|Implemented in this survey?|
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.
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:
Maintaining the principle of "from institutionalized care toward community-based care", the document confirmed the four objectives below:
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:
2. Policy measures to improve the quality of mental health care include:
3. Policy measures on services supporting people with mental disorders living in the community include:
4. Policy measures on bringing about a better understanding on psychiatric diseases and disorders include:
As described above, the current objectives of the government can be summerized as;
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.
Mental health care providers, community services providers, patients with mental disorders and their families, prefectures, public Insurers
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
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.
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.
|Implemented in this survey?|
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.
The approach of the idea is described as:
amended: Review of the 2006 plan of mental health
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.
|Ministry of Health, Labour and Welfare||very supportive||strongly opposed|
|Psychiatric Hospitals||very supportive||strongly opposed|
|Psychiatric clinics||very supportive||strongly opposed|
|Residential care providers||very supportive||strongly opposed|
|Japan Medical Association||very supportive||strongly opposed|
|Newspapers||very supportive||strongly opposed|
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.
|Ministry of Health, Labour and Welfare||very strong||none|
|Psychiatric Hospitals||very strong||none|
|Psychiatric clinics||very strong||none|
|Residential care providers||very strong||none|
|Japan Medical Association||very strong||none|
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.
Mid-term review or evaluation
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.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
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.
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
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.