[Special Feature: Post-Corona Healthcare Policy] Ichiro Innami: What is Needed for Post-Corona Healthcare Policy

2023/07/05

Nearly three and a half years have passed since the start of the COVID-19 pandemic, and on May 8, the classification of COVID-19 under the Infectious Diseases Control Law was moved to "Class 5," the same as seasonal influenza. This marks the de facto end of the pandemic. During this period, policies such as border measures, priority measures to prevent the spread of disease, and the distribution of subsidies were implemented. Leveraging that experience, the Infectious Diseases Control Law and the Act on Special Measures for Pandemic Influenza and New Infectious Diseases were amended. Furthermore, criticism regarding the response of clinics during the pandemic led to issues concerning the system and development of family doctors, resulting in certain legislative changes, such as the creation of a self-reporting system for medical institutions. Additionally, online medical consultations and online medication guidance were partially deregulated. Furthermore, discussions are underway to include infectious disease countermeasures in the 8th Medical Plan formulated by prefectures. In this way, institutional reforms have already been made to a certain extent. In this article, I would like to consider what further measures are necessary.

Healthcare is directly linked to the lives and health of the public. The healthcare delivery and insurance systems have been formed over a long history since the Meiji era and continue to the present day. The global pandemic of emerging infectious diseases has enabled international comparisons of public health and medical delivery in various countries based on a unified perspective of infectious disease control. In the process of considering the differences in responses between Japan and other countries, the structural problems of Japan's medical system have been reaffirmed.

After the war, infectious disease control was an extremely important issue, and thanks to the public health center system, infectious diseases such as pulmonary tuberculosis were suppressed to a considerable extent. On the other hand, against the backdrop of economic growth, population growth, and an aging society, the disease structure shifted from infectious diseases to lifestyle-related diseases. Consequently, the number of public health center facilities, staff, and national treasury contributions—the pillars of infectious disease control—have been reduced recently. Regarding medical institutions, the number of (public and official) hospitals capable of handling Class 2 infectious diseases like COVID-19 and the number of infectious disease hospital beds were reduced, and the training (medical education and residency) of doctors and nurses capable of handling infectious diseases was also insufficient. From the perspective of medical institutions, there may have been a sense that infectious disease control was the job of public health centers and not within their own domain.

Japan was once a leader in vaccine development, but since the 1970s, the government lost a series of class-action lawsuits over vaccination injuries, leading to a hesitant approach to vaccine policy. If a factory is built for vaccines, subsidies are required for its maintenance. Companies also withdrew from the vaccine business, resulting in a loss of human resources and expertise. There was a significant gap compared to the United States, which viewed vaccines as a matter of national security and provided continuous support.

Even before COVID-19, there were outbreaks such as Severe Acute Respiratory Syndrome (SARS) (2002) and Middle East Respiratory Syndrome (MERS) (2012), but serious measures were not taken in Japan. It was in this context that the large-scale COVID-19 pandemic struck.

If public health centers and infectious disease hospitals, which are the cornerstones of infectious disease control, are insufficient, general medical institutions must respond. However, Japan's medical delivery system had structural problems that prevented an immediate response.

First, even though the number of doctors and nurses per capita is at an international level, the capacity of hospitals to respond was inherently small because hospital sizes are small and small-to-medium-sized hospitals make up the majority. In addition, because the number of hospital beds is extremely high, the system was one of "low-density medicine" where care for each inpatient is spread thin. When trying to secure beds for a sudden increase in severe COVID-19 patients who require intensive labor, there is a shortage of personnel to maintain other beds. This is the reason why medical care (beds) became strained despite the high total number of beds.

Second, since 80% of Japanese hospitals are private, the national and local governments could request cooperation from hospitals but could not issue direct orders. The number of COVID-19 infections and severe patients varied greatly by region; while beds were strained in one prefecture, they were not as strained in an adjacent prefecture. However, attempts to facilitate the flexible exchange of beds and personnel across prefectural borders were hampered by coordination delays. To provide appropriate medical care for patients ranging from mild to severe, dynamic flexibility in beds and personnel between hospitals, between hospitals and welfare facilities, and between prefectures is essential. However, Japan's national and local governments lacked the strong legal authority to coordinate these.

The role of public health centers, the cornerstone of infectious disease control, will be reviewed. Prefectures will formulate "Prevention Plans," and public health centers will formulate "Health Crisis Response Plans (provisional name)," with functional strengthening centered on budgets and personnel (public health nurses and experts/supporters known as IHEAT). In the 8th Medical Plan (FY2024–29) created by prefectures, emerging infectious disease countermeasures will be added as a sixth project in addition to the traditional five diseases and five projects. Regional medical visions aimed at differentiating outpatient functions and differentiating/reducing hospital bed functions will also be considered.

Online medical consultations and medication guidance, which did not function sufficiently before the COVID-19 pandemic, have made some progress through special measures for COVID-19. Regarding the sale of antibody test kits at general pharmacies, the Council for Promotion of Regulatory Reform achieved this despite opposition from industry groups. Regarding the refusal of fever clinics and the neglect of severe patients, discussions on the system and development of family doctors have taken place, and although insufficient, strengthening is being pursued.

As described above, responses in the medical system have achieved a certain degree of results. On the other hand, more fundamental causes, including problems with the medical system during normal times, have become clear. These are the delay in digital transformation (DX) and the lack of national government involvement. It can be said that both of these arise from a mutual entanglement of excessive decentralization, excessive protection of personal information, and an excessive risk-aversion orientation. To state the conclusion first, for both emerging infectious disease countermeasures and reforms of the medical delivery system during normal times, it is necessary to strengthen national involvement, increase the uniformity of operations across prefectures, and reconstruct response capabilities to be suitable for the digital age.

First, the biggest challenge revealed by the COVID-19 pandemic is the delay in DX across Japan as a whole. From tracking the movements of COVID-positive patients to information sharing and collaboration between local governments, public health centers, and hospitals, and even the procedures for distributing Special Fixed-sum Cash Handouts as an emergency economic measure, delays, inefficiency, and inaccuracies due to analog procedures were prominent.

Advanced initiatives are spreading. In Yamaguchi Prefecture, from the beginning of the pandemic (January 2020) until the 4th wave (April–June 2021), situational awareness was conducted by handwriting on large sheets of paper posted on walls, followed by whiteboards and magnet cards, email, and FAX. However, by the 7th wave (July–October of the same year), a cloud-based system called YICSS was developed. From tracking the number of infected people (public health centers) to selecting treatment and hospitalization locations, and moving patients to hospitals or care facilities, public health nurses, doctors, care facility staff, and government officials were able to share information under appropriate authority distribution.

However, the COVID-19 crisis is not limited to prefectural borders. Even in Yamaguchi Prefecture, communication with the neighboring Hiroshima Prefecture was ultimately conducted via phone and email. If the national government takes the lead in introducing a nationwide common system, rapid and smooth collaboration between neighboring prefectures should become possible.

Regarding the nature of regulations, many problems were pointed out. National staffing standards and other rules under the guise of ensuring medical safety hinder the efficiency of operations through the introduction of nursing care robots, surveillance cameras, and the outsourcing of dispensing. Periodic reporting obligations using paper documents have little meaning. On the other hand, process and outcome evaluations to ensure the crucial quality of medical care are lacking.

End-to-end digital medicine, centered on online consultations, electronic prescriptions, online medication guidance, and electronic payments, is expected to promote access to healthcare for the busy working generation. However, it has been hindered by the "face-to-face" principle and vested interests, and has not progressed as much as expected.

Regarding consultations, there are constraints such as the inability to perform palpation online. However, to improve access to healthcare for the busy working generation, further deregulation is necessary. On the other hand, regarding medication guidance, since the system does not allow pharmacists to make diagnoses, there is no need for it to be conducted face-to-face. Online medication guidance should be the principle, but it is only permitted in extremely localized cases due to resistance from related organizations.

The "Digital Agency" was established in 2021, and the "Medical DX Promotion Headquarters," composed of relevant ministers with the Prime Minister as the head, was established within the Cabinet Secretariat in 2023. Extensive discussions on medical DX have begun. It is expected that reforms will progress by examining fundamental aspects, including the nature of regulations.

In the medical and long-term care fields, many notices (especially related to pharmacies) created 60 years ago in the mid-1950s to mid-1960s, when there were no PCs, mobile phones, or the internet, still remain today. Notices are considered "technical advice" from one administrative agency to another, but in reality, they are regulations that bind the private sector.

The notices issued by the national government are uniform, but the problem lies in their interpretation and operation. In the first local decentralization reform in the late 1990s, the authority to interpret laws and regulations was granted to local governments such as prefectures and municipalities. The interpretation and operation of notices issued by the national government are left to the field, and in some cases, diverse procedures are added or operations differ depending on the person in charge. For example, if the representative of a nursing care provider operating nationwide changes, they must create, seal, and submit change notifications entirely on paper, matching the individual formats of over a thousand local governments. While local governments should have discretion over policy content, there is no need for uniqueness in procedures or documents.

Since health and medical information is sensitive, personal information protection tends to become excessive in an attempt to zero out the risk of information leakage. Combined with the unique legal interpretations of local governments, documents and procedures become complex and "Galapagos-ized." The personal information protection systems previously established by each local government have been abolished, and the amended Next-Generation Medical Infrastructure Act currently under discussion is expected to bring improvements to the primary and secondary use of medical information. This should be closely monitored.

Since the regional nature of medical care is high, medical plans formulated by prefectures are the main approach. Through legislative amendments, prefectural governors can now enter into agreements with individual medical institutions within their regions during normal times. During the spread of an infectious disease, they can issue recommendations, instructions, and publicize violations of instructions regarding medical delivery, but they do not have the authority to issue orders. The format of the agreements should be unified by the national government to ensure that regional or individual characteristics are not exerted in individual agreements.

In the first place, COVID-19 was not a crisis for prefectures, but a crisis for the nation. The degree of medical strain also varied by prefecture. While the amended law has mechanisms for the exchange of personnel across prefectures, there are no provisions for the exchange of beds. The wide-area exchange of personnel also involves cumbersome procedures. In times of crisis, the national government should be able to immediately issue orders to non-strained prefectures for personnel dispatch and bed exchange, rather than just "requests for support."

The fundamental reason why rapid policy formation does not occur during a crisis is likely that the Constitution lacks emergency clauses, making it difficult to restrict local autonomy and private rights. However, in addition to emerging infectious diseases, there are also large-scale disasters and security issues. Saving lives is the primary function of the state. Whether in emergency responses or in medical system reforms during normal times, national involvement should be further strengthened before the heat of the COVID-19 pandemic cools down.