HEALTH SYSTEM IN FOCUS

1. HEALTH SYSTEMIN FOCUS JAPAN Reporters: Lustre,Ceferino Salisi, James Members: Sabularce, Joey Motos, Jeffrey de Guzman,Angelo Dubrico, Gretchen

2. Profile of JAPAN • 3rd largest economy in the world (recently surpassed by China) • constitutional monarchy with a parliamentary government • 47 perfectures

3. Japan has a healthcare system characterized by universal health insurance coverage, as all Japanese citizens belong to one of the country’s health insurance systems.

4. hybrid system funded by job-based insurance premiums and taxes -- is universal and mandatory, and consumes about 8 percent of the nation's gross domestic product

5. BISMARCKIAN Model • State-mandated social insurance, started by Bismarck in 1883, 1st Chancellor in Germany • Covers all or most citizens through employer and employee payments to insurance , while providing care through public & private providers found in Germany, Japan, Belgium, France, Netherlands

6. DEMOGRAPHIC Characteristics and Health Status of the Japanese People

7. Demographic Characteristics • As of May 2010: population 127, 360, 000 Male: 62, 010, 000 Females : 65, 340, 000

8. Distribution by Age group

9. The average life expectancy remains among the highest in the world. • In 2009: 86.44 years - women 79.59 years – menIn 2008, the crude birth rate was 8.7 per 1000 persons and the crude death rate was 9.1 per 1000 persons

10. Natality

11. 19.6 per 1,000 8.6 per 1,000

12. Yearly comparison of live birth rates by age group of mother

13. General Mortality

14. General Mortality • death rates had gradually declined since 1957, recording the lowest rate of 6.0 in 1979 and 1982. • deaths have demonstrated an upward trend, and death rates have been growing, reflecting the aging of the population

15. Trends in deaths and death rates, 1955-2006 8.5 per 1,000

16. General Mortality • Due to a highly-technological, competition-oriented society, the stress levels felt by all age groups are rising. • The number of suicides in Japan surpassed the 30,000 mark for the first time in 1998 and has since remained in the range of 30,000 per year, registering at 30,649 in 2009. • The number of suicides was particularly high for men in their 20s, 30s and 40s.

17. 273 143

18. infant mortality

19. Trends in infant deaths and infant death rates, 1955-2006

20. Causes of infant deaths

21. Causes of Infant Deaths • 30% congenital malformations • 13.8% respiratory and cardiovascular diseases

22. fetal Mortality

23. Trends in foetal deaths and fetal death rates, 1955-2006

24. Health Service Delivery (Organization and Administration)

25. Four Primary Mechanisms: • Public health centers– prevention and maintenance, • Physician offices – solo-practice physician in smaller communities • Clinics – in large communities, in-/outpatient care offered • Hospitals – more than 20 beds and contain higher level of technology

26. Public Health System • 411 Public health centers by perfectures • doctor, dentist, pharmacist, veterinarian, X-ray specialist, nurse, dietician • Regulatory(licensing, sanitation) • 2,692 Municipal health centers • Community health promotion • General services

27. The four subsystems are not always closely coordinated and continually compete for resources. • Traditional medicine is extensively practiced and herbal medicines are widely sold.

28. Organizational Structure

29. Health Insurance System • There is universal coverage of the population by statutory health insurance • Three insurance schemes: • SMHI , for employees of large companies and their dependents • GMHI, for employees of small to medium-sized corporations and their dependents • NHI, for the self-employed

30. Public-administered financing through numerous schemes, • Delivery is highly fragmented/decentralized, • Private hospitals dominate the hospital system, • Hospitals operate as a closed system, • There is freedom to choose providers, • There is no gate-keeper system,

31. Payment system is fee-for- service under a national uniform price schedule, • There is long waiting time but short consultation time, • Expenditure on drugs comprises a high share of total health expenditure, • There is no complete separation of drug prescribing and dispensing,

32. Utilization of Health Facilities • Overutilization • 14 consults per person per yr (vs 4 consults in US, 2003) • 13.8 days ave. stay in acute beds in hospital (vs. 5.6 US,2006) • Overprescribing of diagnostic tests (doctors own equipment) Source: The Challenge of Reforming Japan’s Health System. McKinsey &Company Nov 2008

33. Responsiveness and Client Satisfaction • Long waiting time • 50% of the time > 30 mins • Short care time spent with physician -13.5 % < 3 mins, 54% 3-9 mins Source: 2010 Japan Ministry of Health data

34. Financial Risk Protection • Overall Health spending • 14% in out of pocket expenditures

35. HUMAN HEALTH RESOURCE James Salisi

36. Pharmacists • Only secondary role versus physicians in dispensing medications

37. Nurses • 980 nurses per 100,000 (2008 data), improved from 821 in 2000 • Nurses in Japan have similar situations as in other OECD nations—lack of autonomy, low salaries, lack of professional recognition, MDs in teaching positions • Public health nurses have most advanced training • Clinical nurses • Nurse midwives • Assistant nurses

38. Four levels of nursing: • Public health nurse: graduate program, provide home health, pediatric check-ups, industrial health • Clinical nurse: 3 yrs beyond high school, 80% in hospital, 15% in clinics • Nurse Midwives: Critical role in prenatal care and delivery, clinical training & practicum, 50% hospital based, 33% own practice • Assistant nurse: 2 year vocational program, like LPN in US (Tracey Lynn Koehlmoos, PhD, MHA,Lecture 13, HSCI 609 Comparative International)

39. Physicians • Decline in number especially in pediatrics and obstetrics • 222 per 100,000 in 2008 (very lowfor OECD, since average is 300 per 100,000) • No academic differentiation between specialist and generalists • Most clinics and small hospitals are owned and operated by private physicians • However, the trend is now away from private FFS practice toward more prestigious, salaried hospital-based practice (Tracey Lynn Koehlmoos, PhD, MHA, Lecture 13, HSCI 609 Comparative Internation)

40. Physicians as businessmen • Physicians as pharmacists • Physicians as policy makers • No emphasis on informed consent or full disclosure

41. Midlevel and other Health Professionals • Allied medical professions have been slow to develop • Midwives, health admin, mental health counselling, psychotherapy, • Medical technology • Emergency medical services • Long term care

42. HEALTH FINANCING

43. Universal insurance (all employers offer coverage for employees and dependents, 1995) –started 1961 • National insurance program supplements for those not fully employed • Health Insurance Law of 1922 • New Medical Service Law 1948

44. Health costs are lowered by: • limiting prices for pharmaceuticals and discouraging high-cost services

45. Promoting an appropriate combination of the fee-for-service reimbursement system (medical fees are paid for each medical act) and fixed payment system (a fixed amount of fee is paid regardless of individual medical act), and encouraging appropriate division of roles and collaboration between hospitals and clinics.

46. Health and welfare services for disabled and senior citizens • The proportion of Japan's social security expenditure to national income registered 24.4 percent. (70% elderly cost) – SHJ 2010

47. Distribution of health spending • 49.2% insurance • 36.4% taxes • 14.4% out of pocket • 1/3 of spending for elderly Source: Japan:Health Systems Review,vol. 11, No.5, World Health Organization, 2009

48. Health Spending • 6.6%of GDP (Gross Domestic Product), among the lowest in OECD countries, from a low of 2.6% of GDP in 1956, yet GDP growth is stagnating • $ 2,600 per capita in 2005

49. Health Facilities • 80% of hospitals and 94% of clinics(20 beds) are privately owned

50. Health Regulation and Governance