[Special Feature: Post-Corona Healthcare Policy] Ichiro Innami: What is Needed for Post-Corona Healthcare Policy

Nearly three and a half years have passed since the start of the COVID-19 pandemic, and on May 8, the classification of COVID-19 under the Infectious Diseases Control Law was shifted to "Class 5," the same as seasonal influenza. This marks the de facto end of the pandemic. During this period, policies such as border control measures, priority measures to prevent the spread of disease, and the disbursement of subsidies were implemented. Leveraging that experience, the Infectious Diseases Control Law and the Act on Special Measures for Pandemic Influenza and New Infectious Diseases were amended. Furthermore, criticism regarding the response of clinics during the pandemic led to challenges in the system and development of family doctors, resulting in certain legislative changes, such as the creation of a self-reporting system for medical institutions. Additionally, online medical consultations and online medication guidance were partially deregulated. Furthermore, discussions are underway to include infectious disease countermeasures in the 8th Medical Plan formulated by prefectures. In this way, institutional reforms have already been made to a certain extent. In this article, I would like to consider what further measures are necessary.

Medical care is directly linked to the lives and health of the people. The medical provision and insurance systems have been formed over a long history since the Meiji era and continue to the present day. The global pandemic of emerging infectious diseases enabled international comparisons of health and medical provision in various countries based on a unified perspective of infectious disease control. In the process of considering the differences in responses between Japan and other countries, the structural problems of Japan's medical system were reaffirmed.

After the war, infectious disease control was an extremely important issue, and thanks to the public health center system, infectious diseases such as pulmonary tuberculosis were suppressed to a considerable extent. On the other hand, against the backdrop of economic growth, population growth, and aging, the disease structure shifted from infectious diseases to lifestyle-related diseases. Consequently, the number of public health center facilities, staff, and national treasury contributions—the pillars of infectious disease control—have been reduced in recent years. Regarding medical institutions, the number of (public and official) hospitals capable of handling Class 2 infectious diseases like COVID-19 and the number of infectious disease beds were reduced, and the training (medical education and residency) of doctors and nurses capable of handling infectious diseases was also insufficient. From the perspective of medical institutions, there may have been a sense that infectious disease control was the job of public health centers and not within their own domain.

Japan was once a leader in vaccine development, but since the 1970s, the government lost a series of class-action lawsuits over vaccination injuries, leading to a hesitant approach to vaccine policy. Vaccines require subsidies for maintenance once a factory is built. Companies also withdrew from the vaccine business, resulting in a loss of human resources and expertise. There was a large gap compared to the United States, which viewed vaccines as a matter of national security and provided continuous support.

Even before COVID-19, there were outbreaks such as Severe Acute Respiratory Syndrome (SARS) (2002) and Middle East Respiratory Syndrome (MERS) (2012), but serious measures were never taken in Japan. It was in this context that the large-scale COVID-19 pandemic struck.

If public health centers and infectious disease hospitals, which are the cornerstones of infectious disease control, are insufficient, general medical institutions must respond. However, Japan's medical provision system had structural problems that prevented an immediate response.

First, even though the number of doctors and nurses per capita is at an international level, the capacity of hospitals to respond was inherently small because hospital sizes are small and small-to-medium-sized hospitals make up the majority. Additionally, because the number of hospital beds is extremely high, the system was one of "low-density medical care," where care for each inpatient is spread thin. When trying to secure beds for the sudden surge of severely ill COVID-19 patients who require intensive labor, there is a shortage of personnel to maintain other beds. This is the reason why medical care (beds) became strained despite the high total number of beds.

Second, since 80% of Japanese hospitals are private, the national and local governments could request cooperation from hospitals but could not issue direct orders. The number of COVID-19 infections and severely ill patients varied greatly by region; while beds were strained in one prefecture, they were not as strained in an adjacent prefecture. However, attempts to facilitate the flexible exchange of beds and personnel across prefectural borders were hampered by coordination delays. To provide appropriate medical care to patients ranging from mild to severe, dynamic flexibility in beds and personnel between hospitals, between hospitals and welfare facilities, and between prefectures is essential. However, the national and local governments in Japan lacked the strong legal authority to coordinate these.

The role of public health centers, the cornerstone of infectious disease control, will be reviewed. Prefectures will formulate "Prevention Plans," and public health centers will formulate "Health Crisis Response Plans (tentative name)," with functional enhancements centered on budgets and personnel (public health nurses and experts/support collaborators known as IHEAT). In the 8th Medical Plan (FY2024–29) created by prefectures, emerging infectious disease countermeasures will be added as a sixth project in addition to the traditional five diseases and five projects. Regional medical visions aimed at differentiating outpatient functions and differentiating/reducing hospital bed functions will also be considered.

Online medical consultations and medication guidance, which did not function sufficiently before the pandemic, made some progress through special measures for COVID-19. Regarding the over-the-counter sale of antibody test kits in pharmacies, the Council for Promotion of Regulatory Reform achieved this despite opposition from industry groups. Regarding the refusal of fever clinics and the neglect of severely ill patients, discussions on the system and development of family doctors have been held, and enhancements are being sought, albeit insufficiently.

As described above, responses within the medical system have achieved a certain degree of success. On the other hand, more fundamental causes, including problems with the medical system during normal times, have become clear. These are the delay in digital transformation (DX) and the lack of national government involvement. It can be said that both of these arise from a mutual entanglement of excessive decentralization, excessive protection of personal information, and an excessive risk-aversion orientation. To state the conclusion first, for both emerging infectious disease countermeasures and reforms of the medical provision system during normal times, it is necessary to strengthen national involvement, increase the uniformity of operations across prefectures, and reconstruct response capabilities to be suitable for the digital age.

First, the biggest challenge revealed by the pandemic was the delay in DX across Japan as a whole. From tracking the movements of COVID-positive patients to information sharing and collaboration between local governments, public health centers, and hospitals, and even the application procedures for special fixed-sum cash transfers as an emergency economic measure, delays, inefficiency, and inaccuracies due to analog procedures were prominent.

Advanced initiatives are spreading. In Yamaguchi Prefecture, from the beginning of the outbreak (January 2020) until the 4th wave (April–June 2021), situational awareness was conducted by handwriting on large sheets of imitation paper posted on walls, followed by whiteboards and magnet cards, and then by email and FAX. However, by the 7th wave (July–October of the same year), a cloud-based system called YICSS was developed. Under appropriate distribution of authority, public health nurses, doctors, nursing care facility staff, and government officials became able to share information ranging from tracking the number of infected persons (public health centers) to selecting treatment and hospitalization locations, and the transfer of patients to hospitals and recuperation facilities.

However, the COVID-19 crisis is not confined to prefectural borders. Even in Yamaguchi Prefecture, communication with the adjacent Hiroshima Prefecture ultimately relied on telephone and email. If the national government takes the lead in introducing a nationwide common system, rapid and smooth collaboration between adjacent prefectures should become possible.

Regarding the nature of regulations, many problems were pointed out. National personnel placement standards and other rules under the pretext of ensuring medical safety hinder the efficiency of operations themselves through the introduction of nursing care robots, surveillance cameras, and the outsourcing of dispensing. Meanwhile, periodic reporting obligations using paper documents have little meaning. On the other hand, process and outcome evaluations for ensuring the crucial quality of medical care are insufficient.

End-to-end digital medicine, centered on online consultations, electronic prescriptions, online medication guidance, and electronic payments, is expected to promote access to medical care for the busy working generation. However, it has been hindered by the "face-to-face" principle and vested interests, and has not progressed as much as expected.

Regarding medical consultations, there are constraints such as the inability to perform palpation online. However, to improve access to medical care for the busy working generation, further deregulation is necessary. On the other hand, regarding medication guidance, since the system does not allow pharmacists to make diagnoses, there is no need for it to be conducted face-to-face, and online medication guidance should be the rule. However, due to resistance from related organizations, it is only permitted in extremely localized cases.

The "Digital Agency" was established in 2021, and the "Medical DX Promotion Headquarters," headed by the Prime Minister and composed of relevant cabinet ministers, was established within the Cabinet Secretariat in 2023, initiating broad discussions on medical DX. It is expected that reforms will progress by examining fundamental aspects, including the nature of regulations.

Looking at the medical and nursing care fields, many notifications (especially related to pharmacies) created 60 years ago in the mid-1950s and 60s, when there were no PCs, mobile phones, or the internet, still remain today. Notifications are considered "technical advice" from one administrative organ to another, but in reality, they are regulations that bind the private sector.

The notifications issued by the national government themselves are uniform, but the problem lies in their interpretation and operation. In the first decentralization reform of the late 1990s, the authority to interpret laws and regulations was granted to local governments such as prefectures and municipalities. The interpretation and operation of notifications issued by the national government are left to the field, and in some cases, diverse procedures are added or operations differ depending on the person in charge. For example, if the representative of a nursing care provider operating nationwide changes, they must create change notifications in paper format, apply seals, and submit them to over a thousand individual local governments, matching each one's specific format. While local governments should have discretion over policy content, there is no need for uniqueness in procedures or documents.

Since health and medical information is sensitive, personal information protection tends to become excessive in an attempt to zero out the risk of information leakage. When combined with the unique legal interpretations of local governments, documents and procedures become complex and "Galapagosized." The personal information protection systems previously established by each local public entity have been abolished, and the amended Next-Generation Medical Infrastructure Act currently under discussion is expected to bring improvements to the primary and secondary use of medical information. This should be closely monitored.

Since medical care has a high degree of regionality, medical plans formulated by prefectures are the main approach. Through legislative amendments, prefectural governors can now enter into agreements with individual medical institutions within their jurisdiction during normal times. During an infectious disease outbreak, they can issue recommendations and instructions regarding medical provision and announce violations of instructions, but they do not have the authority to issue orders. The format of the agreements should be unified by the national government to ensure that regionality or individuality is not exercised in individual agreements.

In the first place, COVID-19 was not a crisis for prefectures, but a crisis for the nation. The degree of medical strain also varied from prefecture to prefecture. While the amended law includes mechanisms for the flexible exchange of personnel across prefectural borders, there are no provisions for the flexible exchange of beds. The procedures for wide-area personnel exchange are also cumbersome. In times of crisis, the national government should be able to immediately issue orders to non-strained prefectures for personnel dispatch and bed exchange, rather than just "requests for support."

The fundamental reason why rapid policy formation does not occur in times of crisis is likely that the Constitution lacks emergency clauses, making it difficult to restrict local autonomy and private rights. However, in addition to emerging infectious diseases, there are also large-scale disasters and security issues. Saving lives is the primary function of the state. Whether in emergency responses or in medical system reforms during normal times, national involvement should be further strengthened before the heat of the COVID-19 pandemic cools down.