Health Care and Social Welfare
While most postwar Japanese relied on personal savings and the support of family, both the government and private companies have long provided assistance for the ill or otherwise disabled and for the old. Beginning in the 1920s, the government enacted a series of welfare programs, based mainly on European models, to provide medical care and financial support. Government expenditures for all forms of social welfare increased from 6 percent of national income in the early 1970s to 18 percent in 1989. The mixtures of public and private funding have created complex pension and insurance systems.
A person who becomes ill in Japan has a number of options. One may visit a Buddhist temple or Shinto shrine, or send a family member in his or her place. There are numerous folk remedies, including hot springs baths and chemical and herbal over-the- counter medications. A person may seek the assistance of traditional healers, such as herbalists, masseurs, and acupuncturists. However, Western biomedicine dominated Japanese medical care in the postwar period.
Public health services, including free screening examinations for particular diseases, prenatal care, and infectious disease control, are provided by national and local governments. Payment for personal medical services is offered through a universal medical insurance system that provides relative equality of access, with fees set by a government committee. People without insurance through employers can participate in a national health insurance program administered by local governments. Since 1973, all elderly persons have been covered by government-sponsored insurance. Patients are free to select physicians or facilities of their choice.
In the early 1990s, there were more than 1,000 mental hospitals, 8,700 general hospitals, and 1,000 comprehensive hospitals with a total capacity of 1.5 million beds. Hospitals provided both out-patient and in-patient care. In addition, 79,000 clinics offered primarily out-patient services, and there were 48,000 dental clinics. Most physicians and hospitals sold medicine directly to patients, but there were 36,000 pharmacies where patients could purchase synthetic or herbal medication.
National health expenditures rose from about ¥1 trillion in 1965 to nearly ¥20 trillion in 1989, or from slightly more than 5 percent to more than 6 percent of Japan's national income. In addition to cost-control problems, the system was troubled with excessive paperwork, long waits to see physicians, assembly-line care for out-patients (because few facilities made appointments), overmedication, and abuse of the system because of low out-of-pocket costs to patients. Another problem is an uneven distribution of health personnel, with cities favored over rural areas.
In the late 1980s, government and professional circles were considering changing the system so that primary, secondary, and tertiary levels of care would be clearly distinguished within each geographical region. Further, facilities would be designated by level of care and referrals would be required to obtain more complex care. Policy makers and administrators also recognized the need to unify the various insurance systems and to control costs.
In the early 1990s, there were nearly 191,400 physicians, 66,800 dentists, and 333,000 nurses, plus more than 200,000 people licensed to practiced massage, acupuncture, moxibustion, and other East Asian therapeutic methods. Since around 1900, Chinese-style herbalists have been required to be licensed medical doctors. Training was professionalized and, except for East Asian healers, was based on a biomedical model of disease. However, the practice of biomedicine was influenced as well by Japanese social organization and cultural expectations concerning education, the organization of the workplace, and social relations of status and dependency, decision-making styles, and ideas about the human body, causes of illness, gender, individualism, and privacy. Anthropologist Emiko Ohnuki-Tierney notes that "daily hygienic behavior and its underlying concepts, which are perceived and expressed in terms of biomedical germ theory, in fact are directly tied to the basic Japanese symbolic structure."
Although the number of cases remained small by international standards, public health officials were concerned in the late 1980s about the worldwide epidemic of acquired immune deficiency syndrome (AIDS). The first confirmed case of AIDS in Japan was reported in 1985. By 1991 there were 553 reported cases, and by April 1992 the number had risen to 2,077. While frightened by the deadliness of the disease yet sympathetic to the plight of hemophiliac AIDS patients, most Japanese are unconcerned with contracting AIDS themselves. Various levels of government responded to the introduction of AIDS into the heterosexual population by establishing government committees, mandating AIDS education, and advising testing for the general public without targeting special groups. A fund, underwritten by pharmaceutical companies that distributed imported blood products, was established in 1988 to provide financial compensation for AIDS patients.
The futures of Japan's health and welfare systems are being shaped by the rapid aging of the population. Medical insurance, health care for the elderly, and public health expenses constituted about 60 percent of social welfare and social security costs in 1975, while government pensions accounted for 20 percent. By the early 1980s, pensions accounted for nearly 50 percent of social welfare and social security expenditures because people were living longer after retirement. A fourfold increase in workers' individual contributions was projected by the twenty-first century.
A major revision in the public pension system in 1986 unified several former plans into the single Employee Pension Insurance Plan. In addition to merging the former plans, the 1986 reform attempted to reduce benefits to hold down increases in worker contribution rates. It also established the right of women who did not work outside the home to pension benefits of their own, not only as a dependent of a worker. Everyone aged between twenty and sixty was a compulsory member of this Employee Pension Insurance Plan.
Despite complaints that these pensions amounted to little more than "spending money," an increasing number of people planning for their retirement counted on them as an important source of income. Benefits increased so that the basic monthly pension was about US$420 in 1987, with future payments adjusted to the consumer price index. Forty percent of elderly households in 1985 depended on various types of annuities and pensions as their only sources of income.
Some people are also eligible for corporate retirement allowances. About 90 percent of firms with thirty or more employees gave retirement allowances in the late 1980s, frequently as lump sum payments but increasingly in the form of annuities.
Japan also has public assistance programs benefiting about 1 percent of the population. About 33 percent of recipients are elderly people, 45 percent were households with sick or disabled members, and 14 percent are fatherless families, and 8 percent are in other categories.
Japanese often claim to outsiders that their society is homogeneous. By world standards, the Japanese enjoy a high standard of living, and nearly 90 percent of the population consider themselves part of the middle class. Most people express satisfaction with their lives and take great pride in being Japanese and in their country's status as an economic power on a par with the United States and Western Europe. In folk crafts and in right-wing politics, in the new religions and in international management, the Japanese have turned to their past to interpret the present. In doing so, however, they may be reconstructing history as a common set of beliefs and practices that make the country look more homogeneous than it really is.
In a society that values outward conformity, individuals may appear to take a back seat to the needs of the group. Yet it is individuals who create for themselves a variety of life-styles. They are constrained in their choices by age, gender, life experiences, and other factors, but they draw from a rich cultural repertoire of past and present through which the wider social world of families, neighborhoods, and institutions gives meaning to their lives. As Japan set out to internationalize itself in the 1990s, the identification of inherent Japanese qualities took on new significance, and the ideology of homogeneity sometimes masked individual decisions and life-styles of postindustrial Japan.
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