Addressing the Physician Shortage

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

National policies to address the physician shortage in Japan have been developed because serious physician shortages have been reported in certain specialties and in rural areas. Although the national government was reluctant to directly intervene and rather help local governments at first, the ruling parties have increasingly taken more direct measures including development of a doctor dispatch system or a temporal increase of quotas for medical schools as the public attention has risen.

Purpose of health policy or idea

National policies to address the physician shortage, developed since 2003, have the overall aim to solve the physician shortage in rural areas and/or in specialities, such as paediatrics and obstetrics, where physician shortage has been most serious.

To achieve this objective, measures to moderate demand and increase supply of physicians has been gradually developed with a long-term view. In addition to these measures, six urgent measures have been proposed:

• development of a national system of dispatching physicians to areas experiencing physician shortages;
• change of work arrangements to decrease over-workloads of hospital physicians;
• improving work environments for female physician, e.g. by making nurseries more available for them; develolping effective management skills of human resources among hospital manager, particulary with consideration to working environments; more flexible job scheduling by e.g. part-time jobs at public hospitals has been discussed.
• redistribution of quotas for primary training for physicians between urban and rural hospitals;
• reduction of physician anxiety with legal issues, e.g. by development of formal medico-legal systems and no fault compensation systems in obstetrics care; and
• increase of number of physicians who are to work in rural areas and in some specialities experiencing physician shortage.

Most of those measures have been financed by FY 2007 Budget, which was approved by the Diet.

Main points

Main objectives

The policy aims to ensure that health care providers, especially in rural areas, can employ enough specialist physicians to deliver good services to patients. To achieve the aim, the policies apparently have the following objectives although the objectives were not explicitly declared:

• To moderate demands for specialist care at hospitals by developing alternative delivery of care such as free telephone counselling;
• to increase supply of physicians to work at hospitals by temporally increasing quotas of medical schools and improving the work environment of physicians;
• to increase efficiency of hospital specialist care by reorganizing hospitals; and
• to develop a national framework to dispatch doctors to hospitals facing an acute shortage of physicians.

Type of incentives

Various subsidies , e.g. for re-organizing hospitals and facilitating collaboration at the prefectural level, are developed as financial incentives.

Non-financial incentives are provided in the form of development of human resource skills and temporal increase of quotas for medical schools.

Groups affected

Physicians, hospitals and medical schools, local governments

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Following the policies gradually developed by various committees under the MHLW, current policies have the following features:

• The policies follow the general policy that in the long run the total number of physicians in Japan is projected to be sufficient to supply health care thus quotas of medical schools for new students shall not be increased permanently;
• The policies combine the preceding polices on health care delivery, i.e. reorganizing hospitals according to stated functions to increase technical efficiency and networking between health care providers;
• The preceding policies were concerned with the shortage of physicians in general, whereas the new policies explicitly target shortages in certain specialties; and
• The government takes new measures to improve the work environment of physicians at hospitals.

Political and economic background

Decentralization has been drastically promoted during the last decades. The number of municipalities has been decreasing by mergers promoted by the state. State ear-marked subsidies and block grants have been cut down, while taxation powers have been transferred to local governments. While the general economy has been recovering, significant economic disparities between regions exist.

In 1997 the Cabinet decided to reduce quotas of medical schools to contain health care cost in its policy on fiscal reform. Although the actual number of registered physician has gradually increased, hospitals in rural areas have faced physician shortages especially in pediatrics and obstetrics since the early 2000s.  Physician shortages drove hospitals in rural areas to close down obstetric and pediatric wards, which resulted in growing public concern. Consequently this issue has been increasingly covered by the media and it has become a hot issue.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Shortage of physicians, particularly obstetricians and pediatricians, has been increasingly recognized in rural areas since the beginning of the twentyfirst century. The media reported about pregnant women who had to take a long drive to consult a physician and about children and their parents who had difficulties to consult a pediatrician. The physician shortage has increasingly become a political issue to be addressed.

Addressing physician shortages has been a challenging task. Many kinds of ideas have been gathered to develop policies for it.

Initiators of idea/main actors

• Government

• Providers

• Media: Support the policies in general, but criticize certain aspects.

• Political Parties

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

National associations of local governments have pressed the Government to address the problem of physician shortages, backed by civil actions at local level. Since 2002 the Japan Association of City Mayors (JACM) requested the central government to take additional measures to ensure secure delivery of pediatric care, particularly emergency care to children. It requested the Government to take urgent measures to address shortages of pediatrists and obstetricians in November 2006. In June 2007, the JACM again requested the Government to develop systems to assign doctors to rural areas and support hospitals managed by local governments. Furthermore, the media had aroused people's attention through feature articles and programs. 

Meanwhile, in 2005, the Inter-ministerial Committee on Community Medicine, which consists of representatives from the Ministry of Health, Labour and Welfare (MHLW), the Ministry of Education, Culture, Sports, Science and Technology (MEXT), and the Ministry of Internal Affairs and Communications (MIC) established a policy document for addressing physician shortage. The document proposed a strategy to solve physician shortages with various indirect measures, including re-organization of health care providers, clarification of responsibilites of the national and local governments, revision of medical education for community medicine, strengthening supports for rural areas, and changes of physician job market and workload. In the document, major responsibilites and actions were expcted to be done at local level and lacks national mechanism to promote the policies. The media supports the aim of the policies, but criticized that it would not work promptly.

Then the New Policy was established in 2006. The document newly proposed the following measures taken by the Government in addition to the measures by prefectural governments: establishement of a national body, the Central Committee for Helping Community Medicine, to cope with policies on training and job markets of physicians; temporal increase of quotas for medical school located in prefectures facing serious physian shortage; allocation of subsidies to rennovate health care fascilities to prefectures where number of physicians per population is lowest.

Since it has become a hot issue more and more, major political parties paid attention to how to address physician shortages. As a result, the ruling parties released six  measures (see section Purpose of the Policy) to enhance and implement the existing policies several months before the House of Councillor election in 2007.

Actors and positions

Government
Local governments	very supportive		strongly opposed
Ministry of Health, Labour, and Welfare	very supportive		strongly opposed
Ministry of Internal Affairs and Communications	very supportive		strongly opposed
Ministry of Education, Culture, Sports, Science and Technology	very supportive		strongly opposed
Providers
Local government hospitals	very supportive		strongly opposed
University hospitals	very supportive		strongly opposed
Media
National Newspspers	very supportive		strongly opposed
Local Newspapers	very supportive		strongly opposed
Political Parties
Liberal Democratic Parity	very supportive		strongly opposed
New Komei	very supportive		strongly opposed
Democratic Parity	very supportive		strongly opposed
Japan Communist Party	very supportive		strongly opposed
Social Democratic Party	very supportive		strongly opposed

Actors and influence

Government
Local governments	very strong		none
Ministry of Health, Labour, and Welfare	very strong		none
Ministry of Internal Affairs and Communications	very strong		none
Ministry of Education, Culture, Sports, Science and Technology	very strong		none
Providers
Local government hospitals	very strong		none
University hospitals	very strong		none
Media
National Newspspers	very strong		none
Local Newspapers	very strong		none
Political Parties
Liberal Democratic Parity	very strong		none
New Komei	very strong		none
Democratic Parity	very strong		none
Japan Communist Party	very strong		none
Social Democratic Party	very strong		none

Positions and Influences at a glance

Adoption and implementation

At the central level, the Central Committee for Helping Community Medicine has been established. It is in charge to support prefectures with securing the medical workforce to deliver quality health care. Responding to requests from prefectures, the committee gives technical and professional advice, requests relevant organizations to cooperate, assign consultants on community health systems, and to dispatch doctors to hospitals. The MHLW also has organized a special team, consisting of officials of the MHLW, the MIC, and the MEXT, to support actions taken by prefectures.

In the FY 2007 budget, the Government increased subsidies:

1. to develop strategies of prefectures and models for action;
2. to concentrate pediatric and obstetric care into hospitals considering access of patients as well as an efficient allocation of the medical workforce;
3. to develop capacities of hospitals that provide ambulatory pediatric services;
4. to support training hospitals in rural areas and/or training programs in pediatrics and obstetrics;
5. to make nurseries at hospitals more available for physicians;
6. to build employment agencies for female physicians and midwives;
7. to develop telephone counseling for pediatric health;
8. to transport patients by helicopters between islands;
9. to develop no fault compensation systems in obstetrics care; and
10. to investigate and analyze causes and processes of medical accidents, develop a formal system for investigating medical accidents, and to examine possible alternative conflict resolutions.

By the urgent measures released by the ruling parties and the Government in May 2005, quotas for medical schools will increase temporarily. Furthermore the Government will develop a national system to dispatch physicians to hospitals facing an acute shortage of physicians.

Expected outcome

Since reasons for physician shortages are complex, it is reasonable that policies intended to address them include various measures such as those mentioned above. The complexity of the problem also suggests that it is very difficult to tell the outcomes of the policy. Some measures, such as assignment of consultants and dispatch of doctors will produce outcomes shortly, though whether the outcome will result in securing medical work force or not is uncertain. Long-terms results of other measures, such as improvement of work environment and temporal increase of quotas for medical students, would be more controversial. However, since the national and local governments will have better communication on the issue, the national government can more adequately update their measures or allocate additional resources according to the changing situation.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

Quality-this policy has various measures on human resources as well as health care providers and apparently lacks direct impacts on quality of health services. Since access is a prerequisite of quality of services, the policy may have impacts on access to quality services.

Equity- if the policy can solve physician shortage , it will increase geographical equity of access to health care, though whether it can solve or not is unclear.

Efficiency- though some measures such as re-organization of health care providers may increase technicall efficinecy, overall imact are unclear because various cross-sectoral measures will be done.

References

Sources of Information

The Cabinet. Policies on Fiscal Reform. 1997.

Inter-Ministerial Committee on Community Medicine. New Policies to Address Physician Shortages. 2006.

Research Committee on Medical Education. The second report. 2006.

The Liberal Democratic Party. Urgent policies to address physician shortages. 2007.

Directors of National Association of Deans of National Medical Schools and National Association of Directors of National University Hospitals. Securing physician workforce in community: a proposal. 2005.

Author/s and/or contributors to this survey

Matsuda, Ryozo

Ryozo Matsuda is professor in community health and health policy at the College of Social Sciences, Ritsumeikan Univerisity. This report was written when he was a visiting fellow at LSE Health, London School of Economics and Political Science.

Suggested citation for this online article

Matsuda, Ryozo. "Addressing the Physician Shortage". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/jp/a10/2