Health Systems in Transition Vol. 11 No. 5 2009 Japan Health system review Kozo Tatara • Etsuji Okamoto Editors: Sara Allin • Ryozo Matsuda Health Systems in Transition Written by Kozo Tatara, Open University of Japan Etsuji Okamoto, Department of Management Sciences, National Institute of Public Health Edited by Sara Allin, European Observatory on Health Systems and Policies Ryozo Matsuda, Ritsumeikan University, Kyoto, Japan Japan: Health System Review 2009 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Offi ce for Europe, the Governments of Belgium, Finland, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organisation and administration JAPAN © World Health Organization 2009, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about this to: Publications WHO Regional Offi ce for Europe Scherfi gsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/PubRequest The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. 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ISSN 1817-6127 Vol. 11 No. 5 Health systems in transition Japan Contents Preface ............................................................................................................v Acknowledgements .......................................... ...........................................vii List of abbreviations .....................................................................................ix List of tables and fi gures ...............................................................................xi Abstract ........................................................... ...........................................xiii Executive summary ......................................................................................xv 1. Introduction ..........................................................................................1 1.1 Geography and sociodemography .................................................1 1.2 Economic context ..........................................................................5 1.3 Political context .............................................................................7 1.4 Health status ...................................................................................9 2. Organizational structure .....................................................................19 2.1 Overview of the health system ....................................................19 2.2 Historical background ..................................................................20 2.3 Organizational overview ..............................................................33 2.4 Decentralization and centralization .............................................39 2.5 Patient empowerment ..................................................................41 3. Financing ...........................................................................................49 3.1 Health expenditure .......................................................................52 3.2 Population coverage and basis for entitlement ............................56 3.3 Sources of funds ..........................................................................60 3.4 Pooling of funds ...........................................................................65 3.5 Purchasing and purchaser–provider relations ..............................66 3.6 Payment mechanisms ...................................................................67 4. Regulation and planning ....................................................................71 4.1 Regulation ....................................................................................71 4.2 Planning and health information management ............................75 iii Health systems in transition Japan 5. Physical and human resources ...........................................................83 5.1 Physical resources ........................................................................83 5.2 Human resources .........................................................................89 6. Provision of services ..........................................................................95 6.1 Public health ................................................................................95 6.2 Patient pathways ........................................................................107 6.3 Primary/ambulatory care ...........................................................108 6.4 Inpatient care .............................................................................110 6.5 Health care for the elderly .........................................................112 6.6 Emergency care ..........................................................................113 6.7 Pharmaceutical care ...................................................................114 6.8 Long-term care ...........................................................................117 6.9 Mental health care ......................................................................124 6.10 Dental care ...............................................................................126 6.11 Complementary and alternative medicines ..............................128 6.12 Health care for specifi c populations .........................................128 7. Principal health care reforms ...........................................................133 7.1 Analysis of recent reforms .........................................................133 7.2 Future developments ..................................................................137 8. Assessment of the health system .....................................................141 8.1 Objectives of the health system .................................................141 8.2 Distribution of costs and benefi ts across the population ...........142 8.3 Effi ciency of resource allocation ...............................................144 8.4 Technical effi ciency ...................................................................144 8.5 Quality of care ...........................................................................145 8.6 Contribution of the health system to health improvement .........145 9. Conclusions ......................................................................................149 10. Appendices ......................................................................................151 10.1 References ................................................................................151 10.2 Principal legislation .................................................................157 10.3 Useful web sites .......................................................................158 10.4 HiT methodology and production process ...............................159 10.5 The review process ..................................................................162 10.6 About the authors .....................................................................162 iv Health systems in transition Japan Preface he Health Systems in Transition (HiT) profi les are country-based reports that provide a detailed description of a health system and of reform Tand policy initiatives in progress or under development in a specifi c country. Each profi le is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profi les are based on a template, which is revised