthcare Services in Japan:Medical Practice by Foreign Doctors in the National Strategic Special Zone Locations of the Zones are -10 areas are -a total of 264 businesses are certified in the 10 areas i.e. urban regeneration, business creation, overseas workers, tourism, healthcare, nursing care, childcare, employment, education, agriculture, forestry and fisheries and future technology Locations of the National Strategic Special Zones Source: The Prime Minister s Official National Strategy Special Zone Webpage URL: https://www.kantei.go.jp/jp/singi/tiiki/kokusentoc/ (accessed on 10 June 2018) 15

Measures for Globalising Healthcare Services in Japan:Medical Practice by Foreign Doctors in the National Strategic Special Zone Existing Regulations on Healthcare Services Provided by Foreign Doctors -the qualification system for doctors in Japan: Medical Practitioners Act -Article 17 No person except a medical practitioner shall engage in medical practice -Article 2 A person who wishes to become a medical practitioner shall pass the National Examination for Medical Practitioners and receive a licence from the Minister of Health, Labour and Welfare Exceptions are 1foreign doctors allowed to practice if they obtain medical licences issued by Minister for Health, Labour and Welfare after taking and passing the National Examination for Medical Practitioners in accordance with the Medical Practitioners Act 2for medical practice under a clinical training programme for foreign medical practitioners since 1987 3recruitment of doctors under bilateral agreements established between Japan and the United Kingdom, the United States, France and Singapore 16

Measures for Globalising Healthcare Services in Japan:Medical Practice by Foreign Doctors in the National Strategic Special Zone National Strategic Special Zone and Healthcare Service systems -healthcare is one of the regulatory reform categories of the National Strategic Special Zones and includes the establishment of new medical schools as one of the means to increase the number of doctors -the partial lifting of restrictions on the healthcare services provided by foreign doctors Deregulation in the National Strategic Special Zones - in accordance with the Act for Partial Amendment under the Act on National Strategic Special Zones and the Act on Special Districts for Structural Reform enacted in July 2015, restrictions on the healthcare services provided by foreign doctors on the basis of bilateral agreements in the National Strategic Special Zones in Tokyo area have been partially lifted -foreign doctors began to provide healthcare services to all foreign residents in Tokyo, excluding Japanese nationals -under this system, a British doctor was offered a position at Keio University Hospital, an American doctor and a French doctor at Juntendo University Hospital and two American doctors at St Luke s International Hospital and St Luke s Medilocus in December 2015, in September 2017, a British doctor was hired by Tokyo medical and surgical clinic 17

Discussion Comparison between Means for Quantitative Expansion of Healthcare Services in Japan and Foreign Countries -in the UK and Singapore, doctors from abroad are welcomed to compensate for the shortage of medical personnel in addition to enhancing domestic medical training with an aim to increase the number of doctors -especially English-speaking countries, because the language barrier tends to be low compare to Japan, hiring foreign professionals has enabled a response to the expansion of domestic demand -it takes 10 years to train a doctor from scratch, recruiting qualified professionals from abroad has reduced the cost of training workers, thereby streamlining the provision of services -in Japan, with greater language barriers and the regulation of the Medical Practitioners Act, hiring foreign doctors in the same way as the UK and Singapore is not an appropriate means to address the expansion of healthcare demand in Japan in the short term 18

Discussion Issues and Prospects of Globalising Healthcare Services in Japan -even after the accreditation of medical institutions by the JMIP and the lifting of restrictions on medical practice of foreign doctors on medical practice of foreign doctors in the National Strategic Special Zones, the scope of target populations and areas is still limited the distribution of 43 medical institutions certified by the JMIP in Japan as of June 2018, over 40% of certified medical institutions are concentrated in the Kanto region including Tokyo -leaving much room for improvement in Japan s current healthcare service system in order to meet the needs of foreign patients -the relaxation of the restrictions imposed on the provision of healthcare to foreign patients by foreign doctors in the National Strategic Special Zones solely applies to the bilateral agreements between the Japanese government and the governments of the four countries with a more flexible framework and has not yet been developed sufficiently to meet the quantitative demands of foreign patients. 19

Conclusion Ageing, Globalising, and Healthcare Services -the country needs to response to the diversification of the healthcare needs, in addition to the quantitative healthcare needs -healthcare needs that have diversified as a result of the increase in the number of foreign patients give rise to the need for diverse restructuring of the conventional healthcare service system in Japan Denizenship and Healthcare Right in Japan -the concept of guaranteeing rights based on a residence status akin to denizenship needs to be incorporated into the provision of actual medical welfare services and other public services. -responding to the healthcare needs of foreign residents in Japan is indispensable from the perspective of the application of the concept of denizenship to the real society 20

Bibliography Baker, C, (2018) NHS staff from overseas: statistics, Briefing Paper No.7783, House of Commons Library. Cabinet Office (2017) Ageing Society Policy White Paper, Nikkei Printing. Ministry of Education, Culture, Sports, Science and Technology, (2017) Increase in the Number of Students Admitted to Medical Schools. Ministry of Foreign Affairs of Japan, (2017) Diplomatic Blue Book 2017, Nikkei Printing. Ministry of Justice (2017) Published documents on definite values at the end of June 2017. Singapore Medical Council 2015 Singapore Medical Council Annual Report. JMIP Website URL:http://jmip.jme.or.jp/ National Strategic Special Zones, Prime Minister of Japan and His Cabinet URL:https://www.kantei.go.jp/jp/singi/tiiki/kokusentoc/ Acknowledgement This work was supported by Grant-in-Aid for Young Scientists (B) KAKENHI Grant Number JP17K13877 21

Thank you for your kind attention 22