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Offline: Japan: a mirror for our future
Comment
Offline: Japan: a mirror for our future
APF/Getty Images
Reuters
The printed journal includes an image merely for illustration
When a visitor from the West goes to Japan, many things are different. Attendants bow as buses depart from Tokyo’s Narita airport. Editorials in Japanese newspapers (even in translation) are disarmingly respectful of authority. Smoking among men seems the rule rather than the exception. These differences should not divert the visitor from recognising centuries-old Japanese international engagement, reaching out for cultural and intellectual exchange, even at moments when Japan seemed most divided from the world. Japan might appear to desire isolation. In fact, it craves global inclusion. Much of Japan’s economic and health-care success (it has one of the longest life expectancies and lowest infant mortality rates in the world) can be explained by the nation’s ability to rapidly absorb the discoveries and innovations of others. So we should take seriously Japan’s endemic political crisis and threats to its health system. 2011 is the fiftieth anniversary of universal health coverage in Japan. That milestone is now in jeopardy. *
Takemi Office
Corbis
Japan’s health policy has relied on a vast bureaucracy. 3500 separate health-insurance funds constitute half of all health-system financing. The rest comes from taxation and co-payments. Japan’s population is 127 million (living in 47 prefectures and 1844 municipalities). It is forecast to decline to 100 million by 2050, with over a third older than 65 years. With six prime ministers in the past 5 years, and a recent corrosive row in the ruling Democratic Party of Japan (producing a distracting leadership vote on Sept 14), Japan is suffering a phase of political instability. With rapidly rising rates of obesity and diabetes, together with a huge and increasing burden of suicide, Japan’s health leaders have important work to do. * Critical is the need for evidence to inform decisions about the future of Japan’s health. The prerequisites for sciencebased policy making may seem obvious. Researchers to generate and systematically combine evidence. Scientistleaders to be advocates for that evidence. A political culture that demands reliable knowledge for policy making. Institutions that can produce that knowledge and transmit it to policy makers. And an environment in which new policies are evaluated rather than simply imposed. 858
Although there are enlightened exceptions, none of these determinants are fully met in today’s Japan. * A damaging deficit is non-participation. The notion of a broad, inclusive, and pluralistic deliberative public process to achieve some measure of agreement about the future of Japan’s health system is absent. Large vested interests dominate. By contrast, the voice of the academic community is almost silent. There are few credible highlevel advocates for the values underpinning universal coverage. Civil society is mostly weak. And the media are failing to hold Japan’s Government accountable for its health policies. Among a group of highly informed and research-intensive health policy makers, such as Keizo Takemi and Kenji Shibuya, there is agreement that major structural health reforms are needed. The administrative madness of health must be treated definitively. Primary care should be strengthened. There ought to be a sustainable solution for the long-term care of older Japanese. Like many western countries, there needs to be a social settlement about the purpose of Japan’s health system and what taxpayers are willing to pay towards it. * It is easy to be negative. A quarter of the Japanese public believes their country has “little influence”. Japan’s economic troubles seem to be contracting its ambition, narrowing its vision, trimming (even eliminating) parts of its domestic and international capacity. But this ambience of pessimism is fostering a false belief in defeat. This is not acceptable. The success of Japan’s health system matters not only because of its importance to Japanese citizens, but also because Japan is a barometer of western health. Worse, Japan’s contribution to global health continues to be unfairly neglected by the international community. Japan has enormous soft power. The country now seeks to marshall its considerable resources to claim its rightful place globally, as well as to improve its policy making domestically. Now is the right moment to use the current political uncertainty to prepare for radical, not incremental, change. A small fuse has been lit. Richard Horton [email protected]
www.thelancet.com Vol 376 September 11, 2010
Offline: Japan: a mirror for our future
APF/Getty Images
Reuters
The printed journal includes an image merely for illustration
When a visitor from the West goes to Japan, many things are different. Attendants bow as buses depart from Tokyo’s Narita airport. Editorials in Japanese newspapers (even in translation) are disarmingly respectful of authority. Smoking among men seems the rule rather than the exception. These differences should not divert the visitor from recognising centuries-old Japanese international engagement, reaching out for cultural and intellectual exchange, even at moments when Japan seemed most divided from the world. Japan might appear to desire isolation. In fact, it craves global inclusion. Much of Japan’s economic and health-care success (it has one of the longest life expectancies and lowest infant mortality rates in the world) can be explained by the nation’s ability to rapidly absorb the discoveries and innovations of others. So we should take seriously Japan’s endemic political crisis and threats to its health system. 2011 is the fiftieth anniversary of universal health coverage in Japan. That milestone is now in jeopardy. *
Takemi Office
Corbis
Japan’s health policy has relied on a vast bureaucracy. 3500 separate health-insurance funds constitute half of all health-system financing. The rest comes from taxation and co-payments. Japan’s population is 127 million (living in 47 prefectures and 1844 municipalities). It is forecast to decline to 100 million by 2050, with over a third older than 65 years. With six prime ministers in the past 5 years, and a recent corrosive row in the ruling Democratic Party of Japan (producing a distracting leadership vote on Sept 14), Japan is suffering a phase of political instability. With rapidly rising rates of obesity and diabetes, together with a huge and increasing burden of suicide, Japan’s health leaders have important work to do. * Critical is the need for evidence to inform decisions about the future of Japan’s health. The prerequisites for sciencebased policy making may seem obvious. Researchers to generate and systematically combine evidence. Scientistleaders to be advocates for that evidence. A political culture that demands reliable knowledge for policy making. Institutions that can produce that knowledge and transmit it to policy makers. And an environment in which new policies are evaluated rather than simply imposed. 858
Although there are enlightened exceptions, none of these determinants are fully met in today’s Japan. * A damaging deficit is non-participation. The notion of a broad, inclusive, and pluralistic deliberative public process to achieve some measure of agreement about the future of Japan’s health system is absent. Large vested interests dominate. By contrast, the voice of the academic community is almost silent. There are few credible highlevel advocates for the values underpinning universal coverage. Civil society is mostly weak. And the media are failing to hold Japan’s Government accountable for its health policies. Among a group of highly informed and research-intensive health policy makers, such as Keizo Takemi and Kenji Shibuya, there is agreement that major structural health reforms are needed. The administrative madness of health must be treated definitively. Primary care should be strengthened. There ought to be a sustainable solution for the long-term care of older Japanese. Like many western countries, there needs to be a social settlement about the purpose of Japan’s health system and what taxpayers are willing to pay towards it. * It is easy to be negative. A quarter of the Japanese public believes their country has “little influence”. Japan’s economic troubles seem to be contracting its ambition, narrowing its vision, trimming (even eliminating) parts of its domestic and international capacity. But this ambience of pessimism is fostering a false belief in defeat. This is not acceptable. The success of Japan’s health system matters not only because of its importance to Japanese citizens, but also because Japan is a barometer of western health. Worse, Japan’s contribution to global health continues to be unfairly neglected by the international community. Japan has enormous soft power. The country now seeks to marshall its considerable resources to claim its rightful place globally, as well as to improve its policy making domestically. Now is the right moment to use the current political uncertainty to prepare for radical, not incremental, change. A small fuse has been lit. Richard Horton [email protected]
www.thelancet.com Vol 376 September 11, 2010