Michael R. Reich Global Health & Population, HSPH

26 April 2012

Reflections on Japan’s 50 Years of

Universal Health Coverage

2

“Reflections”

• Not a focused research presentation• More of a personal perspective• Japan has had universal coverage since

1961, kokumin kaihoken seido ( 国民皆保険制度 ) = 50 years

• Japan has had Michael coverage since 1971 = 40 years

Field Research in Japan, 1971-74

Me

Presentation Based onLancet Japan Series

Leaders of the Japan Research Group

Prof. K. Takemi Prof. N. Ikegami Prof. K. Shibuya

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50 Years Since Achieving Universal Health Coverage

• Major improvements in health status in the postwar period

• Japanese women have ranked as number one in life expectancy for 25 years

Life Expectancy of WomenFor G7 Countries

source: MHLW.

1950

1951

1952

1953

1954

1955

1956

1957

1958

1959

1960

1961

1962

1963

1964

1965

1966

1967

1968

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1970

1971

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1991

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1998

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2003

2004

2005

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2008

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2010

0

20

40

60

80

100

Year

Un

der-

5 M

ora

lity

（p

er

10

00

liv

e

bir

ths）

Japan’s Under-5 Morality （ 1950-2008 ）

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Boys

GirlsMDG 4: Reduce

by 2/3’s(1950-1965)

92 (1950)

24 (1965)

Source: ランセット日本特集号 Population Health

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In 50 Years Since AchievingUniversal Health Coverage

• Also excellent control of national medical expenditures in Japan

• Today Japan’s NME represent only 8.1% of GDP, placing them at number 20 among OECD countries

• Cost control has continued, even with rapid aging of the population

Medical Expenditure among OECD Countries (2005）

source: MHLW.

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Reasons for Japan’s Successes

• Not easy to explain• Public health policies, • High literacy rates and educational levels, • Diet and exercise, • Economic growth, and • A stable political environment

Perry and his Black Ships“Open” Japan in 1853

Recent Historical Context - 1

• About 3.2 million deaths during WW2

Hiroshima after the Bomb

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Recent Historical Context - 2

• Under the Occupation, social change and democratization

• New public health policies introduced• Effective control of infectious diseases and

tuberculosis• From 1947 to 1955, average life

expectancy increased by 14 years• Serious pollution problems in 1960s

Expanding Coverage

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Japan’s Achievements

“Good Health at Low Cost with Equity”Four main points:• Universal coverage with increasing equity• Cost containment and service quality• Policies for ageing• Impressive gains in population health

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Growing Social Challenges

• the rise of part-time and temporary employment for young workers

• growing number of young women who postpone marriage and child-bearing

• ever-expanding number of elderly• increasing sense of widening income

inequality and diversity in values

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Serious problems in Japan’s Political Economy

• Twenty years of economic stagnation

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Japan’s Challenges Ahead

• Three major issues for Japan’s health system:

1. National fiscal situation and healthcare financing

2. Political governance3. Changing expectations about health

and quality

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Political Merry-Go-Round

27 August 2011: PM candidatesFor Japan Democratic Party

According to the Economist (17 March 2011)： Japan is “a despondent country with a dysfunctional political system”

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Three Reform Proposals

• Clarify national values of “human security” for structural reform

• Redefine the roles of central and local governments

• Improve the quality of healthcare

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Conclusions

• Possible to achieve progress in public health without a school of public health

• Fee for service reimbursement does not always lead to cost escalation; institutions and political economy matter

• The pursuit of universal coverage is not a one-time effort, but a long historical and political process