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Yasuo SUGIURA, M.D.Bureau of International Health Cooperation
National Center of Global Health and Medicine
Case-example: how Japan reduced maternal and newborn mortality
over the past 100 years
– key strategies, lessons for other countries in the Region
9/22/2015
Aim • This presentation aims to help you
learn the laws and regulations that supported maternal, newborn, and child health in Japan over the years.
Contents
• Quick review of the Japanese history
• Elementary school enrollment rate
• MCH indicators
• Health Laws
• Health financing
• A short film “Health Centers Today”
Basic education
Economy & development
Laws & regulations
Health
Small private school(Temple school)
Public elementary school
A closed –door policy
Image
samurai
WWII
steam locomotiveradio broadcast
aging society & declining birthrate
Traditional medicine
Western medicine
a concept of hospital
Foreign ships
Family registration law(1871)Medical regulation(1874)
National health insurance law(1938)
Medical practitioners law(1947)Medical care law(1947)Public health nurses, midwifes and nurses law(1947)Child welfare law(1947)Statistics law(1947)
Public health center law(1937)
18681603 1912 1926 1989
Taisho eraMeiji eraEdo era Showa era Heisei era
economic growth
cholera
Quick review of Japanese history
Pre WWII
Maternal and child health law (1965)
Post WWII
The opening of a country
歌川広重の「諸芸稽古図会」
Basic education
Economy & development
Laws & regulations
Health
Small private school(Temple school)
Public elementary school
A closed –door policy
Image
samurai
WWII
steam locomotiveradio broadcast
aging society & declining birthrate
Traditional medicine
Western medicine
a concept of hospital
Foreign ships
Family registration law(1871)Medical regulation(1874)
National health insurance law(1938)
Medical practitioners law(1947)Medical care law(1947)Public health nurses, midwifes and nurses law(1947)Child welfare law(1947)Statistics law(1947)
Public health center law(1937)
18681603 1912 1926 1989
Taisho eraMeiji eraEdo era Showa era Heisei era
economic growth
cholera
Quick review of Japanese history
Pre WWII
Maternal and child health law (1965)
Post WWII
The opening of a country
Strategy
Plan
Resource
Finance
Regulations
Laws
Elementary school enrollment rate from 1873 to 1983WWIIWWI
0
20
40
60
80
100
Female
Male
%
year
Meiji era Taisho era Showa era
Elementary school enrollment rate from 1873 to 1983WWIIWWI
0
20
40
60
80
100
Female
Male
%
year
0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-
FemaleMale
age million people0 2 4 6246
Meiji era Taisho era Showa era
Elementary school enrollment rate from 1873 to 1983WWIIWWI
0
20
40
60
80
100
Female
Male
%
year
0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-
FemaleMale
million people0 2 4 6246age
Meiji era Taisho era Showa era
Elementary school enrollment rate from 1873 to 1983WWIIWWI
0
20
40
60
80
100
Female
Male
%
year
0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-
FemaleMale
million people0 2 4 6246age
1950Meiji era Taisho era Showa era
Elementary school enrollment rate from 1873 to 1983WWIIWWI
0
20
40
60
80
100
Female
Male
%
year
0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-
1975
FemaleMale
million people0 2 4 6246age
Meiji era Taisho era Showa era
Elementary school enrollment rate and infant mortality rate(IMR)
WWIIWWI
0
20
40
60
80
100
ElementarySchool
Female
Male
IMR
%
year
0
20
60
100
140
180
IMR(/1000births)
WWIIWWI
0
20
40
60
80
100
ElementarySchools
Female
Male
Life Expectancy Females
Males
IMR
%
year
0
20
60
100
140
180
IMR
40
60
80
50
70
age
Elementary school enrollment rate, IMR, and life expectancy
WWIIWWI
0
20
40
60
80
100
ElementarySchools
Females
Males
Life Exp. F
Life Exp. M
GDP/capita
IMR
%
year
GDP/capita(X1,000
yen)
0
20
60
100
140
180
IMR (/1000births)
2,000
1,600
1,200
800
400
0
($1,111)
($2,222)
Elementary school enrollment rate, IMR, life expectancy, and GDP/capita
Evolution of Health Administration in Meiji Era and Related Data
Year (Japanese system)
Year (Western system)
Attendance rate (%) of primary
educationKey events and selected Health Laws
Maternal and child health laws and
regulations
Boys Girls
1867 Return of political power to Emperor by Tokugawa Shogunate
Meiji era
2 1869 Abolition of feudal domains and establishment of prefectures
4 1871 Enactment of Family Registration Law
5 1872 Health Bureau, Ministry of Education
7 1874 46.2 17.2 Establishment of Medical Regulation
8 1875 50.8 18.7 Health Bureau, Ministry of Interior
9 1876 54.2 21 Local health administration → Police
22 1889 64.28 30.45 Constitution of Empire of Japan
27 1894 77.14 44.07
28 1895 76.65 43.87
30 1897 80.67 50.86 Communicable Diseases Prevention Law
31 1898 82.42 53.73 Amendment of Family Registration Law
32 1899 85.06 59.04 Establishment of Midwives Regulations
33 1900 90.35 71.73 Establishment of Waste Cleanup Law and Sewerage Law
37 1904 97.16 91.56
39 1906 98.16 94.84 Medical Practitioners Law and Dentists Law
Establishment of Medical Regulation1874
1899Establishment of Midwives Regulations
Meijiera
MCH laws ®ulations
Key events and selected health laws
Enactment of Family Registration Law1871
1 1912 98.8 97.62 Establishment of health guidance organizations
3 1914 98.8 97.67
4 1915 98.93 97.96 Nurses Regulations
5 1916 99.01 98.18 Establishment of Health and Hygiene Investigation Committee
6 1917 99.05 98.38
7 1918 99.12 98.58
11 1922 99.41 99.19 Enactment of Health Insurance Law
12 1923 99.32 99.15
9 1934 99.58 99.58 Imperial Gift Foundation Boshi-Aiiku-Kai
10 1935 99.59 99.59
12 1937 99.59 99.6 Public Health Center Law (old) Launch of guidance for expectant and nursing mothers and infants
Maternal and Child Protection Law
13 1938 99.6 99.63 National Fitness Law and National Mobilization Law
Establishment of Ministry of Health and Welfare
National Health Insurance Law
14 1939 99.62 99.64
15 1940 99.64 99.65 General Guidelines for Establishment of Population Policy and National Fitness Law
Nationwide implementation for infants (examination)
16 1941 99.7 99.73 Public Health Nurses Regulations and National Eugenic Law
17 1942 99.71 99.75 National Medical Care Law Maternal Handbook System and Fitness Handbook
18 1943 99.75 99.77
19 1944 99.76 99.78
20 1945 99.78 99.81
Taisho era
Year (Japanese system)
Year (Western system)
Attendance rate (%) of primary
education
Health administrationGeneral laws/regulations
and key events Maternal and child health
Laws and regulations / Policy measures
Showa era
Boys Girls
MCH laws and regulations
Key events and selected health laws
Public Health Center Law (old)1937
Maternal & Child Protection LawEstablishment of Ministry of Health and Welfare
National Health Insurance Law
1938Showa era
Tokyo
Osaka
Gifu
図 GHQ公衆衛生福祉局長サムス准将と勝俣稔厚生省衛生局長
占領期の厚生省東京衛生試験所(医薬品編) 宮原誠
Year (Western system)
Attendance rate (%) of primary
education
Total fertility
rate
Boys Girls TFR
Showa era
21 1946 99.63 99.72 Constitution of Japan
22 1947 99.78 99.8 Public Health Center Law (new) Establishment of Children's Bureau, Ministry of Health and Welfare
4.54
Medical Care Law Child Welfare Law
New Medical Practitioners Law and new Dentists Law
New Public Health Nurses, Midwives and Nurses Law
Statistics Law
23 1948 99.62 99.67 Enactment of Vaccination Law Enactment of Vaccination Law 4.4
General Guidelines for Maternal and Child Health Measures
Eugenic Protection Law
33 1958 99.79 99.82 Maternal and child health centers Health guidance for premature infants
2.11
36 1961 99.8 99.83 Universal national health insurance Home-visit guidance for new-born infants 3-year health checkup
1.96
40 1965 99.8 99.83 Maternal and Child Health Law 2.14
43 1968 99.81 99.86 Maternal and child health promoter system 2.13
44 1969 99.81 99.85 Detailed examination of infants 2.13
49 1974 Childhood chronic diseases program 2.05
52 1977 18-month health checkup 1.8
Year(JapaneseSystem)
Child Welfare Law
MCH laws and regulations
Key events and selected health
laws
Statistics Law
1947
Maternal and Child Health Law1965
Showa era
Number of new health laws introduced after World War II
1946-
551956-
651966-
751976-
83Total
Human resource qualification
10 5 5 0 20
Environmental health 6 2 2 3 13
Disease prevention 5 0 0 0 5
Drug control 5 0 0 0 5
Medical services 3 2 0 0 5
Public health center 1 1 0 0 2
Education 1 0 0 1 2
Food sanitation 1 0 0 0 1
Management 0 1 0 0 1
Biological weapon 0 0 0 1 1
Total 32 11 7 5 55
Japanese Policy & Law related with MCH
WWIIWWI
1868
160
3
Edo era Meiji era Taisho era Showa era Heisei era
Time trend of MCH indicators in Japan from 1899 to 1999
Maternal mortality ratio (MMR)(per 1000,000 live births)
Infant mortality rate (IMR) (per 1,000 live births)
Neonatal mortality rate (NMR) (per 1,000 live births)
MMR
IMR
NMR
Medical Regulation (1874)
Midwives Regulations
Public Health Center Law (old)
Maternal and Child Protection Law
WWIIWWI
Maternal and Child Health Law(1965)
Child Welfare Law(1947)
1868
160
3
Edo era Meiji era Taisho era Showa era Heisei era
Medical Regulation (1874)
MMR
IMR
NMR
The MCH indicators and related regulations in Japan between 1899 and 1999
Maternal and Child Health Law1947
Child Welfare Law Maternal and Child Health Law
1965
providing health guidance to expectant and nursing mothers and children, doing health check-up for children, and delivering MCH handbook.
・ High MMR to compare with developed countries・ Regional difference of IMR in Japan・ Transfer most MCH activities from provincial governors to municipal heads.
Notification of pregnancy( 15)
Deliver Maternal and Child Handbook( 16)
Prenatal check up( 13)
Home guidance( 17)
Delivery
Postnatal, one year and half, 3 year-old child check up( 10 /12 /13)
Home guidance ( 11/19)
Registration of low birth-weight ( 18)
Medical and infant care services( 20)
Continuum of care on Maternal and Child Health Law in Japan
( Article No.)
Institutional delivery 99.8%
Home delivery 0.2%
Figure 2-39 Childbirth Trends by Mode
1947 1960
Note: Institutional delivery is the sum of hospital, clinic and midwifery center deliveries.Source: Statistics and Information Department, Minister’s Secretariat, Ministry of Health and
Welfare, “Vital Statistics”
1996 (Year)
Health Financing in Japan
Annual government expenditure in Japan from 1937 to 2009
Total expenditure
The ministry of health and welfare
X1,000 Japanese yen$ 830 billion
$ 249 billion
Showa era Heisei era
High economic growth
WWII
%
Percentage of the ministry of health and welfare expenditure among the government expenditure
Showa era Heisei era
High economic growth
WWII
Elementary school enrolment rate. IMR, and the expenditure rateof the ministry of health among the total expenditure in Japan Elementary school enrolment rate, IMR, and the expenditure rateof the ministry of health among the total expenditure in Japan
Meiji era Taisho era Showa era
WWIIWWI
IMR100%
60%
20%
40%
80%
0%
ElementarySchool
Female
Male
IMR
%
%
%
%
%
%
Expenditure rate of the Ministry of Healthand Labour
Proportion of the burden of national medical expenses in Japan
by resource (FY2011)
( 26%)( 12.4%)
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iryouhoken/iryouhoken01/index.html
%
%
%%
Patient’s payment $39 billion
Total $325.4 billion
$1=120円→ 1兆円= $8.3 billion
insured
Employer
Insurance premium
$158.5 billionState subsidyLocal government
Public subsidy $125.3 billion
(Employees pay health insurance feeevery month)
(at a hospital)
Breakdown of the draft budget of the Ministry of Health, Labour and Welfare
(FY 2014)
Medical care $ 93 billion( 37.1%)
Pension $ 88.8 billion( 35.5%)
Welfare $ 45.7 billion( 18.2%)
Long-term care $ 21.6billion( 8.7%)
Employment $1.7 billion( 0.6%)
$ 251.6 billion
$1=120円→ 1兆円= $8.3 billion
(insurance for elderswho need care)
(unemployment insurance)
Breakdown of salary in Japan as an example
Healthcare insurance( 3%)Pension( 6%)
Income tax( 7%)
Inhabitant tax( 8%)
Long-term care insurance( 0.4%)
Employment insurance( 0.6%)
Take-home pay (75%)
a short film“Health Centers Today”
(1949)
After 4 years since the end of WWII
WWIIWWI
1868
160
3
Edo era Meiji era Taisho era Showa era Heisei era
Time trend of MNCH indicators in Japan from 1899 to 1999
MMR
IMR
NMR
Medical Regulation (1874)
a short film“Health Centers
Today”(1949)
Annual expenditure of Health and Sanitation in Japan X million yen
$ 8.3 billion
$ 3.3 billion
Showa era Heisei era
High economic growth
%
Percentage of annual expenditure of “Health and sanitation” in the total expenditure of the government of Japan