Michael R. Reich Global Health & Population, HSPH 26 April 2012

1. Reflections on Japan’s 50 Years of Universal Health Coverage Michael R. Reich Global Health & Population, HSPH 26 April 2012

2. “Reflections” • Not a focused research presentation • More of a personal perspective • Japan has had universal coverage since 1961, kokuminkaihokenseido (国民皆保険制度) = 50 years • Japan has had Michael coverage since 1971 = 40 years

3. Field Research in Japan, 1971-74 Me

6. Presentation Based onLancet Japan Series Leaders of the Japan Research Group Prof. K. Takemi Prof. N. Ikegami Prof. K. Shibuya

7. 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

8. Life Expectancy of WomenFor G7 Countries source: MHLW.

9. Japan’s Under-5 Morality（1950-2008） 92 (1950) Boys Girls MDG 4: Reduce by 2/3’s (1950-1965) 24 (1965) Source: ランセット日本特集号 Population Health

10. 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

11. Medical Expenditure among OECD Countries (2005） source: MHLW.

12. 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

13. Perry and his Black Ships “Open” Japan in 1853

14. Recent Historical Context - 1 • About 3.2 million deaths during WW2 Hiroshima after the Bomb

15. 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

16. Expanding Coverage

17. 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

18. 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

19. Serious problems in Japan’s Political Economy • Twenty years of economic stagnation

20. Japan’s Challenges Ahead • Three major issues for Japan’s health system: • National fiscal situation and healthcare financing • Political governance • Changing expectations about health and quality

21. Political Merry-Go-Round According to the Economist (17 March 2011)： Japan is “a despondent country with a dysfunctional political system” 27 August 2011: PM candidates For Japan Democratic Party

22. 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

23. 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