Detailed planning for secure health care delivery Country: Japan Partner Institute: Kinugasa Research Institute, Ritsumeikan University, Kyoto Survey no: (9)2007 Author(s): Matsuda, Ryozo Health Policy Issues: System Organisation/ Integration, Political Context, Access, Responsiveness Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract The Health Care Reform Act passed in 2006 states that prefectural health care plans shall include detailed descriptions and indicators, set by the national government, on health services resources, utilization, and outcomes for four diseases (cancer, stroke, acute myocardial infarction, and diabetes) and five areas of health care (ambulatory medicine, disaster medicine, rural medicine, prenatal medicine, and child health care). 2. Purpose of health policy or idea The existing prefectural health care plans, which have been intended to mostly control the number of hospital beds, have been increasingly regarded as insufficient in meeting the population health needs and increasing efficiency in providing health care. This resulted in a revision of the national guideline for planning prefectural health care delivery. Main objectives The revision of the national guideline aims to maintain and develop national health care delivery by making prefectures more involved into and, therefore, responsible for local health care delivery. Type of incentives Incentives are mostly non-financial, but some financial incentives have been included. Groups affected Prefectures, Ministry of Health, Labour and Welfare, providers 3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial - 1 -
Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral This policy is innovative in the following sense: 1. planning mechanisms, though abstract and broad, with financial incentives for bulding a better health care delivery system rather than restricting its expansion have been introduced both at the local and at the national level; 2. with the obligation to develop subplans for selected health services, prefectures are more likely to become responsible for and get involved in managing local health care delivery; 3. making subplans with the involvement of health care providers, health professionals, and local people can enhance coordination among these groups to better meet local health needs, which may lead to more efficient provision of health care. One interesting point is that the national government seems cautiously to avoid taking explicit responsibilities for health care delivery. Although the MHLW has to establish principles for building better health care delivery and politically it cannot escape from the issue, prefectures are the central actors responsible for improving local health care delivery within their contexts. The national goverment is to support prefectures in achieving their own goals determined by themselves. Thus, no national standards for health care delivery have been established. However, since equity in health care utilization cannot be practically neglected, some mechanism to increase geograhpical equity would become necessary. 4. Political and economic background This policy is consistent with the major current objective of health policy: providing quality health care efficiently. However, it extends the present scope of prefectural health care delivery plans, which had been mostly intended to restrain the number of hospital beds since the 1980s. The objective of restricting the number of beds has been partially achieved. However, as patients have increasingly experienced problems in using appropriate health care during the last decade, policies to maintain and further develop a high-quality health care delivery system have been demanded rather than policies that resctict health care provision. Since prefectures differ both in problems and in available resources, these policies shall be developed locally as well as nationally. Change based on an overall national health policy statement See above. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea Since 1985, prefectures have the obligation to make health care plans containing the "necessary number of hospital beds" within each prefecture, which is calculated according to a formula given by the Government. A Governor can - 2 -
prohibit providers from increasing the number of hospital beds if the actual number of hospital beds in his/her prefecture is larger than the "necessary number of hospital beds". This means the primary intention of prefectural health care delivery plans is regulating the total number of hospital beds. In that sense, prefectural plans have worked well. Moreover, prefectural health plans usually refer to broad principles for developing health care delivery. However, those principles have unsatisfactory impacts on the actual development of health care, especially with regard to meeting the growing needs of the population. The Ministry of Health, Labour and Welfare (MHLW) therefore now foresees substantial measures to make local health care delivery meet the health care needs more efficiently. The idea of developing selected areas of health care that are of high priority can already be found in a 2002 policy document by a project team in the MHLW. But the policy making process is likely to be accelerated by the criticism delivered by the Council for Regulatory Reform, which was a special body within the Cabinet Office for promoting regulatory reform and mostly consisted of private company executives and academics. It criticized that the restriction of hospital bed numbers curbs competition between providers, resulting in the fact that the number of beds becomes a provider's "vested interest". This criticism lead to the Cabinet's "Three-Year Program for Promoting Regulatory Reform (Revised)" published in 2003, which stipulates that health care plans are to be revised to achieve more efficient health care delivery. In 2005, an Ad Hoc Commitee for Health Care Planning (an advisory body for the MHLW) established the following principles for the revision: health care planning shall contribute to the development of a transparent and understandable health care system for the public; effective planning and evaluation based on numeric indicators shall be develped to achieve high-quality and evidence-based health care; prefectures shall have more active roles and discretion in making and implementing heatlh care delivery plans that meet their own population's needs. The last principle followed the trend of administrative decentralization which had been strongly promoted by the Government since the mid-1990s. The committee proposed the idea that health care delivery plans should include subplans on specified health care areas such as ambulatory care and cancer treatment. It also argued that the national government shall develop specified frameworks and indicators, including structural, process, and outcome dimensions, for subplanning to support prefectures. Furthermore, the Government has created a new grant to prefectures to support prefectures in developing local health systems from FY 2006 on. The idea that care subplans for selected areas of health care should be made may be influenced by the National Service Frameworks (NSFs) in the United Kingdom, although the guidelines published by the central government in Japan are not national standards, but technical advise just for deliberation. Initiators of idea/main actors Government Approach of idea The approach of the idea is described as: renewed: Detailed descriptions in health care plans are not so novel tools. However, it requires innovations in collecting and analyzing data on health care provision. Innovation or pilot project Else - The Ministry of Health has developed a model plan and is conducting pilot data synthesis. - 3 -
Stakeholder positions The necessity for subplans for selected health services in prefectural health care plans were proposed in the interim report of the Ad Hoc Committee for Health Care Planning, an advisory body to the MHLW, in 2005. The driving forces behind this idea seem to be academics and bureaucrats concerned with planning health care delivery, backed by demand for quality and safe health care of the public. Since this revision is to change prefectural's roles significantly, officials at the MHLW had talks with senior level officials from prefectures. At the same time, the National Governor's Association argued that they should have discretion to make plans that suit their local situations and that more regulatory and financial power should be given to them for effectively implementing health care plans. The Government had already planned to introduce subsidies for developing local health care delivery systems from FY 2006 on. These subsidies can be used more flexibly by prefectures and have a legal basis by the 2006 Health Care Reform Act. The Act also gives prefectures authority to collect the necessary information from providers. The Health Care Committee of the Social Security Council, a permanent advisory committe to the MHLW, published "A View on Future Health Care" in 2005, which Includes principles on revision of prefectural health care plans. Although the issue of resource allocation for better health care delivery has occupied the interest of the public, the revision of health care plans has not attracted the attention of the media and the public. Rather, the mass media covered children or pregnant women who have difficulties in finding appropriate health care or physicians whose workloads were seriously heavy. According to the revised guidelines made and published by the MHLW in 2007, subplans for selected health services shall describe functions of health services with particular names of health facilities, which is not easy especially in urban areas. Tokyo prefecture argued that there should be alternative ways to nominating names of facilitites for describing health care delivery subplans. Actors and positions Description of actors and their positions Government Ministry of Health very supportive strongly opposed Council for Regulatory Reform very supportive strongly opposed Cabinet Office very supportive strongly opposed Committee for Health Care Planning very supportive strongly opposed Influences in policy making and legislation This policy has been already enacted by the 2006 Health Care Reform Act. Each prefecture has the obligation to analyze its situation of health care delivery and add a detailed description to the present plan in 2008. In July 2007, the MHLW issued two circulars which include guidelines on preparing prefectural health care plans including subplans on specified health services and on making subplans for coordinated delivery in specified areas of health care. The latter guideline includes the following apects: basic clinical knowlege and servcie models on each area of health services; collecting qualitative and quantitive information on health status, utilization, health facilities, human resources, available technologies and health outomes; designing and coordinating health care provision in local settings; involving hospitals, health professions, local people and others concerned; and - 4 -
setting numerical goals for minitoring and evaluation. It also stated that subplans should describe which health facilicies carry out functions that should be fulfilled in prefectures. The guidelines are referred to as "technical advice" rather than a statement of national standards or goals. Each gudeline for a specifed area of health services contains less than 20 A4 size pages with very limited references. Legislative outcome success Actors and influence Description of actors and their influence Government Ministry of Health very strong none Council for Regulatory Reform very strong none Cabinet Office very strong none Committee for Health Care Planning very strong none Positions and Influences at a glance Adoption and implementation The Ministry of Health, Labour, and Welfare is in charge of developing the national guidelines which would be influential in developing detailed prefectural health care plans. To enhance capacities of prefectural officials, the Government has organized special courses for them. However, research in 2006 revealed that there existed wide differences in terms of data collection and utilization between prefectures. - 5 -
The 2006 Health Care Reform Act makes subplans on the following areas compulsory from 2008 on: ambulatory care disaster health care rural health care prenatal health care child health care; and health services to prevent or treat four diseases (cancer, acute myocardial infarction, stroke and diabetes). The national government publised guidelines in June 2007, which include practical and basic information and help for prefectural planners. Prefectures can choose indicators by themselves without any compulsory indicators, although examples for indicators have been given in the guideline. They include structual indicators (number of hospital beds, number of institutions that can perform special treament, etc.), process indicators (e.g. prevalence of smoking, proportion of population who use health check-ups, and proportion of patients for whom a discharge planning was made, etc.) and outcome indicators (adjusted mortality, proportion of stroke patients dicharged to their home, etc.). The guidelines will be updated when new research evidence is available. Monitoring and evaluation First, all prefectural health care plans with subplans for selected areas of health care are to be sent to the MHLW when they will be determined. Secondly, prefectural health plans are evaluated for revision every five years. Thus this policy can be reviewed at that time. Review mechanisms Mid-term review or evaluation Dimensions of evaluation Structure, Process, Outcome 6. Expected outcome With detailed descriptions of health care provision in selected areas of health care included in health plans, prefectures are responsible to make efforts to achieve the goals given in the description. However, tools to achieve the goals are not clear, especially in terms of financing: Prefectures do not have sufficient own funds to meet the goals. Rather they necessarily depend on payments from public health insurance funds and subsidies from the Government. In this sense supplementary policies for achieving the goals should be established. The supplementary policies, however, would be very controversial because prefectures will have more revenue from tax rather than from state subsidies by the decentralization reform and have more discretion with regard to expenditure. One problem is whether prefectures are able make transparent and understandable plans that can be evaluated in the future or not. Another problem is that the implementation of the plans may be hard due to lack of appropriate funds or regulatory measures. Since the Government sets no explicit goals in terms of health care provision except for the abstract principle, i.e. providing quality health care efficiently, which lacks the equity dimension, there are concerns that inequalities between rich and poor prefectures may increase. Quality of Health Care Services marginal fundamental - 6 -
Level of Equity system less equitable system more equitable Cost Efficiency very low very high With the obiligation and authority to develop revised health care delivery plans with subplans for selected health care areas, prefectures will gradually become more responsible and increase their capacity for managing local health delivery. However, at least two caveats exist. First, as health care is mostly financed by the public health insurance system, which has been administered at the national level, it remains to be seen if the relatively small amount of subsidies for prefectures (new subsidies of less than 40 billion yen have been introduced in FY 2006) are sufficient to support prefectures in taking on their new and extended responsibilitiesthe and in the achievement of their goals. Secondly, health care providers may respond to financial incentives by the payment system of the public health insurance rather than those subsidies. This reponse may lead to failure of improving coordination among them. Meanwhile, local accountability of heatlh expenditures has been increased under the public health system, which may have a synergy effect with revised health care plans. 7. References Sources of Information Ministry of Health, Labour and Welfare (2003): A Vision on Reform of Health Care Delivery. Cabinet (2003): Three-Year Program for Promoting Regulatory Reform (new Revised). Ad Hoc Commitee for Health Care Planning (2005): Revision of Health Care Planning under the Health Care Act 2006: An interim report. Health Care Committee, Social Security (2005): A Vision on Better Health Care Delivery. Ministry of Health, Labour and Welfare (2007): Guidelines for Secure Delivery of Health Care: a draft for public comment. Ministry of Health, Labour and Welfare (2007): A Guideline for Planning Health Care Delivery (Circular No.0720003, from the Health Policy Bureau). Ministry of Health, Labour and Welfare (2007): A Guideline for Developing Subplans for Selected Health Services (Circular No.0720001, from Medical Service Division, Health Policy Bureau). Author/s and/or contributors to this survey Matsuda, Ryozo Suggested citation for this online article Matsuda, Ryozo. "Detailed planning for secure health care delivery". Health Policy Monitor, March 2007. Available at http://www.hpm.org/survey/jp/a9/3-7 -