Yasuo SUGIURA, M.D.Bureau of International Health Cooperation

National Center of Global Health and Medicine

Case-example: how Japan reduced maternal and newborn mortality

over the past 100 years

– key strategies, lessons for other countries in the Region

9/22/2015

Aim • This presentation aims to help you

learn the laws and regulations that supported maternal, newborn, and child health in Japan over the years.

Contents

• Quick review of the Japanese history

• Elementary school enrollment rate

• MCH indicators

• Health Laws

• Health financing

• A short film “Health Centers Today”

Basic education

Economy & development

Laws & regulations

Health

Small private school(Temple school)

Public elementary school

A closed –door policy

Image

samurai

WWII

steam locomotiveradio broadcast

aging society & declining birthrate

Traditional medicine

Western medicine

a concept of hospital

Foreign ships

Family registration law(1871)Medical regulation(1874)

National health insurance law(1938)

Medical practitioners law(1947)Medical care law(1947)Public health nurses, midwifes and nurses law(1947)Child welfare law(1947)Statistics law(1947)

Public health center law(1937)

18681603 1912 1926 1989

Taisho eraMeiji eraEdo era Showa era Heisei era

economic growth

cholera

Quick review of Japanese history

Pre WWII

Maternal and child health law (1965)

Post WWII

The opening of a country

歌川広重の「諸芸稽古図会」

Basic education

Economy & development

Laws & regulations

Health

Small private school(Temple school)

Public elementary school

A closed –door policy

Image

samurai

WWII

steam locomotiveradio broadcast

aging society & declining birthrate

Traditional medicine

Western medicine

a concept of hospital

Foreign ships

Family registration law(1871)Medical regulation(1874)

National health insurance law(1938)

Medical practitioners law(1947)Medical care law(1947)Public health nurses, midwifes and nurses law(1947)Child welfare law(1947)Statistics law(1947)

Public health center law(1937)

18681603 1912 1926 1989

Taisho eraMeiji eraEdo era Showa era Heisei era

economic growth

cholera

Quick review of Japanese history

Pre WWII

Maternal and child health law (1965)

Post WWII

The opening of a country

Strategy

Plan

Resource

Finance

Regulations

Laws

Elementary school enrollment rate from 1873 to 1983WWIIWWI

0

20

40

60

80

100

Female

Male

%

year

Meiji era Taisho era Showa era

Elementary school enrollment rate from 1873 to 1983WWIIWWI

0

20

40

60

80

100

Female

Male

%

year

0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-

FemaleMale

age million people0 2 4 6246

Meiji era Taisho era Showa era

Elementary school enrollment rate from 1873 to 1983WWIIWWI

0

20

40

60

80

100

Female

Male

%

year

0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-

FemaleMale

million people0 2 4 6246age

Meiji era Taisho era Showa era

Elementary school enrollment rate from 1873 to 1983WWIIWWI

0

20

40

60

80

100

Female

Male

%

year

0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-

FemaleMale

million people0 2 4 6246age

1950Meiji era Taisho era Showa era

Elementary school enrollment rate from 1873 to 1983WWIIWWI

0

20

40

60

80

100

Female

Male

%

year

0-56-1112-1718-2324-2930-3536-4142-4748-5354-5960-6566-7172-7778-8384-

1975

FemaleMale

million people0 2 4 6246age

Meiji era Taisho era Showa era

Elementary school enrollment rate and infant mortality rate(IMR)

WWIIWWI

0

20

40

60

80

100

ElementarySchool

Female

Male

IMR

%

year

0

20

60

100

140

180

IMR(/1000births)

WWIIWWI

0

20

40

60

80

100

ElementarySchools

Female

Male

Life Expectancy Females

Males

IMR

%

year

0

20

60

100

140

180

IMR

40

60

80

50

70

age

Elementary school enrollment rate, IMR, and life expectancy

WWIIWWI

0

20

40

60

80

100

ElementarySchools

Females

Males

Life Exp. F

Life Exp. M

GDP/capita

IMR

%

year

GDP/capita(X1,000

yen)

0

20

60

100

140

180

IMR (/1000births)

2,000

1,600

1,200

800

400

0

($1,111)

($2,222)

Elementary school enrollment rate, IMR, life expectancy, and GDP/capita

Evolution of Health Administration in Meiji Era and Related Data

Year (Japanese system)

Year (Western system)

Attendance rate (%) of primary

educationKey events and selected Health Laws

Maternal and child health laws and

regulations

Boys Girls

　 　 1867 　 　 Return of political power to Emperor by Tokugawa Shogunate 　

Meiji era

2 1869 　 　 Abolition of feudal domains and establishment of prefectures 　

4 1871 　 　 Enactment of Family Registration Law 　

5 1872 　 　 Health Bureau, Ministry of Education 　

7 1874 46.2 17.2 Establishment of Medical Regulation 　

8 1875 50.8 18.7 Health Bureau, Ministry of Interior 　

9 1876 54.2 21 Local health administration → Police 　

22 1889 64.28 30.45 Constitution of Empire of Japan 　

27 1894 77.14 44.07 　 　

28 1895 76.65 43.87 　 　

30 1897 80.67 50.86 Communicable Diseases Prevention Law 　

31 1898 82.42 53.73 Amendment of Family Registration Law 　

32 1899 85.06 59.04 　 Establishment of Midwives Regulations

33 1900 90.35 71.73 Establishment of Waste Cleanup Law and Sewerage Law 　

37 1904 97.16 91.56 　 　

39 1906 98.16 94.84 Medical Practitioners Law and Dentists Law 　

Establishment of Medical Regulation1874

1899Establishment of Midwives Regulations

Meijiera

MCH laws &regulations

Key events and selected health laws

Enactment of Family Registration Law1871

1 1912 98.8 97.62 Establishment of health guidance organizations 　 　

3 1914 98.8 97.67 　 　 　

4 1915 98.93 97.96 Nurses Regulations 　 　

5 1916 99.01 98.18 Establishment of Health and Hygiene Investigation Committee 　 　

6 1917 99.05 98.38 　 　 　

7 1918 99.12 98.58 　 　 　

11 1922 99.41 99.19 Enactment of Health Insurance Law 　 　

12 1923 99.32 99.15 　 　 　

9 1934 99.58 99.58 　　 Imperial Gift Foundation Boshi-Aiiku-Kai

10 1935 99.59 99.59 　 　 　

12 1937 99.59 99.6 Public Health Center Law (old) 　Launch of guidance for expectant and nursing mothers and infants

　 　 　 　 　 Maternal and Child Protection Law 　

13 1938 99.6 99.63 National Fitness Law and National Mobilization Law 　 　

　 　 　 　 Establishment of Ministry of Health and Welfare 　

　 　 　 　 National Health Insurance Law 　 　

14 1939 99.62 99.64 　 　 　

15 1940 99.64 99.65 General Guidelines for Establishment of Population Policy and National Fitness Law 　

Nationwide implementation for infants (examination)

16 1941 99.7 99.73 　Public Health Nurses Regulations and National Eugenic Law

　

17 1942 99.71 99.75 National Medical Care Law 　 Maternal Handbook System and Fitness Handbook

18 1943 99.75 99.77 　 　 　

19 1944 99.76 99.78 　 　 　

20 1945 99.78 99.81 　 　 　

Taisho era

Year (Japanese system)

Year (Western system)

Attendance rate (%) of primary

education

Health administrationGeneral laws/regulations

and key events Maternal and child health

Laws and regulations / Policy measures

Showa era

Boys Girls

MCH laws and regulations

Key events and selected health laws

Public Health Center Law (old)1937

Maternal & Child Protection LawEstablishment of Ministry of Health and Welfare

National Health Insurance Law

1938Showa era

Tokyo

Osaka

Gifu

図　 GHQ公衆衛生福祉局長サムス准将と勝俣稔厚生省衛生局長

占領期の厚生省東京衛生試験所（医薬品編）　宮原誠

Year (Western system)

Attendance rate (%) of primary

education

Total fertility

rate 　

Boys Girls TFR

Showa era

21 1946 99.63 99.72 Constitution of Japan 　 　 　

22 1947 99.78 99.8 Public Health Center Law (new) 　 Establishment of Children's Bureau, Ministry of Health and Welfare

4.54

　 　 　 　 Medical Care Law Child Welfare Law 　 　

　 　 　 　 New Medical Practitioners Law and new Dentists Law 　 　 　

　 　 　 　

New Public Health Nurses, Midwives and Nurses Law

Statistics Law

　 　 　

23 1948 99.62 99.67 Enactment of Vaccination Law Enactment of Vaccination Law 　 4.4

　 　 　 　 　　 General Guidelines for Maternal and Child Health Measures 　

　 　 　 　 　 Eugenic Protection Law 　 　

33 1958 99.79 99.82 　Maternal and child health centers Health guidance for premature infants

2.11

36 1961 99.8 99.83 　 Universal national health insurance Home-visit guidance for new-born infants 3-year health checkup

1.96

40 1965 99.8 99.83 　 Maternal and Child Health Law 　 2.14

43 1968 99.81 99.86 　 Maternal and child health promoter system 　 2.13

44 1969 99.81 99.85 　 　 Detailed examination of infants 2.13

49 1974 　 　 　 Childhood chronic diseases program 　 2.05

52 1977 　 　 　 　 18-month health checkup 1.8

Year(JapaneseSystem)

Child Welfare Law

MCH laws and regulations

Key events and selected health

laws

Statistics Law

1947

Maternal and Child Health Law1965

Showa era

Number of new health laws introduced after World War II

1946-

551956-

651966-

751976-

83Total

Human resource qualification

10 5 5 0 20

Environmental health 6 2 2 3 13

Disease prevention 5 0 0 0 5

Drug control 5 0 0 0 5

Medical services 3 2 0 0 5

Public health center 1 1 0 0 2

Education 1 0 0 1 2

Food sanitation 1 0 0 0 1

Management 0 1 0 0 1

Biological weapon 0 0 0 1 1

Total 32 11 7 5 55

Japanese Policy & Law related with MCH

WWIIWWI

1868

160

3

Edo era Meiji era Taisho era Showa era Heisei era

Time trend of MCH indicators in Japan from 1899 to 1999

Maternal mortality ratio (MMR)(per 1000,000 live births)

Infant mortality rate (IMR) (per 1,000 live births)

Neonatal mortality rate (NMR) (per 1,000 live births)

MMR

IMR

NMR

Medical Regulation (1874)

Midwives Regulations

Public Health Center Law (old)

Maternal and Child Protection Law

WWIIWWI

Maternal and Child Health Law(1965)

Child Welfare Law(1947)

1868

160

3

Edo era Meiji era Taisho era Showa era Heisei era

Medical Regulation (1874)

MMR

IMR

NMR

The MCH indicators and related regulations in Japan between 1899 and 1999

Maternal and Child Health Law1947

Child Welfare Law Maternal and Child Health Law

1965

providing health guidance to expectant and nursing mothers and children, doing health check-up for children, and delivering MCH handbook.

・ High MMR to compare with developed countries・ Regional difference of IMR in Japan・ Transfer most MCH activities from provincial governors to municipal heads.

Notification of pregnancy（ 15）

Deliver Maternal and Child Handbook（ 16）

Prenatal check up（ 13）

Home guidance（ 17）

Delivery

Postnatal, one year and half, 3 year-old child check up（ 10 /12 /13）

Home guidance （ 11/19）

Registration of low birth-weight （ 18）

Medical and infant care services（ 20）

Continuum of care on Maternal and Child Health Law in Japan

( Article No.)

Institutional delivery 99.8%

Home delivery 0.2%

Figure 2-39 Childbirth Trends by Mode

1947 1960

Note: Institutional delivery is the sum of hospital, clinic and midwifery center deliveries.Source: Statistics and Information Department, Minister’s Secretariat, Ministry of Health and

Welfare, “Vital Statistics”

1996 (Year)

Health Financing in Japan

Annual government expenditure in Japan from 1937 to 2009

Total expenditure

The ministry of health and welfare

X1,000 Japanese yen$ 830 billion

$ 249 billion

Showa era Heisei era

High economic growth

WWII

%

Percentage of the ministry of health and welfare expenditure among the government expenditure

Showa era Heisei era

High economic growth

WWII

Elementary school enrolment rate. IMR, and the expenditure rateof the ministry of health among the total expenditure in Japan Elementary school enrolment rate, IMR, and the expenditure rateof the ministry of health among the total expenditure in Japan

Meiji era Taisho era Showa era

WWIIWWI

IMR100%

60%

20%

40%

80%

0%

ElementarySchool

Female

Male

IMR

%

%

%

%

%

%

Expenditure rate of the Ministry of Healthand Labour

Proportion of the burden of national medical expenses in Japan

by resource (FY2011)

（ 26%）（ 12.4%）

http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/iryouhoken/iryouhoken01/index.html

%

%

%%

Patient’s payment $39 billion

Total $325.4 billion

$1=120円→ 1兆円＝ $8.3 billion

insured

Employer

Insurance premium

$158.5 billionState subsidyLocal government

Public subsidy $125.3 billion

(Employees pay health insurance feeevery month)

(at a hospital)

Breakdown of the draft budget of the Ministry of Health, Labour and Welfare

(FY 2014)

Medical care 　 $ 93 billion（ 37.1%）

Pension $ 88.8 billion（ 35.5%）

Welfare $ 45.7 billion（ 18.2%）

Long-term care 　 $ 21.6billion（ 8.7%）

Employment 　 $1.7 billion（ 0.6%）

$ 251.6 billion

$1=120円→ 1兆円＝ $8.3 billion

(insurance for elderswho need care)

(unemployment insurance)

Breakdown of salary in Japan as an example

Healthcare insurance（ 3%）Pension（ 6%）

Income tax（ 7%）

Inhabitant tax（ 8%）

Long-term care insurance（ 0.4%）

Employment insurance（ 0.6%）

Take-home pay (75%)

a short film“Health Centers Today”

(1949)

After 4 years since the end of WWII

WWIIWWI

1868

160

3

Edo era Meiji era Taisho era Showa era Heisei era

Time trend of MNCH indicators in Japan from 1899 to 1999

MMR

IMR

NMR

Medical Regulation (1874)

a short film“Health Centers

Today”(1949)

Annual expenditure of Health and Sanitation in Japan X million yen

$ 8.3 billion

$ 3.3 billion

Showa era Heisei era

High economic growth

%

Percentage of annual expenditure of “Health and sanitation” in the total expenditure of the government of Japan