Why Japan Has Made Worldwide Access to Healthcare Coverage a Critical Element of Its Foreign Policy

Posted on by Laurie Garrett

From Thanksgiving to December 7, I was in Japan, a guest of the Ministry of Foreign Affairs, marking my third visit to the country in 2013. The chief reason for multiple treks to Tokyo, and elsewhere in Japan, is Prime Minister Abe’s staunch support of universal health coverage (UHC) as the primary post-2015 aspirational target for global health. As Abe explained in the Lancet in September, “Global health is standing at a crossroads,” between more than a decade of powerful disease-specific achievements, and the dawn of a far broader, all-health approach, worldwide. Earlier this year, Abe launched his strategy on global health diplomacy, naming worldwide creation of UHC its primary feature.

Abe’s UHC gambit is part of an overall, marked shift in Japanese foreign policy that is at once far to the right of the country’s position eighteen months ago, under Prime Minister Yoshihiko Noda, and significantly more engaged in world affairs.

(Courtesy Reuters/Kim Kyung Hoon)

(Courtesy Reuters/Kim Kyung Hoon)

As 2011 opened, Yoshihiko Noda was the new prime minister of Japan, and the first from the left-leaning Democratic Party of Japan (DPJ). Japan has been in economic difficulties, and now stagnation, since the late 1990s, and prior to the DPJ’s swing to power, the long-dominant Liberal Democratic Party (LDP) shuffled through leaders faster than the official portraits of prime ministers could get swapped out of the nation’s post offices. Noda’s election signaled a radical shift in popular opinion, as Japanese wearied of LDP power struggles and incompetence. And Noda ushered an era focused on cutting government spending, fixing a long list of domestic problems, and pulling back from the world diplomatic stage. The budget for the Ministry of Foreign Affairs was cut, and years of often nasty relations with South Korean and China – based on tensions dating to World War II – seemed to simmer down.

On March 11, 2011, Japan was struck by a Richter scale 9.0 earthquake, followed by a massive tsunami that, among other things, shattered the Daichi nuclear power plant in Fukushima prefect, north of Tokyo. The Noda government started falling apart even as the earthquake wrenched building foundations, and within months, the LDP had maneuvered its way back into power.

Shinzo Abe won the Diet’s vote, and took over the prime minister’s office in early 2012. He immediately announced his government’s “three pillars” of economics, setting in motion a sort of Asian version of Obama’s quantitative easing policies. Stock markets around the world generally applauded. And in January 2013, Abe’s minister of foreign affairs Fumio Kishida announced his three pillars of foreign policy: “The first of the three main pillars is the ‘Strengthening of Measures Against International Terrorism.’ The second is ‘Support for the Stabilization of Sahel, North Africa, and Middle East Regions.’ The third is the ‘Promotion of Dialogue and Exchange with Islamic and Arab countries.’”

(Courtesy Reuters/Cheryl Ravelo)

(Courtesy Reuters/Cheryl Ravelo)

Over dinner in September, Minister Kishida told me the three pillars had shifted to a broader focus since the crisis in Mali in January 2013. First, foreign policy aimed at strengthening Japan’s economic and trade positions in the world. Second: reappraisal of Japan’s relations with its Asian neighbors, especially China and South Korea. And finally, the Abe government wishes to reinvigorate its Ministry of Foreign Affairs overall, engaging far more significantly in United Nations and multilateral diplomacy and foreign assistance. The crucial element of that third foreign policy pillar is promotion of UHC, and diplomacy aimed at making universal health the target for the Sustainable Development Goals (SDGs) that will replace the MDGs in 2016 as the world’s targets for achievement by 2025.

The Kishida stratagem is a mixed bag for global health advocates. Tensions in Asia have risen sharply over the last year, with Abe’s nationalistic brand of Japanese patriotism coming to diplomatic blows with President Park Geun-hye’s equally nationalistic South Korean views, both sides conjuring memories of World War II. And political tensions with Beijing have soared, now featuring saber-rattling over China’s declaration of a strategic air space that includes portions of the East China Sea and islands that Japan considers part of its national territory.

Not coincidentally, the Japanese Diet just passed a tough new state secrets bill, debate over which had protestors marching in the streets when I was in Tokyo. Citizens’ civil liberties groups and scientists argued the bill would paralyze free speech and publication. Spawned in party by Edward Snowden’s leaks of U.S. National Security Administration documents, the Japanese bill would impose severe prison sentences on journalists or anybody else who leaks government information, including, perhaps, regarding the Daichi nuclear power plant radiation leaks. The opposition DPJ members of the Diet came to near fisticuffs with LDP leaders after top LDP official Shigeru Ishiba, wrote on his blog that protests against the state secrets bill were, “not so different from an act of terrorism.”

(Photograph by Kimimasa Mayama/EPA via the   Guardian  )

(Photograph by Kimimasa Mayama/EPA via the Guardian)

A group of thirty top scholars and Nobel laureates in Japan denounced the bill, saying it, “threatens the pacifist principles and fundamental human rights established by the constitution and should be rejected immediately…Even in difficult times, protecting the freedom of the press, of thought and expression and of academic research is indispensable.”

It is not in the interests of global health advocates to get dragged into this three-way enmity, or be perceived as favoring Seoul, Tokyo, or Beijing.

On the other hand, Abe’s and Kishida’s pillars offer real opportunity for health and development practitioners and leaders of developing countries. There is a lot on the line for Japan. The Japan International Cooperation Agency (JICA) – which is roughly equivalent to the U.S. Agency for International Development – is making UHC a central component of its activities. Vice President Joe Biden was in Japan last week as part of a tour of Tokyo, Seoul, and Beijing, aimed at calming tensions surrounding China’s air space claims. Biden and Abe hammered out a joint statement on trade and foreign policy that originally included strong support for UHC. At the last minute, Ministry of Foreign Affairs sources told me, Biden ordered the UHC paragraph removed, and Abe’s anxious staff literally chased the Americans down a red carpet to the vice president’s jet, begging for re-inclusion of lines. They were not successful.

I doubt explanation for Biden’s action is necessary for American readers, but for the sake of the global audience it is worth recalling that the Affordable Care Act, sometimes called “Obamacare” has proven deeply divisive in the U.S. On the right, Republicans are nearly universally opposed to the Act, and from the left many Democrats feel its health provisions are inadequate – they favor far more expansive coverage. Before passage of the ACA nearly fifty million Americans were without health insurance of any kind, and millions more had some form of insurance that provided so little coverage that severe medical problems often proved bankrupting to the individuals. Even if the ACA survives the seemingly endless attacks from the right, and manages to fix its many roll-out flaws to improve the rate of sign-on by U.S. citizens, it will still leave some twenty million Americans without insurance. This domestic crisis put Biden in an awkward position in Tokyo vis-à-vis universal health coverage.

In addition, the U.S. government has no federal law or Constitution statement stipulating that its citizens have a “right to healthcare.” In contrast, the 1946 Constitution of the World Health Organization states that “the right to the highest attainable standard of health” and the United Nations has enshrined health as a “right.” The majority of the nations of the world, including nearly all the democracies, designate healthcare as a citizen’s “right."

(Figure by  Hiroaki Matsuura , July 2013)

(Figure by Hiroaki Matsuura, July 2013)

The United States is the only OECD nation that does not have federal or Constitutional language granting healthcare to its populace as a right of citizenship, either as an aspirational goal for the state, or a stipulated mandate or entitlement. Moreover, there is considerable opposition inside the country to framing health as a “right” or even a government service. As John Mackey, CEO of the Whole Foods company, wrote in the Wall Street Journal, “Health care is a service that we all need, but just like food and shelter it is best provided through voluntary and mutually beneficial market exchanges. A careful reading of both the Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter. That's because there isn't any. This ‘right’ has never existed in America.”

Two days after the Biden confab, Abe met with World Bank President Jim Kim, who was in Tokyo for a joint Bank/Japan summit on UHC. Abe vowed to Kim that he will raise the topic of UHC in every official foreign visit he makes for the duration of his reign as prime minister, according to officials present at the meeting.

On December 6, 2013, at the summit co-hosted by the World Bank and Japan on UHC, Deputy Prime Minister Taro Aso told an audience that included the World Health Organization’s director-general Margaret Chan, the Bank’s Kim, and several ministers of health, that Japan, “has an obligation to promote global health cooperation on health,” because of its own history with universal healthcare. After World War II, with its economy and most major cities in shambles, Japan’s male life expectancy was merely sixty years, and female was sixty-three. In 1958 the government made a calculus for its post-war recovery: Getting Japan back on its feet as a nation would require a healthy, productive labor force. Aso told the gathering that it was perceived as a matter of self-interest, even the survival of the nation, to pass the 1958 Universal Insurance Act.

By 1961, despite having a per capita GDP of only $4,000, Japan achieved universal health coverage for all its citizens – proof, powerful LDP political leader Keizo Takemi told the summit, that “health does not come after economic development, health promotes economic development.” Or, as Aso put it, “Investing in people is key to decreasing poverty and increasing economic growth.”

Today Japan is a victim of its own UHC success, with male life expectancy topping eighty years, and females at eighty-six: the longest in the world. In my travels the challenge for Tokyo is obvious, as small towns and villages across the country are overwhelmingly populated by the elderly, many of them highly dependent on social and medical services. More than 30 percent of Japan’s health expenditures go to medical treatments delivered in the last year of individuals’ lives – most of them, for the final weeks. A top official from the prime minister’s office told me the demographic shift in aging Japan, coupled with this disproportionate share of health expenditure in the final moments of life, is absolutely unsustainable. The economy can’t handle it, and politically this trend, if unchecked, will topple future governments.

Japanese health authorities are focusing on the gap between years lived, and the numbers of healthy years lived, free of debilitating, crippling, or dementing illness. That gap in 2013 for men is 9.13 years; for women it is 12.68 years. In other words, a Japanese female born in 2013 may expect to live an average of eight-six years, but only 73.32 of those years will find her fully mobile, free of constant pain, lucid and in command of her faculties and without dependency day-to-day on health or social services.

So for Japan the diplomatic stakes behind its UHC play are mirrored by domestic exigencies that are becoming more urgent every year.

In early December 2013 the G8 (including Japan and the United States) adopted a target urged by the United Kingdom of doubling research and development funding, and finding “a cure for dementia” by 2025. The ambitious eight-point G8 plan predicts that by 2030, if no radical steps are taken now, some 66 million people will be living with dementia. Already dementia, alone, costs one percent of annual GDP in the United Kingdom. UK Prime Minister David Cameron said in a press conference that, “discovering a cure or treatment for dementia is 'within our grasp,’” by 2025, or in twelve years’ time.

I’m a bit stumped by this. Such a set of targets implies that within twelve years the following will transpire:

  1. All the various forms of dementia and their causes will be discovered by scientists, and characterized sufficiently to provide pharmaceutical companies with genuine targets for treatment.
  2. “Cure” implies reversing actual neuron deterioration, plaque formation, and stroke-caused asphyxiation damage, and other physical causes of dementia. Theoretically this would mean within a mere twelve years having stem cell technology or other interventions that could actually destroy damaged neurons and replace them with healthy ones, inside the brains of living people.
  3. Drug companies would figure out affordable and ethical means for conducting massive clinical trials and garnering FDA approval.
  4. And patent squabbles between the BRICS and developed nations would be sufficiently resolved to allow worldwide access to said interventions at a price tag still profitable to the innovating companies.

While the G8 dementia target set may seem wildly unrealistic, The World Bank argues that countries can reasonably attain UHC by 2040, in measurable steps. At the Tokyo summit the Bank’s top global health official, Tim Evans, unveiled the Bank’s scheme for monitoring UHC progress. The scheme divides health into two broad categories: Infectious plus current MDG goals; and non-communicable ailments, injuries and mental health. Each of these two broad categories is tackled with a long list of prevention strategies, and a separate list of treatments and care. For example, one prevention target for maternal mortality is listed as family planning; the treatment strategy is “delivery.” The Bank’s scheme bears careful scrutiny by all global health advocates. 

(Figure from Joint WHO / World Bank Group  Discussion Paper , December 2013)

(Figure from Joint WHO / World Bank Group Discussion Paper, December 2013)

Evans tells me a massive version of the monitoring scheme will soon be posted on the Bank’s website, allowing specialists to scrutinize each measurement parameter, from universal access for anti-HIV drugs to institutional care for Alzheimer’s sufferers.

But who will pay for all of this? A growing chorus of major multilateral institutions, including the “silos” such as the Global Fund and GAVI, are committing their funds and expertise to health systems development and the broader goals of UHC. Japan may be in the leadership of this fight, but it is hardly alone. As Global Fund chief strategist Osamu Kunii put it at the summit, the Global Fund, “needs to use its money for catalytic purposes,” creating “better alignment between disease fights and country health plans and financing.” Nearly a third of Global Fund grants now support health systems development, Osamu said.

Like many of his fellow Japanese, Osamu is proud that the Global Fund’s creation was spawned from the Okinawa gathering of the G8 in 2000. The G8 adopted targets for elimination of HIV, malaria, tuberculosis and other infectious diseases, which were drafted by the government of Prime Minister Yoshiro Mori. Those targets, crafted by Tokyo bureaucrats, became the MDGs, and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

It remains to be seen whether Prime Minister Shinzo Abe can successfully emulate such an ambitious scale of global health achievement as he promotes UHC. But foreign policy and health diplomacy followers had better pay attention: Japan means business.