Midcourse review of "Health Japan 21"

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

Abstract

In 2000, the Government developed a set of objectives for health promotion for the period 2001-2010, which is called "Health Japan 21". The midcourse review of "Health Japan 21" in 2007 revealed ambiguous results: prevalence of obesity among male adults and diabetes among adults had increased, whereas mortality caused by cardiovascular diseases among both male and female adults had decreased.

Purpose of health policy or idea

"Health Japan 21" is an 10-year national campaign intended to promote healthy behaviours of the national population and build healthy environments with actions of communities, worksites, health professionals and other related organizations by establishing and sharing the national objectives. The national objectives have been established for the purpose of sharing goals in the whole nation rather than  administrative objectives of the Government. It is expected to serve as the basis for the development of prefectural and municipal plans. The overall goals of the campaign are to prolong length of healthy life and improve quality of life.

After various scientific research and public debates, the Government has established objectives for "Health Japan 21" in the following nine areas:

• food and nutirition;
• physicial activities;
• mental health;
• tobacco;
• alcohol;
• oral health;
• diabetes;
• cardiovascular diseases;
• and cancer.

General descriptions, specified objectives, baseline measures and targets for the year 2010, and possible interventions are given for each area. For some objectives there are numerical indicies for sub-groups, such as groups by gender and life-stages. For example, the area of "physical activies" has six objectives for health promotion, one of which is "to increase daily walking", indicated by  the number of walk steps per day. Mortality and morbidity rats are not included (therefore outcomes means status of health behaviours).

The Goverment has implemented various measures before and after the enactment of the Health Promotion Law (for an earlier account of the legislation see Implementing the Health Promotion Law (2)2003). The Goverment has:

• established a framework for national health promotion;
• established and updated a common guideline for health examinations provided on legal bases;
• developed surveys on health behaviours and chronic diseases;
• organized special events for the campaign with concerned organizations;
• organized basic training courses for volunteers for health promotion;
• promoted researches on health promotion;
• published scientific guidelines for specified areas exemplified by "A Guide for  Physical Excercise"in 2006.
• disseminated relevant information to the public through the mass media as well as new media such as the internet and i-mode mobile phone.

Since "Health Japan 21" is a national movement, local governments have been expected to get involved voluntarily, but some mechanisms for involvement of local governments exist. First, the law obliges prefectures to expend their effort to promote health as well as to make prefectural health promotion plans, which are local versions of the national objectives. Prefectures can set priorities by themselves, based on local health status and avilable resources, but should take the framework of the Government into consideration in developing plans. Secondly, the Government introduced a small amount of subsidies for local governments to develop local plans in addition to existing subsidies for providing community health services. Thirdly, the Government has developed health promotion programmes, such as personal behavioural services, with local governments.

The midcourse review is intended to assess the status of the national objectives in terms of outcomes and processes, to analyse influential factors, to reveal challenges for further development of the movement.

Main points

Main objectives

The midcourse review is  intended to check the present activities for promoting health and trends in health behaviours and change them for better outcomes.

Type of incentives

Mostly non-financial, but some financial incentives are closely related.

Groups affected

Prefectures, General Public

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

This review was conducted in the circumstances that health promotion policy has moved from a broad national movement to specified programmes on individual health behaviour in the context of health care reform. Although a midcourse review itself is not so innovative in terms of ideas, the review not only analysed information from the initial perspectives of "Health Japan 21", but also integrated individual behavioural services provided by the 2006 Health Care Reform Law.

Most parts of the review were written by a consensus of commitee or council members. Even the intense controversies as to objectives on smoking prevalance were compromised through the consensual approach so that it was  published on the given schedule.

Political and economic background

Healthy and secure living have increasingly become key words in the political scene. In 2004, the Liberal Democratic Party created "A Strategy for Health Frontier", which principally aimed at prolongation of healthy life and focused prevention of chronic disease and frailness that are believed to increase health and long-term care needs. Later, the strategy formally became a part of the Government's policy.

Also, the idea that prevention is a better way of controlling health expenditures than simply cutting down prices paid by the pulic health insurers has become popular. This change of perception took place by the counterarguments of the Ministry of Health, Labour and Welfare(MHLW) to the arguments for introduction of more competitive mechanisms into health care. The counterarguments have been backed by health professionals that usually think prevention is better than treatment.

Individual health behaviour has been paid attention in the mass media with a term, the "metabolic syndrome" ( a combination of medical disorders that increase a person's risk for cardiovascular disease, like high blood pressure, obesity, etc.). This scientific term has become a high-profile term in reference, first, to prevention of chronic diseases, and then, to decrease health expenditures This attention has been introduced in the process of implementing the 2006 Health Care Reform Law by the Government. The law put public health insurers under an obiligation to provide screening tests and behavioural services for the insured regarding diabetes, obesity,  and other diseases significantly affected by health habits.

Political circumstances on tobacco control have slightly changed: support for tobacco control has increased as a result of the enforcement of the WHO Framework Convention on Tobacco Control (FCTC).

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

The scheduled midcourse review is part of the national objectives for "Health Japan 21". Although the idea of the midcourse review can be traced to similar objectives in other countries, such as "Healthy People" in the United States, midcourse reviews have been usual and necessary for most programmes and plans of the national and local government in Japan. Off course this "culture of evaluation" can be traced to other countries.

Initiators of idea/main actors

• Government : Ministry of Finance is in charge of controlling and taxing tobacco, but it has not be involved in the review.

• Civil Society : Controversies existed in the civil society as to policies on tobacco.

• Scientific Community

• Private Sector or Industry

• Political Parties : The Liberal Democratic Party was mostly supportive except on adding an objective on smoking prevalence.

Approach of idea

The approach of the idea is described as:
renewed: Similar ideas can be found in "Healthy People" in the US

Innovation or pilot project

Else - A system for regular surveys on health behaviours has been established.

Stakeholder positions

The national and local governments as well as health professionals have supported the review process. Since the obejctives of "Health Japan 21" are mostly on individual behaviour, food industries, fitness clubs and other industries potentially related to health have been looking for business opportunities.

While the brewing and distilling industry are apparently neutral, some tobacco industries are against setting an obejctive of reducing prevalence of smoking among adults altough they support prevention of smoking among teenagers.

Actors and positions

Government
Ministry of Health, Labour, and Welfare	very supportive		strongly opposed
Ministry of Finance	very supportive		strongly opposed
Civil Society
Anti-smoking movement	very supportive		strongly opposed
Pro-smoker movement	very supportive		strongly opposed
Scientific Community
Academics	very supportive		strongly opposed
Technical Staff in the MOH	very supportive		strongly opposed
Private Sector or Industry
Tobacco industry	very supportive		strongly opposed
Food industry	very supportive		strongly opposed
Fitness industry	very supportive		strongly opposed
Brewing and distilling industry	very supportive		strongly opposed
Political Parties
Liberal Democratic Party	very supportive		strongly opposed

Influences in policy making and legislation

The review process was initiated by by a scientific advisory committee for the MHLW. But before the review started, the Government planned to develop and spread more effective person-based interventions to promote healthy behaviour. The review reflected this new idea(which should be given by another report). Thus a new objective on the metabolic syndrome was added. Put simply, the committee reviewed the objectives and its trends, acitivites for promoting health, and plans made by local governments and analysed them for updating the objectives and developing new strategies.

The most controversial issue is whether an objective on the reduction of the percentage of smokers among adults should be added. The original national objectives do not include such an objective, although there were arguments for including it. In the review , the scientific advisory committee argued that the objetive should be added with consideration to the FCTC. On the other hand, some companies expressed their opposition against an objective on reduction of smoking among adults because it would arise too much interventions to private life, the idea of which was backed by the ruling Liberal Democratic Party. In the end, the review recommended as a new objective successful smoking cessation, instead of smoking prevalence among adults. Still, smoking prevalence among adults will be monitored as a reference indicator.

Legislative outcome

success

Actors and influence

Government
Ministry of Health, Labour, and Welfare	very strong		none
Ministry of Finance	very strong		none
Civil Society
Anti-smoking movement	very strong		none
Pro-smoker movement	very strong		none
Scientific Community
Academics	very strong		none
Technical Staff in the MOH	very strong		none
Private Sector or Industry
Tobacco industry	very strong		none
Food industry	very strong		none
Fitness industry	very strong		none
Brewing and distilling industry	very strong		none
Political Parties
Liberal Democratic Party	very strong		none

Positions and Influences at a glance

Adoption and implementation

First methodologies for reviewing were investigated from 2002 to 2004. Then a scientific advisory committee colleced and analysed information on "Health Japan 21". The committe reported their on-going review to a subcommittee of the Health Sciences Council, which is a standing advisory committe in charge of promoting health sciences and public health.Taking comments from tabacco companies, and the public comments submitted, the subcommitee revised the draft and finally published the midcourse review in April 2007.

Monitoring and evaluation

As mentioned above, a survey system on health behaviours has been established. In addition to that, the national and local governments conduct research if necessary.The objectives are established until 2010 when the final review will probably be done.

Review mechanisms

Mid-term review or evaluation

Dimensions of evaluation

Structure, Process, Outcome

Results of evaluation

Structure and Process
A system for systematically gathering national data on health habits has been developed. The Health Japan 21 Council, a national organization for promoting Health Japan 21 was established in 2001. All prefectures have established their local health promotion plans by April 2002, while 54 percent of municipalities have their plans as in July 2006.
Identified problems include little assignment of priorities in the plan, lack of effective programs at the national level, lack of mechanisms for mobilizing the whole society, effective and responsible mechanisms for intervention, and lack of human resources.

Outcomes
In some focus areas, including good nutrition, physical activities, mental health, no clear progress has been observed, while in others, such as oral health, smoking and cardiovascular disease, some indicators show considerable or dramatic progress. There have been considerable differences in the change of the indicators between population sub-groups, which should be paid attention. Some focus areas are yet to be evaluated with more consistent indicators.

Expected outcome

The review recommended that:

• representative indicators shall be selected for making daily tasks easily understandable for people;
• new objectives,e.g. on the metabolic syndrome shall be added for promoting relevant activities;
• effective educational tools shall be developed and spread;
• health screening and education to cope with the metabolic syndrome shall be delivered by public health insurers, as the 2006 Health Care Reform Law provides;
• co-operation with fitness industries, food industries, other health related industries shall be enhanced.
  
  Also, he formal objectives and principles established by the Government will be changed according to the recommendation of the review. Also, this review might support a policy shift from the initial characteristics of "Health Japan 21", a broad health promotion movement to specified person based programmes to achieve healthy behaviours.

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

References

Sources of Information

SubCommittee for Community Health and Nutrition and Health Promotion, Health Sciences Council(2007) Midcourse review of " Health Japan 21".

Minutes of SubCommittee for Community Health and Nutrition and Health Promotion.

Newspapers

 

Author/s and/or contributors to this survey

Ryozo Matsuda

Suggested citation for this online article

Ryozo Matsuda. "Midcourse review of "Health Japan 21"". Health Policy Monitor, April 2007. Available at http://www.hpm.org/survey/jp/a9/1