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Japan’s fifth wave of COVID-19 has subsided and the country is now looking to ease social and travel measures that were imposed during the pandemic.

Throughout the pandemic, there has been a distinct lack of clarity on the specific roles and responsibilities of the central, prefectural and local governments. This has resulted in delayed responses, miscommunication and intentional obfuscations that are far from helpful when Japan is in the middle of a health crisis.

It is now time for a serious debate on what Japan has learned since the coronavirus emerged almost two years ago, and what structural and legal changes are needed to address any weaknesses in the health system.

There are six key areas that the administration of Prime Minister Fumio Kishida should urgently address.

Clarify responsibility

The 1999 Infectious Diseases Control Law was amended in 2020 to cover COVID-19. The legislation, coupled with a 2012 law on responses to new infectious diseases, was amended again to give the prime minister the authority to declare a health emergency and authorize payments to individuals and businesses who cooperate with COVID-19 measures. Additional amendments were enacted to provide a framework for penalties for noncompliance earlier this year.

Given the urgency of the situation and the steadfast opposition from some political parties, the government struck a compromise. Authority was assigned to each of the 47 prefectural governors to execute detailed actions to contain the pandemic and enforce their orders through civil fines.

The administration of Prime Minister Yoshihide Suga and Tokyo Gov. Yuriko Koike repeatedly clashed over the metropolitan government's handling of COVID-19. | KYODO
The administration of Prime Minister Yoshihide Suga and Tokyo Gov. Yuriko Koike repeatedly clashed over the metropolitan government’s handling of COVID-19. | KYODO

The legislation and Japan’s national health system work reasonably well for local outbreaks of known diseases, but they have proven to be inadequate when the country is facing a national health crisis.

What hamstrung the nation’s response in particular was that the prime minister does not have an adequate set of mandates in his or her arsenal, unlike leaders in other democratic nations. This is a hangover from the years before and during World War II when Japan’s military-led government severely restricted individual rights and freedoms. However, the specters of the 1930s and ’40s should not be a pretext for inaction when action is needed. If the buck stops with the prime minister in dealing with a pandemic, they need to have the authority and tools at their disposal to direct the nation’s response.

As we have seen over the past two years, Japanese citizens will hold the government, specifically the prime minister, responsible for assuming direct control of the national response. Recent polls have indicated that a clear majority recognizes there is an issue here. Most people appear to support granting the prime minister greater authority in a health crisis, as was done legislatively when the lack of authority inhibited effective responses during past natural disasters and then again after the Fukushima nuclear disaster following the earthquake and tsunami of March 11, 2011.

The National Governors’ Association, which supported the amendments to the laws, has also highlighted persistent issues in aligning accountability and authority.

On Oct. 2, the association urged the Kishida administration to strengthen the health care system, specifically calling for the government to secure hospital beds, tests and treatment. The latter request appears to recognize the limitations of local government. Under the Infectious Diseases Control Law, prefectural governors were responsible for securing hospital beds and setting up adequate testing centers through central government funding.

The government could subsidize the consolidation of small, understaffed and less-efficient hospitals and clinics into larger ones that can afford the acquisition costs for expensive medical diagnostic and treatment equipment required for ICUs as well as staff that have been trained to operate them. | REUTERS
The government could subsidize the consolidation of small, understaffed and less-efficient hospitals and clinics into larger ones that can afford the acquisition costs for expensive medical diagnostic and treatment equipment required for ICUs as well as staff that have been trained to operate them. | REUTERS

When Japan faces a national health crisis, the prime minister should have the legal authority, accompanied by ongoing consultation with lawmakers and relevant prefectural governors, as well as advice from a permanent health crisis panel, to take the following steps:

  • Declare a national health emergency either nationwide or specifically targeting affected regions or prefectures.
  • Require designated commercial businesses to limit operating hours or close for defined periods with appropriate compensation.
  • Limit train, airline and other public transportation schedules to manage the movement of people.
  • Close or place restrictions on schools, large event venues and amusement parks.
  • Require private and public hospitals to support the response with appropriate compensation.

As seen in the recent amendment to the Infectious Diseases Control Law, Japan’s Bar Association and the main opposition parties will likely oppose or attempt to minimize the authority granted to the prime minister, citing concerns over excessive power, protection of private property and individual privacy.

These concerns deserve appropriate consideration. The public will hold the prime minister accountable for a health crisis. And Japan should extend authority to create and execute a national response with checks and balances as appropriate, but with full understanding that speed is of the essence.

Tear down bureaucracy

To better combat pandemics in the future, a rethink of government apparatus is also in order.

Before 2001, the ministry responsible for social security (health, welfare and pensions) and the ministry overseeing labor issues were independent administrative bodies. Aiming to streamline and de-silo the bureaucracy, the two branches of government were amalgamated in 2001 into the Ministry of Health, Labor and Welfare, boasting around 28,000 employees and overseeing 35% of Japan’s entire annual budget — the single largest entity.

It’s time to admit the consolidation was a mistake. The Ministry of Health, Labor and Welfare should be split into two separate bodies, with one focusing on social security and the other on labor matters. In separating them, the respective roles and the responsibilities of each entity should be clearly delineated.

Within the reconfigured health ministry, we need to create and fund a center for disease control with the same authority as the Centers for Disease Control and Prevention in the United States to act as a “control tower” of sorts that cuts across all relevant government ministries in a health emergency.

As many as 1 million trained health care staff have stopped working in hospitals in Japan since the global pandemic has been declared due to inflexible work rules and family commitments. | REUTERS
As many as 1 million trained health care staff have stopped working in hospitals in Japan since the global pandemic has been declared due to inflexible work rules and family commitments. | REUTERS

Japan has lacked anyone operating in this control tower capacity over the past two years.

Japan’s new equivalent to the CDC could be built on the excellent research and development and technical capabilities of the National Institute of Infectious Diseases. In a national health crisis, Japan’s new CDC would report directly to the prime minister.

Digitize health care

Much has been made of the inability of the central government to rapidly distribute the ¥100,000 cash payments to each household in Japan in May 2020. Fingers have also been pointed at the use of fax machines by local governments and public health centers to report time-sensitive information, as well as the lack of basic IT skills by untrained staff at local and prefectural governments.

The government should develop and deploy standard reporting and data systems linking relevant national ministries to all 47 prefectures and 1,741 local governments, providing the equipment, software, maintenance and regional training required. Once deployed, prefectural and local governments should not be allowed to opt out. Transparency, as well as accuracy, are critical to good communication.

During the pandemic, some local governments chose not to report data as and when required. Some even refused to follow health ministry reporting protocols, with the Tokyo Metropolitan Government, for example, refusing to follow the definition used by other areas of the country to report the number of severe cases in ICU and instead insisting on its own definition.

Other prefectures did similar things with other critical statistics, with a number of them resisting instructions from the health ministry to share vaccine data at a local level. The prefectures that were slow in implementing the vaccination rollout were afraid of being called out. So much for transparency.

South Korea has been able to distribute cash subsidies to recipients five times faster than Japan. South Korea created a unified national system based on a resident registration number system and mandated it for tax, national insurance programs and residence. This system has provided the South Korean government with an efficient way to transfer payments to every recipient using credit card companies for final delivery.

Japan created its My Number system with similar objectives starting with the issuance of cards in 2016 to link government systems for social insurance, tax, and, in Japan’s case, disaster countermeasures. Political opposition has raised concerns over privacy, government surveillance and data leaks to block every attempt to mandate it.

Preliminary proposals have surfaced calling for the creation of a permanent public and private consortium on vaccines that will identify pharmaceutical companies that have or can quickly establish the expertise required to develop and produce domestic vaccines amid a pandemic. | REUTERS
Preliminary proposals have surfaced calling for the creation of a permanent public and private consortium on vaccines that will identify pharmaceutical companies that have or can quickly establish the expertise required to develop and produce domestic vaccines amid a pandemic. | REUTERS

With Japan’s My Number system voluntary in application, about 50 million people or just 40% of the eligible population had been covered as of September. As a result, when the government wanted to transfer ¥100,000 to each person, officials had no way to do it as they did not have access to at least one financial account in every household. The funds for the subsidy were instead sent to prefectural and local bodies for subsequent disbursement. And each town and ward in those local authorities then mailed out forms to each household one by one using their processes.

Such integral issues with Japan’s My Number system need to be resolved and a program implemented to increase coverage to above 70%. This is key to establishing an effective digitalization system. The decision to allow My Number cards to be combined with an individual’s health insurance card, which officially began on Oct. 20, is a good first step. Linking the My Number card to new or renewed driver’s licenses and other cards the population uses daily as well as connecting it to all local and national tax filings is a must.

The same issue plagues the COVID-19 subsidies payable to business operators such as restaurants owners who are curtailing their operating hours. In many cases, it can take up to three months to transfer the funds.

Develop domestic vaccines

Preliminary proposals have surfaced calling for the creation of a permanent public and private consortium on vaccines that will identify pharmaceutical companies that have or can quickly establish the expertise required to develop and produce domestic vaccines. Legislation with adequate funding needs to be passed once lawmakers return to parliament following the Lower House election.

Japan’s unfortunate history with vaccines is now fairly well-known, so the government should never again allow itself to be in a position in which it is entirely dependent upon vaccine supplies from abroad. National health crises abroad can quickly spiral into an international health crisis that negatively impacts extended global supply chains.

Get more hospital beds

Japan has more hospital beds per capita than any of its peers in the Group of Seven. Japan’s 12.8 beds per 1,000 people compares favorably to 2.4 beds per 1,000 people in the United Kingdom, 2.5 in Canada, 2.8 in the United States and 7.9 in Germany.

However, the majority of Japan’s hospital beds can be found in private institutions. In Japan, private institutions make up about 80% of the total number of hospitals nationwide, operating around two-thirds of the 4,255 facilities that are able to handle acute care patients. In Europe, those percentages are reversed, with 70-80% of all hospital beds found in public hospitals.

Japan has more hospital beds per capita than any of its peers in the Group of Seven, though 80% of them can be found in private clinics and hospitals. | REUTERS
Japan has more hospital beds per capita than any of its peers in the Group of Seven, though 80% of them can be found in private clinics and hospitals. | REUTERS

In normal times, the large number of private facilities operating in Japan gives patients multiple treatment options. As the pandemic has shown, however, a medical system dependent on a large number of small, privately owned hospitals that lack equipment and specialist staff is highly problematic amid a national health crisis.

Japan needs to balance public and private health needs better. The government should subsidize the consolidation of small, understaffed and less-efficient hospitals and clinics into larger ones that can afford the acquisition costs for expensive medical diagnostic and treatment equipment required for ICUs as well as staff that have been trained to operate them.

In Europe and the United States, governments have the legal authority to mandate hospitals to respond to health needs during a crisis. As noted above, the prime minister should have that legal authority when a national health crisis is declared.

Secure more medical staff

Japan also lags in the number of doctors it has at its disposal, with 2.4 physicians per 1,000 people compared to 2.6 in the United States, 2.8 in the United Kingdom and 4.3 in Germany. Nurses are also hard to find.

Medical schools are notoriously expensive in Japan, and the old saying remains true that “only the children of a doctor can afford to study to be a doctor.” Medical education in Japan should become tuition-free to encourage all individuals regardless of financial status to become doctors, although the government would probably need to allocate a portion of its annual budget to ensure this happens. In order to make this happen, the number of available slots needs to be significantly increased in public and private medical schools.

Japan has fewer doctors at its disposal per capita compared to its peers in the Group of Seven. | REUTERS
Japan has fewer doctors at its disposal per capita compared to its peers in the Group of Seven. | REUTERS

Nurses are similarly in short supply, and the pandemic revealed that as many as 1 million trained health care staff were no longer working in hospitals due to inflexible work rules and family commitments. The regulatory environment for licensed nurses needs to be more flexible so that they can return to flexible work schedules after having children and support the health system.

The pandemic has highlighted systemic weaknesses in the country’s health system that have subsequently led to miscommunication, confusion, inefficiency and a misallocation of resources.

To be better prepared for the next health crisis, Japan needs to address those weaknesses as soon as possible and the Kishida administration should use its honeymoon period to push through these changes.

Edo Naito is a commentator on Japanese politics, law and history. He is a retired international business attorney, and has held board of director and executive positions at several U.S. and Japanese multinational companies.

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