Commentary / Japan

Japan needs to prioritize a 'population health' approach

by Ryo Kubota

Japan’s population is aging and declining faster than that of any other country. As such, the government, research institutions and the life science industry are highly incentivized to leverage Japan’s history of technical innovation to ease this burden. One of the lowest hanging and best fruits for improving health care outcomes remains unpicked: prioritizing population health and medicine.

Population health is often confused with public health but the two ideas are not the same. Public health focuses on which drugs, vaccines and large-scale campaigns can treat or prevent a disease. By contrast, population health focuses on understanding why some people are more likely than others to get sick and identifies interventions to reduce the rate of hospitalization or pharmaceutical intervention. Elderly individuals, for example, are particularly vulnerable to chronic lifestyle diseases and are among the most likely to suffer catastrophic health consequences if they are not detected early.

A focus on population health emphasizes proactive prevention to overcome the problems that drive poor health conditions. Advocates of this approach believe that successful initiatives require examining the societal structures, attitudes and behaviors that influence individual and group health. The complex influences on health mean that a range of interventions and approaches — from national spending and legislation around food, housing, education, employment and immigration to social networks and collective action at the local community level — are needed for population health.

This way of thinking has benefits for health and health care, but its implementation can be a policy nightmare. Nevertheless, Japan is supremely equipped to deal with such complex policy challenges as a result of its long history of encouraging healthy lifestyles. Moreover, this is another opportunity for Japan to lead the world in health care innovation and benefit directly as a result.

How would a population health approach benefit Japan? Consider diabetes and dementia. In 2016, the Health, Labor and Welfare Ministry estimated that 10 million adults had diabetes, and dementia has been diagnosed in more than 5 million people. The government estimates that dementia diagnoses will increase to 6 percent to 7 percent of the population by 2030. Definitive symptoms of dementia or diabetes often do not emerge until significant damage is done. Yet these diseases are influenced by socioeconomic and environmental factors, and have chronic, progressive development.

Successful management of population health starts with early identification and tracking of these trends. While small studies exist, there is a paucity of data in Japan on the prevalence of both diseases, and how those trends are affected by social determinants. This is exactly the research that a country-wide approach to population health would facilitate. Results would benefit health and science and improve longevity, both in Japan and worldwide.

With this in mind, the next question is: What would moving to population health require? In addition to an empowered chief medical officer, a population health approach would require the creation of a school of population health in academic and clinical training centers. Japan’s future medical practitioners and health policy leaders will need to understand, follow, and treat individuals and designated groups while considering the larger public.

Japan’s health system must also move away from doctor- and pharmaceutical-centric systems toward empowering nurse practitioners and community health providers. While Japan spends roughly half as much on health care as a percentage of GDP as the United States does, it spends about twice as much on drugs as a percentage of total health care costs. If young doctors are trained in a system that embraces a more affordable and effective distribution of tasks, the focus of the health system can shift to population health.

In terms of policy, prevention must be prioritized in practice and not just on paper. For example, vaccination — the most tangible prevention tool of modern medical science — lacks vocal champions in Japan. The health ministry, arguably the government body with the greatest authority to champion this essential tool, is notoriously silent on the issue. This silence is all the more disturbing given the loud voice of the country’s anti-vaccine movement, whose statements and claims have all been debunked.

The lack of attention paid to population health is ironic given Japan’s successful post-World War II public health and sanitation programs, which form the foundation of many World Health Organization programs today. It is time for the nation to marry such historical skills with a deliberate focus on population health.

Numerous developed countries, primarily Western, are already making concerted efforts to integrate population health approaches into their health systems and policies. Cases from the United Kingdom, the United States and Australia show how and where to begin.

The U.K.’s National Health Service’s focus on population health can be seen through numerous initiatives, such as a government-run hospital charity that provides peer support to HIV patients. In Somerset, a new model that coordinates health and care services is being developed for people with three or more long-term conditions. Furthermore, general practitioners in Derbyshire work with the Citizens Advice Bureau to offer information on benefits, employment, immigration and other primary care issues.

In the U.S., key determinants of population health like health care, education and income remain outside the authority of public health agencies and current resources provide inadequate support for traditional — let alone emerging — public health functions. However, the U.S. Center for Disease Control (CDC) features two population health strategies: the 6|18 Initiative for health care purchasers, payers, and providers and the Health Impact in 5 Years initiative focused on community-level changes.

Australia offers the most comprehensive integration of population health. It explicitly focuses on research, as evidenced by University of Technology Sydney’s Australian Centre for Public and Population Health Research. Additionally, the government values research networks, such as the Population Health Research Network, which collates and makes available national health data for vital research. Finally, the Department for Health and Wellbeing coordinates the Population Health Survey Module System, a multifaceted service available to the government and NGOs to obtain data on a range of population health issues.

Japan can and should introduce legislation, research and programs that prioritize population health. This approach could be implemented in one distinct community like the U.K.’s Somerset program, through focused national strategies such as the U.S. CDC strategy, or through a comprehensive policy like the one seen in Australia.

Japan’s demographic and economic challenges require health care policies that ease the financial burden and increase the quality of life for the country’s rapidly aging and declining population. The cultivation of such expertise at scale will require the creation of a school, or dedicated programs within multiple existing schools, focused on this concept. As long as such expertise is lacking, efforts to improve health care will fall short — possibly addressing key issues for unique groups on paper but failing in practice to address the underlying issues of the group as a whole.

Most importantly, Japan cannot afford to delay taking steps to prioritize population health. Government debt is higher than ever, and GDP growth is very modest. This economic reality, combined with the country’s aging labor force, skyrocketing health care and welfare costs, and rising prices for cutting-edge therapies such as novel cancer drugs and regenerative medicine demanded by older populations, means that Japan can no longer spend whatever is needed for health care. The country has the highest number of MRI and CT scanners (per 1 million people) in the world, and three times as many outpatient visits as in the U.S. Hospital stays in Japan are likewise three times as long as in the U.S. Life science innovation alone will not solve these problems.

Ryo Kubota is chairman, president and CEO of Acucela Inc., a subsidiary of Kubota Pharmaceutical Holdings, and a visiting professor at Keio University School of Medicine.