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Review of Mental Health Care Reform

Country: 
Japan
Partner Institute: 
Kinugasa Research Institute, Ritsumeikan University, Kyoto
Survey no: 
(14) 2009
Author(s): 
Matsuda, Ryozo
Health Policy Issues: 
Organisation/Integration des Systems, Finanzierung, Qualitätsverbesserung, Fachkräfte
Others: 
mental health
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja ja ja ja nein

Abstract

The Government reviewed its 2004 vision for reforming mental health and welfare services. The vision has tried to transform hospital-centred mental health care into community-based care for people with mental disorders by developing community services and reducing psychiatric hospital beds. The review recognized little change in the number of hospitalized patients and proposed new policy initiatives.

Purpose of health policy or idea

Mental health has increasingly been becoming an important health issue in Japanese society as in other countries in the last two decades. Although new pharmaceuticals and medical equipments for treating mental illness have been introduced swiftly, community care for persons with mental illness has been extremely slow to develop. Consequently, patients with serious mental diseases are usually hospitalized in Japan and have difficulties in living in the community.

From the mid-1990s, the Government tried to develop community mental health services enabling persons with mental illness living in the community. Various community welfare services developed and became easier to use. In 2004, the Government published a radical policy document, "A Vision for Reforming Mental Health Care" (MHWL 2004). The Government declared that the time for reforming mental health care had come and established a principle for mental policy: from institutionalized care toward community-based care. The document was quite controversial because it declared a drastic reduction of the number of hospitalized patients with mental illness (also see Masayo Sato. "Reduction in number of beds for mental illness". HealthPolicyMonitor, September 2004. www.hpm.org/survey/jp/c4/2). It estimated sixty nine thousand people could be discharged from hospitals if appropriate community services were made available to them. It also established the objective for the government to develop community mental health services so that everyone could enjoy living in the community and the number of psychiatric hospital beds would be reduced. It seemed very difficult to achieve the objective without a substantial investment in community mental health.

Further Reform of Health and Welfare Services for Persons with Mental Illness

In 2009, the Government reviewed the implementation of the vision and published a new policy document, "Further Reform of Health and Welfare Services for Persons with Mental Illness"(Committee for Reforming Mental Health and Welfare Services 2009). According to the review:

  • The estimated number of people with mental illness who could be discharged from hospitals increased from seventy thousand to seventy-six thousand;
  • The number of psychiatric hospital beds has only slightly decreased; and
  • Both newly and long-term hospitalized patients with mental disorders were more likely to be discharged from hospitals in 2006 than in 2004.

Maintaining the principle of "from institutionalized care toward community-based care", the document confirmed the four objectives below:

  1. To restructure hospital mental health care and develop a community-centred mental health system;
  2. To improve quality of mental health care;
  3. To develop services supporting people with mental disorders living in the community; and
  4. To bring about a better understanding on psychiatric diseases and disorders of the public.

The document describes specific measures for each of these objectives. They are described below.

1. Policy measures on restructuring of hospital mental health care and development of community mental health include:

  • To introduce higher reference standards for personnel staffing in psychiatric hospital wards;
  • To consider differentiate fees relative to the seriousness of mental disorders;
  • To reduce the number of hospitalized patients with schizophrenia by 46.000;
  • To develop institutional care for people with dementia and liaison mental health services;
  • To develop mental health care, particularly for mood disorders, dependence, and child and adolescent psychiatry;
  • To develop a system for early support and intervention for those with mental disorders;
  • To reorganize community mental health systems including community psychiatric hospitals and clinics, hospitals providing highly specialized psychiatric care, general hospitals with liaison psychiatric treatment, and hospitals providing psychiatric emergency services; and
  • To train health professional for providing various psychiatric services in the community.

2. Policy measures to improve the quality of mental health care include:

  • To develop clinical guidelines in psychiatric care;
  • To develop the qualification of psychiatrists and promote training of mental health personnel; and
  • To develop research and development in mental health.

3. Policy measures on services supporting people with mental disorders living in the community include:

  • To make local governments (prefectures) more responsible for developing psychiatric emergency services in the community;
  • To develop multidisciplinary psychiatric teams for crisis interventions;
  • To develop community health services, particularly visiting nursing, and day care services;
  • To promote care management of persons with mental disorders in the community;
  • To develop welfare services, particularly group-care homes and public housings for the mentally handicapped ; and
  • To foster peer support between family care-givers.

4. Policy measures on bringing about a better understanding on psychiatric diseases and disorders include:

  • To give information to people with mental disorders themselves;
  • To foster good communication between people with mental disorders and other community dwellers;
  • To inform the younger generation in collaboration with schools; and
  • To provide information on mental health to the public using the media.

Main points

Main objectives

As described above, the current objectives of the government can be summerized as;

  1.  To restructure hospital mental health care and develop a community-centred mental health system;
  2. To improve the quality of mental health care;
  3. To develop services supporting people with mental disorders living in the community; and
  4. To bring about a better public understanding of psychiatric diseases and disorders.

Type of incentives

The report referes to both financial and non-financial incentives. Financial incentives include increased fees for mental health care. Non-financial incentives include clinical guidelines and change of regulations on personnel staffing in psychiatric hospital wards.

Groups affected

Mental health care providers, community services providers, patients with mental disorders and their families, prefectures, public Insurers

 Suchhilfe

Characteristics of this policy

Innovationsgrad traditionell recht innovativ innovativ
Kontroversität unumstritten kaum umstritten kontrovers
Strukturelle Wirkung marginal recht marginal fundamental
Medienpräsenz sehr gering gering sehr hoch
Übertragbarkeit sehr systemabhängig neutral systemneutral

The new policy initiatives proposed new ways of mental healthcare delivery, which indicates this policy is rather innovative. There seems little controversy on the objectives of the policy review. Although some controversy may exists between providers and the government in deciding fees, its not so critical. In that sense, it is rather consensual.

If community mental health and welfare services would develop dramatically in the next five years, it would definitely have a fundamental impacts, but instead moderate changes will probably take place. Therefore I predict a rather marginal systemic impact. Public visibility has been low, compared to the Health Insurance for the Old-Old.

A part of the policy objectives and measures can be transffered to other countries. However, since the whole policy or strategy is higly contextualized in Japanese mental health policy, transfering only limited parts of the policy measures will work.

Political and economic background

The policy report was published just after the landslide victory of the Democratic Parity of Japan. The change of the ruling party, however, apparently had little effect on the policy developed by the Ministry of Health, Labour and Welfare.

The financial situation of the government has been serious because it accumulates a huge amount of debt. Therefore, it seems difficult to make a substantial investment in mental health care without strong political support.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein ja ja ja ja nein

Origins of health policy idea

 The principle of mental healthcare reform, "from institutional care toward community care" can be traced back at least to the 1970s when community psychiatry was paid a lot of attention attention and was developed in European counties. The mental healthcare system in Japan, however, had developed large institutions or hospitals by that period. The government has gradually made the orientation toward community care clearer in the 1980s and 1990s.

 

Initiators of idea/main actors

  • Regierung
  • Leistungserbringer
  • Medien

Approach of idea

The approach of the idea is described as:
amended: Review of the 2006 plan of mental health

Stakeholder positions

In 2004, the Government published a report on the mental health policy, which declared to transform hospital-centred mental health care into community-based care for those with mental illness (Headquarters for Mental Health and Welfare 2002). The document estimated that 72.000 could be discharged from hospitals to the community if appropriate community-based services were delivered and pointed to the necessity of developing quality community care for those with mental illness.

In April 2008, the Ministry of Health, Labour and Welfare launched a committee for reviewing the 2004 vision and developing the new policy initiatives for mental health and welfare services. The committee consisted of 24 members selected by the Ministry. Those members included representatives from provider and professional organizations of mental health and welfare services, academic and experts, a patient, experts from providers, a mayor, and a journalist. The committee was chaired by the president of the National Center of Neurology and Psychiatry.

The committee reviewed the implementation of the 2004 vision, for which the Ministry submitted analyses on the mental health and welfare services, notes on critical issues and new ideas of policy initiatives, while members of the committee raised their own questions to be discussed in the committee. Generally speaking, members of the committee worked constructively. After 14 meetings, the committee published an interim report on mental health and welfare services in November 2008 and made a pause until March 2009. The committee discussed different issues in its meetings and published the final report in September 2009.

Actors and positions

Description of actors and their positions
Regierung
Ministry of Health, Labour and Welfaresehr unterstützendsehr unterstützend stark dagegen
Leistungserbringer
Psychiatric Hospitalssehr unterstützendunterstützend stark dagegen
Psychiatric clinicssehr unterstützendunterstützend stark dagegen
Residential care providerssehr unterstützendunterstützend stark dagegen
Japan Medical Associationsehr unterstützendunterstützend stark dagegen
Medien
Newspaperssehr unterstützendneutral stark dagegen

Influences in policy making and legislation

Some of the policy measures proposed in the report need legislation to be implemented formally, while others can be enforced by amendments of the Cabinet decrees. The legislation is planned to be passed in 2012. Fees in public health insurance will be revised in 2010 and 2012 to establish financial incentives.

Actors and influence

Description of actors and their influence

Regierung
Ministry of Health, Labour and Welfaresehr großgroß kein
Leistungserbringer
Psychiatric Hospitalssehr großneutral kein
Psychiatric clinicssehr großneutral kein
Residential care providerssehr großneutral kein
Japan Medical Associationsehr großgroß kein
Medien
Newspaperssehr großneutral kein
Ministry of Health, Labour and WelfarePsychiatric Hospitals, Psychiatric clinics, Residential care providersJapan Medical AssociationNewspapers

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

 

Monitoring and evaluation

The final evaluation of the 2004 vision will be conducted in 2014. Achievment of the targets on discharge and others will probably be assessed then, although no information has been given on the process of the evaluation.

Review mechanisms

Halbzeitevaluation

Results of evaluation

 

Expected outcome

Community mental health and welfare services have slowly been growing in Japan. In the last decade, we did not see a drastic shift from institutionalized care to community care or living in the community. However, in the next decade, with the new policy initiatives, we may experience it.

But most things will depend on available resources to invest in mental health and welfare services. Since it is not clear how much resources  the new government will allocate to mental health and welfare,  probable impacts of the policy are difficult to predict.

Impact of this policy

Qualität kaum Einfluss neutral starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering neutral sehr hoch

Although the objectives of the policy are concerned with improving the quality of mental health care, increasing equity, and increasing efficiency, it seems difficult to predict the impacts of this policy because it includes too many different policy measures. However, quality of mental health care is likely to improve.

References

Sources of Information

Committee for Reforming Mental Health and Welfare Services (2009). Further Reform of Health and Welfare Services for Persons with Mental Illness. (in Japanese)

Headquarters for Mental Health and Welfare, Ministry of Health, Labour and Welfare (2004). A Vision for Reforming Mental Health and Welfare Services. (in Japanese)

National Center of Neurology and Psychiatry (not dated). Shift from hospitalized medical treatment to living in the community. www.ncnp.go.jp/nimh/keikaku/vision/index_e.html

Author/s and/or contributors to this survey

Matsuda, Ryozo

Ryozo Matsuda is a professor in health policy at the College of Social Sciences, Ritsumeikan Univerisity. He also serves as an executive board member of the Institue of Human Sciences, Ritsumeikan University.

Empfohlene Zitierweise für diesen Online-Artikel:

Matsuda, Ryozo. "Review of Mental Health Care Reform". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/jp/a14/1