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52
Hiroi Y.
Evaluations of health policy and social protection in Japan
Introduction. Japan has taken the path of extremely rapid industrialization since the late 19th century when the country was still one of Asia’s underdeveloped capitalist states. Japan in those days could be defined as a developing country compared with the industrialized nations of the West, which were model countries for Japan that was at the time making efforts to develop its economy in line with government-guided policies designed to catch up with industrialized nations.
This situation can be characterized by the fact that various influences from Western countries are visible in the design of Japan’s current social security systems, that those engaged in the primary sector had accounted for a large portion of the nation’s population for a long time, and that changes in the employment structure, the advancement of urbanization, as well as the decline in the birthrate have progressed at a very rapid rate. Therefore, Japan’s experience, being very different from that of Western nations, presents unique implications in the context of the design of social security systems, and, regardless of whether it is negative or positive it offers interesting examples useful for studying the themes like the development of social security in transitional economies, as well as social security in developing countries.
In addition, it is necessary to review Japan’s experience from the viewpoint of its rapidly aging population, which has emerged as a result of drastic socioeconomic changes that many developing countries go through, as represented by the sharp decline in the birthrate in the post war era (especially from 1945 - 1954). The problems of an aging population can be already observed in many Asian countries (e.g. China), and are expected to be also experienced in the future by other countries in Asia. Therefore, Japan’s experience also offers unique perspectives concerning measures to deal with a rapidly aging population.
This article aims at evaluating Japan’s experience in social security with reference to its socioeconomic evolutions, placing it in the context of Asian welfare states and explores the future possibility of «Eurasian welfare research network».
1. Basic elements for understanding the development of social security systems in developing countries.
1.1 Economic development and social security - Externalization and socialization of the functioning of families and communities. Generally speaking, as a country goes through the economic development process and builds up its economic systems, its social security system improves along with the transformation of its industrial and employment structures, level of urbanization, family types, disease structure, and population composition in order to secure the livelihood of individuals and households, as well as to achieve a stable income redistribution.
Substantially, following on economic development, any social security system evolves as a public system to supplement (or re-socialize) a weakened «mutual assistance», that has been functioning within individual households or within (rural) communities in an informal fashion.
For example, the pension system originated as an economic mutual assistance system for the elderly practiced particularly by large families (such as three-generation households) in traditional communities. Such mutual assistance systems then became «externalized» to become a public system along with the advancement of industrialization and urbanization, which has resulted in an increase in nuclear family households. In other words, the pension system took over the responsibility of individual families for providing economic assistance to the elderly and institutionalized this responsibility as a social security system. Not only the pension system, but also most other social security systems developed in accordance with the
industrialization, such as health insurance, unemployment benefits and other social welfare services that are designed to support «nuclear family households» defined as «fragile communities», which have emerged outside the traditional types of families and communities in particular areas along with the advancement of urbanization.
The development of the social security systems mentioned above is peculiar to a society in the transitional stage from a pre-industrialized society (or traditional society) to an industrialized society. On the other hand, as a result of its more advanced economic development and maturation, long-term care issues, such as the provision of physical assistance to the elderly, emerge to become the forefront of new challenges along with the increase in life expectancy. In addition, it becomes more critical to support child-raising in a society where nuclear families move towards «individualization», partly due to the increased participation of women in society. This is the stage of a society called «a mature and aging society».
From the viewpoint of the externalization and re-socialization of the functioning of traditional families and communities, the relationship between economic development and social security systems can be explained based on the following three-stage concept (figure 1.1):
A. Pre-industrialized society: mutual assistance within traditional families and communities.
B. Industrialized society: trend towards nuclear families.
C. Mature and aging society: individualization of nuclear family members.
The category «B. Industrialized society» can be further classified into two stages of society - «early industrialized society» and «late industrialized society». As explained above, social security systems are established to supplement the mutual assistance mechanism functioning within traditional farming communities. In an early industrialized society, social security systems are developed to ensure livelihoods for urban workers (employed workers) and their families, the number of which increases along with the advancement of the industrialization and urbanization.
When entering the stage of the late industrialized society, social security systems are required to cover not only employed workers, but also farmers and self-employed workers, in order to make up for the functional decline in the mutual assistance systems of traditional communities. Nonetheless, a certain level of mutual assistance is generally more available to farmers and self-employed workers than to employed workers. As a result, even in developed countries, farmers and self-employed workers are often entitled to limited social benefits, or are not mandated to participate in social security programs. Therefore, it largely depends on the philosophy of each country, as well as its actual status, as to how much consistency can be assured between the social security system for employed workers and that for farmers and self-employed workers. However, it may be said that social security systems generally develop through two stages: the first stage in which employed workers are covered by the system; and the second stage in which the scope of the system extends to all nationals, including farmers and self-employed workers.
In actuality, many Asian countries often encounter difficulties in expanding the coverage of the social security systems that they have already introduced for employed workers to include those working in informal sector businesses, which account for the majority of their populations. (This trend can be observed especially in countries in Group 2). As discussed later in Chapter 2 in reference to the evaluation of Japan’s experience, Japan started to extend the coverage of social benefits not only to employed workers, but also to all people (including farmers and self-employed workers) in a relatively early stage of its economic development. This is one of the characteristics of Japan’s social security
development process. For example, Japan’s National Health Insurance system (Kokuho), managed in the form of a community health insurance, is quite a unique system1.
The coverage of those working in informal sector businesses, such as farmers and the self-employed, is one of the central issues to be discussed for the development of social security system in Asian countries.
1.2. Health care - the concept of the «Health Transition». For the analysis of health care systems, changes in the disease structure are also significant, together with changes in the family structure and employment structure, as mentioned above. In addition, there is another perspective to be referred on this matter - that of the «health transition»2.
The «health transition» is a new concept that has recently been advocated in the fields of public health and international health. This concept is used to comprehensively and dynamically assess in an integrated manner changes in both the disease structure and in social and economic systems, including the population structure, employment structure and industrial structure3. There are basically three health transition stages, as follows.
The first health transition stage refers to a period during which a society is mainly fighting infectious diseases (after having solved problems of starvation and epidemics). In the second health transition stage, leading components of the disease structure shift from infectious diseases to chronic diseases. It is believed that Japan entered the second health transition stage around 1951 when strokes became the leading cause of death instead of tuberculosis, or around 1960, when strokes, cancer and heart disease were ranked in this order as the three main causes of death, each of which has since remained until today4. In the third health transition stage, the emphasis is placed on measures against degenerative diseases of the elderly rather than chronic diseases. In this stage, the medical costs for people aged 65 or older account for a substantial proportion of a society’s total medical costs. Consequently, elderly care issues come to the fore and prompt the society to integrate its health care system and welfare system.
The concept of the health transition calls for a society to develop proper health care systems (in terms of finance and delivery) according to the disease structure at each stage.
In the first health transition stage, people’s health is more affected by factors beyond the control of the individual, such as the infectious agents themselves or the urban environment. Therefore, the society is actively engaged in the improvement of public health by taking such measures as immunization programs and sanitation upgrading projects, which means that such a society is developing «public goods» in the context of economics.
In the second health transition stage, in which chronic diseases are central to the disease structure, improvements in public health are not the mainstream of health care policies since chronic diseases are life style-related diseases that are the concern of individuals rather than being of public concern. In such a society, an insurance system - under which people pay premiums in preparation for the event of an illness - becomes an important option to be introduced in its health care policies. It is in this stage that many countries actually developed their (mandatory social) health insurance systems. As for the delivery of medical services,
1 In the course of the research, the author noticed that policy-making officers and researchers in Asian countries, such as Thailand, China and Laos, were most interested in Japan’s “Kokuho” system among its social security systems.
References: Reports by Hiroi (1999); Jenkins (1993), Ginneken (1999) and Beattie (2000) with regard to the issue of the extension of social security systems to those engaged in informal sector businesses.
2 Aside from studies independently dealing with the themes of social security and welfare states, there have been various research and practices conducted in the field of so-called international health, including those by WHO and other international medical cooperation organizations regarding health care systems in developing countries, including those in the Asian region. See Cleland and Hill (1991), Chen, et al. (eds) (1994), Berman (ed) (1995), etc.
3 For details, see Hasegawa (1993).
4 This three top-ranking diseases at present are shifted as follows: 1. Cancer, 2. Strokes, 3. Heart Disease.
hospitals are the major actors (instead of clinics and general practitioners). In short, a society in the second health transition stage generally focuses on the development of health care systems and medical facilities5.
In the third health transition stage, elderly care issues become more important. The care of the elderly involves not only the aspect of medical treatment in the narrow sense, but also improvement of the quality of life (QOL) for elderly people, which is realized through longterm care for the elderly as well as participation of the elderly in society in the broader spheres of life. Thus there needs to be perspectives on both a «health care model» and a «QOL model» in establishing a health care system in this stage. In a functional sense, the essential points are as follows: (a) Health care system focuses on social services rather than medical care for the elderly. (b) Elderly care services under a system like that are provided at home (or in communities) rather than in institutions. In the third health transition stage it is crucial to produce a system that integrates health care and welfare, as well as services in facilities and services at home (or in communities).
So far, certain aspects for the development of health care and welfare systems have been discussed based on the concept of the health transition, since some services provided under such systems are required to be reviewed from a different angle to that of the analysis of changes in the industrial structure and family structure in the context of the formulation of income security systems, including a pension system.
Table l -1 Economic development/health transition and social security systems
Ht'dllll lISTEl-llai 4 ago/LealliigcaipDCKiih ol llie Лчмке drudiire Hull h care and welfere sjslian PenHai (Income seajllj!) splem Industrial slriK luro.1 Family ЧпиИтсн PcpilaLbnslruc-lure
Finance KINor- ^plem lobe developed EjlK'TCdlld
SUgel Infectious diseases Public heath IrrpnVSfTlEnl pdldK (ErtmcmHttf рШ1ггрЯ5| F'riincirji care sa dres1 1 -| H'IN'III d public rrallh caier; Uniit- mutual Ejtlarnsy-i terns wllliti femllles and пхшть miles A. Pre-lndiEtraUsd Hilely
stage ’ Cfrant disuses . HeainiHEinsu anrssjstein (E*|HTlOT[4 апегд^Ггяп employed worker! lofamH-i iimI sell- employed wh*-■4 ИкрйБрйу Imperial rites' 1 T'.'41 Hlh lll Cl rTRdtalsa'-«tesrri medial radlllles 1-И1МГ- mrthe Emptied worker; Emergence *1 urtHmwrtoers П1К1 III' в. ипиып.пим society Qrl/slagE Lale stage
EspiEkxiDf ro«ragelo raimersand sell einplffjieJ WCTtfefS liideaselnUielr iimnljer; ■ DIsaaLtbritf mbBl^ls-Laiice-s/slews III CGiniTlMMPJiirl--
Tlv- si-'-jhI ok if lly ijslieiii 1st gtflng 'Qrporalfcra aikl Nudear Гатк-
SUgei diseases lllli'J.l(. i| III-Mill and ш№:^-teinfa llteldei iy Shll Idd^fS-i.'iii iii'iili4 twikrrd; ii'.tH Г гге and (птЕив REtniduIng .iikI шедшем tftheheallh tars and wS-fare tjslarrs InCieffiElnlTE ekledy poprln-dm; МшпснпиТй ШПИ1 r-parlJd- padooln society InCTeSE In empkajmEnl ITKOIty С. мпшгел'р] .kiipi society
I- -v.;/ il тжй s&:nrl.ji sptem i ii-yiivi li>:lr.-Kln.J-.' Il>- null
Prepared by 11 ini
In a general sense, the three-stage health transition is a concept that is independent of the three-stage development of the society (Pre-Industrialized Society/Industrialized Society/Mature and Aging Society) already mentioned in relation to the externalization and re-socialization of the functioning of families and communities. However, there is a certain relationship between the two concepts. For example, the aging of the population follows economic development that leads to an increase in life expectancy. Besides, changes in the disease structure are related to the progress of economic systems, as seen in the shift of
5 Japan developed its health care systems and medical facilities mainly in the high growth period from 1955 to 1974.
primary social health concerns from infectious diseases to chronic diseases owing to improvements in sanitary conditions brought about by economic development. Table 1.1 briefly summarizes the relationship between the two concepts at each stage. On the left side, the figure indicates the relationship between changes in the disease structure and the corresponding health care (or welfare) systems to be developed, and the right side indicates the relationship between changes in the industrial/family structure and pensions and other income security systems. This conceptual framework presents an outlook on the relationship between economic development and social security systems.
2. Japan’s experience concerning the development of its social security system
2.1. Significance of the evaluation of Japan’s experience. The former part has outlined social security in Asian countries. In conducting research on such a theme, or in carrying out international cooperation in the field of social security, it is significant for us to evaluate Japan’s own experience as a crucial process.
In fact, this factor has been the one most lacking in Japan’s research and practices in the field of social security. This is partly due to the fact that Japan’s research and policy implementation regarding social security has long been focusing on learning and introducing the systems adopted by the leading countries on this issue (such as the European countries and the US). This has discouraged Japan from promoting interactive communications with other foreign countries, including the Asian region, through transmission of the results of the evaluation of Japan’s experience in the development of its social security systems, as well as from clarifying the characteristics and problems of Japan’s social security system in the context of a comparison with the systems of the same kind in Asian and other developing countries.
2.2. Characteristics and evaluation of Japan’s experience concerning the development of its social security system6. This section gives a detailed explanation and evaluation of Japan’s experience concerning the development of its social security system.
The following are the summarized characteristics of Japan’s social security framework:
(a) Japan’s social security system initially started as a social insurance system based on the German model, and then gradually introduced the elements of (British) universalism.
(b) The government actively included people in the informal sector (farmers, fishers, foresters/self-employed workers) in the social security system when the population of such people was still relatively large. (Uniqueness of the National Health Insurance (NHI) (Kokuho) system).
(c) Some of the social insurance systems have been managed by the government as an insurer. (State-controlled health insurance systems/ National Pension Plan, Employees’ Pension Plan).
(d) Health insurance systems were developed first, followed by the rapid advancement of pension systems.
(1) Trend towards universal coverage and universalism. Firstly, the point that I would like to raise here is (a) above; that Japan’s social security system initially started as a social insurance system based on the German model, and then gradually introduced the elements of universalism. A social insurance system based on the German model can be defined as a social insurance system (especially pension system) designed to deliver benefits to employees according to their earnings, the primary revenues for which come from premiums collected from these employees. This model of social security system is basically instituted for employed workers. Under the German model of such a system, non-employed workers (such as those engaged in agriculture, forestry and fishery, as well as self-employed workers) receive relatively few benefits compared to employed workers. Besides, some systems
classified under the German model do not require mandatory participation for non-employed workers. In Germany, it is voluntary for certain strata of the population, for example selfemployed workers and high-income earners, to participate in its public health insurance system. In addition, some people, such as the non-employed spouses of employees, are not allowed to participate in the nation’s pension scheme.
On the other hand, a universal model social security system - although there are several variations - is generally characterized by the principle of providing all people with equal benefits through tax revenues. Under such a system, there is no substantial difference between employed workers and non-employed workers. Table 2.1 below categorizes three basic models regarding social security systems, including the market-oriented model, which is different from both of the above two models. This categorization is related to the discussions later on7.
Tabl <? 2 -1 Models of social security/welfa re states
Models CharKtefiaic CoiilNm and regions Bask principles
i'„ UnlttrciJ-model ■ OaiEllJef*]E tHlSTE ■Urtwrcai coverage - I-HiUiiiH пишГ- If. I.l-: гегеткЕ ScmdraiUi DaunlilH UK -Iml iin -■.-iili ii -.v- i-:l Uk nnxH u 'Pudlt asslstnoe' (Publicist-;)
B. Social hsuranoe modd - r-'i>-iih- - ||-:1м1| In p;r-iiieito - Г-Тэ 111N сочат employees - l-Hiiil,iiiKlnniir- b ураШгте Gffmanjr, Franca, ett. l-l 1111 I 'd EElSlaxe (Rec£-roal H ip i-x^-mIhii wtdhrammunlUeS)
C. 1.1-ilM HI- llh-1 modd - Мгймимм pul№ esIsUte ■PrtwlE ГвигаикЕ^Иетз ptT- die Isdhg rale - 1 ■■•|h'l'pl ЛИ -.'I Гр'|-.||||| idun-leer апЫзю USA "^Jeif-rrSEJSl^lOe"
I lir>4
As one of the overall characteristics of Japan’s social security system, it was pointed out that Japan’s social security system initially started as a social insurance system based on the German model, and then gradually introduced the elements of (British) universalism. This transition process can be better explained by dividing it into two stages. The first stage is marked by the implementation of the «universal insurance» framework in 1961.The substantial basis of Japan’s universal insurance framework was formed during WWII and then nurtured in the turbulent period immediately afterwards. As already mentioned, a «social insurance system» is not equivalent to a «universal insurance system». Germany, a country with the world’s oldest social insurance system, does not have any universal coverage schemes. (For example, in Germany, it is voluntary for high-income earners to participate in the nation’s health insurance plan, and self-employed workers are not required to join public pension schemes.) Having sought a universal insurance framework, Japan had chosen to follow a different route from Germany, the initial model country for Japan regarding social security, by seeking a universal insurance framework.
Why did Japan decide to establish such a universal insurance framework? In Japan, the term «universal insurance» was originally mentioned in parallel with the national slogan; «universal conscription». Specifically, the history of Japan’s universal insurance framework dates back to the Universal Insurance Movement starting from 1942, which was advocated by the Joint Committee for the Promotion of the National Health Insurance System sponsored by
the Taisei Yokusan Kai or Imperial Rule Assistance Association8. As a result, by the end of 1943, the National Health Insurance (NHI) system covered 95% of all city, town and village governments in Japan, which means that universal coverage had been achieved in Japan except for several large cities. This period of time is sometimes referred to as the First Universal Insurance Era in Japan. In addition, the basis of the current Employees’ Pension Plan was founded around this time as well. (See below).
The 1942 Workers’ Pension Insurance system started covering male factory workers. The 1944 Employees’ Pension Insurance system expanded to female workers and office workers (Workers’ Pension Insurance system was replaced by this system)
The establishment of the above pension plans was driven more by the circumstances of Japan that was on war footing than that of the NHI system.
Japan’s universal insurance framework came to completion in 1961, sixteen years after the end of the war. Nevertheless, its substantive contents, as well as its philosophies and motivations, were nurtured when Japan was at war from 1940 to 1945. It is possible to say that national unity during the war, as well as the strong sense of national integration in the postwar era for achieving the national goal of economic development, was the main driving force for the realization of Japan’s universal insurance framework.
After the above stage that formed the «take-off» stage from the German model, Japan further solidified its universal insurance framework by taking the following measures (German model ^ Universalistic model):
(a) 1982 Elderly Health Care system was established
(b) 1985 Basic Pension system was established
Although most Japanese people (including non-employed workers covered by the NHI) were covered by health insurance by the end of WWII, there had not yet been any pension systems for non-employed workers9. In order to deal with this situation, the non-contributory Welfare Pension Plan was introduced in 1959, which was then replaced by the contributory National Pension Plan enacted from 1961. Thus is the beginning of Japan’s universal pension system10. However, the initial National Pension Plan placed employed workers’ wives who divorced at a disadvantage as they had no independent rights to pensions. Against this background, the Basic Pension Plan was put in place in 1985 based on the philosophy: «Provide pension rights for all people». The concept of a «basic pension» does not exist in Germany. In contrast, it is characteristically common among countries adopting universal model social security systems (the UK, Scandinavian countries, etc.). The structure of Japan’s pension framework is often explained as a «Basic Pension Plan for the bottom tier, Employees’ Pension Scheme for the upper tier.» In other words, Japan’s public pension is the combination of a universal model system (reflected in the Basic Pension Plan in which all people receive the same amount of benefits) and Germany’s social insurance model system (reflected in the Employees’ Pension Plan in which people receive benefits proportional to the amount of premiums they have paid according to their salaries). On looking back at the development of Japan’s pension system, it is possible to see that it has been shifting from a German model system to a universal model system. If this trend continues, Japan’s public pension structure might end up with a single Basic Pension Plan structure by abolishing (privatizing) the Employees’ Pension Scheme. In this sense, Japan’s public pension is considered to be still in the process of becoming a full universal model system.
8 Taisei Yokusan kai is the government-sponsored organization to control whole society, active in Japan during WWII.
9 The difference in the development of Japan’s health care systems and its pension systems will be discussed later.
10 Since a pension system can be deemed a type of insurance system, a universal pension system can be defined as a universal insurance system in a broad sense.
The establishment of the Elderly Health Care system explains well why Japan’s social security is still in the stage of transformation from a German-model system to a universal-model system. The Elderly Health Care system was instituted in the course of the administrative reform starting from 1980s that was initially advocated by the Ad hoc Commission on Administrative Reform. The objective of this system was to «remedy the financial challenges facing the National Health Insurance system without raising the portion funded from the government’s budget (tax revenues)». (In other words, medical expenses for the elderly are shared only by participants in the NHI system.) Japan’s Elderly Health Care system was designed solely to share the medical costs of the elderly by all those insured by the system. There is no such system in Germany. Therefore, in addition to changes in the pension framework, the establishment of the Elderly Health Care system is considered to be another part of the transformation of Japan’s social security system from the German model.
However, it is also possible to understand that Japan’s social security system already varied considerably from a German-model system at the time of the introduction of the NHI system from the viewpoint that the NHI system has been funded from tax revenues in a consistently expanding manner, which never happens in Germany. More specifically, the proportion of tax funding, that is, the share of state support for the cities, towns and villages (insurers) that are actually managing the NHI system has increased as follows:
20% (1953) ^ 25% (1958) ^ 35% (1962) ^ 45% (1966) ^ 50% (1984)
The above trend means that the national government continued to provide financial support for municipalities to develop their NHI programs. This approach is considered as a certain reference for Asian countries.
The shift from the German model to the universalistic model, which applies to both health insurance systems and pension systems, is the basic direction of Japan’s social security system. This direction can be characterized by Japan’s determination to pursue universal insurance for all people (as reflected in the establishment of a universal insurance structure), as well as by its technical approach to come up with a uniform structure concerning contributions and benefits (as represented by the introduction of the «Basic Pension» system). In order to maintain this direction, tax revenues have been injected into Japan’s social security system on a timely basis.
Summarizing the discussions so far, the relationship between the development of Japan’s social security and economic growth since the end of WWII until the end of 1980s can be understood by dividing such economic growth into three stages - (1) «Take-off» stage; (2) «Ascending» stage; and (3) «Terminal» stage. Each stage can be considered to correspond to the development of social security system. (See Table 2.2)
By using this method of stages, a close linkage between Japan’s economic growth and the development of its universal insurance framework can be recognized, both of which have been driven by the nation’s development-oriented aspirations.
Table l-Z Eccnomic growth and the universal insurance framevFurk in Japan
Economic growlli 'logo Dlrwllon concerning a universal insurance syslan IiMNiiImmI progress
1. T-nheoll toge IXitli>:ii|>' liiiniil.ifii -11 ■ H n imv-141 Iieu ran» gs tern HabllsnmBttf Ilk Mill systenV Employee's. l4Y.ni piogmm ipu lug 'ti'tiW)
2. fww.Hu-Uf linf№TCl№IIOII Of 3 l||||\4-..J IIHII ■ mcEsplEm Canpleflon of Uie NHI s^tem/ П im;l Pen si on sctimie (19111)
3. |. |IiIIIH| J ii|n Тн1зШ|¥ПпЛгЛ1тпГаи1уег5а1 iiEurans ■■■■■.Hu rnmewoft Ektedy HeaiiCjE system (igaz); I'-mi I ■■ i r-m pi ogram ■; l G. i
(2) The significance of National Health Insurance (NHI) system for farmers/fishers/foresters and self-employed workers. As discussed in Chapter 1, the most important point in designing a social security system in a developing country is how to deal with its non-employed workers (such as farmers, fishers, foresters and self-employed workers). Michael Jenkins, consultant of the International Social Security Association (ISSA) points out that «Rural, agricultural and informal-sector workers have often been denied the social security protection to which other economic sectors of populations have had access, and this is particularly true in the case of developing countries»11.
At the beginning of this chapter, the following point was raised as one of the characteristics of Japan’s social security framework development: the government actively included people in the informal sector (farmers/self-employed workers) in the social security system (especially health insurance systems) when the population of such people was still relatively large.
This characteristic offers a certain direction for developing countries in terms of the positioning of informal sector workers in their social security systems.
Firstly, we would like to look at Japan’s past situation from a statistical viewpoint. Figure 2.1 compares changes in the proportion of primary sector workers in the labor force of several countries from 1950s to 1980s. This clearly reveals that Japan had a significantly larger primary sector population compared to other developed countries until around 1970 and then this population declined quite sharply after that year. This means that there is a high degree of similarity in the proportion of primary sector workers in Japan in the past and that in developing countries today. Japan’s experience in this regard can therefore serve as a valuable reference for the current developing countries.
As stated above, the treatment of non-employed workers is the most critical point in designing a social security system in a developing country. In other words, Western developed countries did not need to struggle so hard with this issue. These countries had already achieved industrialization and had a comparatively small non-employed worker population before they started to establish and solidify their social security systems from the
ii
late 19th century to middle 20th century, having allowed them to build social security nets covering almost all social strata even if related systems were voluntary-participatory or if such systems did not cover non-employed workers.
Therefore, it is possible to say that Japan, a late-industrialized nation, was the first country that made considerable efforts to include farmers/foresters/fishers and those in the informal sector in the social security system. In other words, Japan presented the first example of the establishment of a social security system in a developing country. Guhan, an Indian economist, refers to the «limitations of formal models» as follows:
«It does not make sense to regard the social programs of France, the United Kingdom and the United States as presenting a shop window from which a developing country can select the goods it prefers. Neither Beveridge nor Bismarck nor Roosevelt can provide a model for social security in developing countries»12.
Japan came up against this issue for the first time in history. Hence, Japan’s experience is considered to offer unique suggestions for the present developing countries. Japan’s experience highlights a problem that is now common to developing countries. It was hard for Japan to incorporate its huge number of primary sector workers into the social security framework as the country had started to introduce and solidify its social security system at a relatively early stage of economic development when the nation’s economic base was shifting from primary sector industries to secondary sector industries.
Incorporating non-employed workers into a social security system is more important for a health insurance system rather than for a pension system, because it is reasonably feasible for households in farming communities to financially support their elderly people, while on the other hand it is difficult to rely on such mutual assistance regarding health care. There is not much difference between people in rural communities and city workers (employed workers) in terms of the need for health care. For this reason, a society is firstly required to deal with health care for farmers, fishers and foresters.
Japan’s option for solving this problem was the introduction of the National Health Insurance (NHI) system, which could be interpreted as a community health insurance system. The National Health Insurance Law enacted in 1938 stipulated that each NHI program be managed by a health insurance association voluntarily established for that purpose, which was the municipality itself or a public corporation. In 1948, the Law was revised to ensure that the NHI mandatory participation system was «principally managed by municipalities», in which specified health insurance associations were allowed to be established in exceptional cases, with the aim of promoting NHI programs across the country. As a result, in 1961, all municipalities throughout the country had NHI programs. This marked the completion of a universal insurance framework in Japan.
Looking back at the time when he was working on the project to establish the NHI system, one government official made the following interesting comments:
«I was asked to work on research on the status of farm villages. I made a report, and at the same time, I just looked into overseas health insurance systems applied to farmers. But I found that they were all workers’ insurance systems. They did not serve as models for Japan where small-scale farming was being practiced by peasants. It was necessary for us to come up with our own system that suited our country’s situation. After much thought, an idea occurred to me. In the traditional family system, the spirit of local unity and the virtue of mutual assistance are still strongly alive in Japan’s local communities, even though they are the products of feudalism. So I thought it would be very feasible to form regional health credit union for each of such communities by utilizing the local people’s sense of integration, under the supervision of central ministries or local municipalities. I thought people would choose to
participate in this kind of program rather than in other programs. — (Omitted) — The basic concept of the NHI system came about in this way»13.
It could be said the NHI system was initially instituted as a form of farmers’ insurance scheme in rural communities (mura in Japanese) when Japan was a less-industrialized country with primary sector workers accounting for more than half of the nation’s labor force. The NHI system is the most unique and most distinctive system among Japanese social insurance systems. Considering the industrial and employment structure of Japan in those days, it is natural, in a sense, for Japan to have pursued a social insurance system like the NHI. Japan’s NHI system could be one of the most viable models when designing public health insurance systems in developing countries that are facing circumstances that are similar to those Japan faced in the past.
The basic question here is: Should a system like the NHI be defined as a type of «Asian» system, or as a «developing country» type of system? Please see below.
1. Asian type system: a system that has a universal meaning for all time in a certain region (for example, Asia) where a particular local (rural) community structure or a unique indigenous family relationship is being maintained.
2. Developing country type system: a system that is effective for a less-industrialized country solely during a certain period of time (for example, during a time when a country has a high primary sector population still with effective traditional local communities).
The above question is related not only to the evaluation of the applicability to developing countries of a system like the NHI, but also to the issues of the NHI system in Japan would have to face in the future. The following are my thoughts concerning this matter.
Considering that the current circumstances surrounding the NHI system are completely different from those when the system was put in place, as well as that the initial objectives of the system have seen a «hollowing out», the NHI system could be rather defined as a developing country type system (above type 2). Therefore, it is possible to say that this type of system «2» works out effectively when a country is at a certain stage of economic development (especially when the country’s population consists mainly of farmers). Now that the participant structure of the NHI system has substantially changed from what was originally intended, Japan is required to at least reconsider the social strata of those to be covered by the NHI system.
Table 2-3 Participant structure of NHI programs managed by municipalities
FY 1*1 fy
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(3) The national government as an insurer. Next is a discussion on the following characteristics of Japan’s social security framework raised as point (c): «Social insurance systems have been managed by the government as an insurer (Government-managed Health Insurance system/National Pension Plan, Employees’ Pension Plan).»
Unlike a tax-subsidized social security system, a social insurance system is usually managed by an autonomous private organization functioning as the insurer, although such
13 The Insurance Department of the Health and Welfare Ministry (1974); Underlined by Hidefumi Kawamura.
organizations are subject to various public regulations. A typical example is a German health insurance organization called Krankenkassen, which is principally fully supported by premiums and is in charge of negotiations with medical associations in terms of medical service fees. In the case of Japan, which is classified as a social insurance model country based on the characteristics of its social security system, the country has quite a rare social insurance framework managed by the nation (= government) as the insurer, as represented by the government-managed Health Insurance system, as well as the National Pension Plan and Employees’ Pension Plan. This government-led social insurance framework, which might have reflected the nation’s paternalism, represents the particular character of Japan in the past as a less-industrialized country, and at the same time has implications for designing social security systems in developing countries.
To be more specific, when looking at Japan’s Health Insurance Associations established by large corporations, it appears that they are more like private organizations. However, according to relevant laws, they are defined as organizations that carry out their operations «instead of the government», which means that the government is in a dominant position compared to private Health Insurance Associations. In other words, the philosophy of Japan’s social insurance is that the government should be responsible for health insurance for all employees and the Health Insurance Associations of large corporations merely act for the government. This is contrary to the idea that health insurance programs for employees should be carried out by their respective Health Insurance Associations. The government becomes the insurer for employees working in corporations that are incapable of establishing a Health Insurance Association. In the course of drafting the Health Insurance Law, there were some arguments regarding the treatment of a few then-existing mutual aid associations. Eventually, the finalized law did not allow these private organizations to continue the operation of their health insurance programs, while providing such qualification for several specified bodies (Japan National Railways, etc.) as exceptional cases (namely, mutual aid associations for public servants). Regarding the discussion about the treatment of the mutual association of Kanebo Co., one of the largest private mutual associations at the time, one scholar made the following interesting comment: «In Western countries, almost all employees’ health insurance programs are being managed by autonomous private organizations. Nevertheless, in our country, the government is compelled to become the insurer since the general public still has a weak consciousness concerning the idea of insurance, which has hampered the development of mutual aid associations»14.
(4) Dual Structure of the Economy and the Significance of the Government-managed Health Insurance. Two types of health insurance system were thus developed: health insurance managed by the government and that managed by associations, in addition to the national health insurance. The government-managed health insurance system, which is insured directly by the government, was for small and medium-sized businesses. From the viewpoint of the design of social security systems in developing countries, or more broadly, of income redistribution in the development process, the government-managed health insurance system can be considered to have been established as a measure to deal with the dual structure of the economy, a phenomenon specific to developing countries.
The problem of the dual economy is a major topic in development economics. An economist explains as follows15: «If large businesses with a high capital-labor ratio are developed while there is a plentiful supply of low-cost labor, which widens the disparity in productivity and wages between large and small-to-medium-sized businesses, then this disparity will result in a growing inequality of income distribution. In Japan, the phenomenon referred to a dual structure of the economy occurred in the process of shifting energy sources
14 For details, see Mori (1923).
15 For details, see Hayami (1995).
from coal to oil during the interwar period. In developing countries at the present time, as a factor causing inequality, this phenomenon is likely to produce a more profound effect than it did in Japan.» With regard to the relationship between the development process and income distribution, which is a more common topic, the graph of economic development and income inequality was studied by economist Simon Kuznets and was hypothesized to yield an inverted U-curve. According to Kuznets’ hypothesis, inequality increases as the GNP per capita grows (the Gini coefficient, a measure of inequality, increases), and then starts to decrease after reaching a certain stage16.
From such a viewpoint, the government-managed health insurance system is considered to have served as a major means of ameliorating the dual economy and the growing inequality of income distribution (in other words, to flatten Kuznets’ inverted U-curve). It is difficult here to accurately evaluate how the system contributed to economic growth itself and reduced income disparities. However, the system may have at least been instrumental in further stabilizing the growth in the small business sector. In other words, it should be recognized that the government-managed health insurance system served as an essential and substantial «measure for small-to-medium-sized businesses.» This viewpoint is considered to have great significance for social security cooperation with developing countries.
Tabib l-A Comparison of the insurers ^financial funders) of health insurance
systems and pension systems by country
UK Gcnndnjf Franco Japan
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Table 2.4 shows an international comparison of insurers that are central to social insurance systems and operate as their financial management bodies. With regard to health insurance, three systems were developed in Japan: the system managed by the government, the system managed by associations of companies, and the national health insurance system insured by local authorities. This has given rise to a unique situation in which the total number of insurers is significantly higher than in other countries. In other words, Japanese health insurance has a unique system supported by the government as a very large-scale insurer alongside many small insurers. In contrast, with regard to pensions, the nation (=government) was defined as the main insurer when the labor pension system was established in 1942, excluding the pension system for government officials and that established by the association of government enterprises. Accordingly, without an equivalent mechanism to a health insurance system managed by associations, the nation has been the dominant insurer. The basic reasons given for this are that the government-insured pension system is less personal than the health insurance system and that the long-term nature of pension schemes inevitably calls for the management by the government. In Japan,
16 The hypothesis states an inverted U-shaped relationship between the GNP per capita (horizontal axis) and the Gini coefficient (vertical axis).
nevertheless, the predominance of the government in the management of the pension system is greater than in other countries. This characteristic is probably due to the origin of the Japanese pension system, where the system was established to fulfill the need for compulsory saving (=capital accumulation) during wartime.
(5) Relationship between health insurance and pensions. The following is a discussion of point (d): the development of health insurance systems came first, followed by the rapid advancement of pension systems.
Firstly, the following two facts should be noted in relation to the delay in the development of Japan’s pension system.
1) As for health insurance, the Health Insurance Law was adopted in 1922 and implemented in 1927. On the other hand, as already stated, there had been no legislation regarding pension plans until the Workers’ Pension Insurance Law was adopted in 1941. In addition, such legislation had been brought about by the special factor of Japan being on a war footing in those days.
2) As for health insurance, the First Universal Insurance coverage had already been attained before WWII owing to the enactment of the National Health Insurance Law in 1938. On the other hand, no pension plans had been available for self-employed workers and farmers until the National Pension Law was enacted in 1961, when Japan’s universal insurance system was completed.
Substantially speaking, the above point 1) refers to employed workers, and the point 2) to farmers and self-employed workers.
Point 1) could be explained like this. Compared with the case in Germany in which the public pension plan for the elderly and the disabled was introduced several years after its public health insurance system was put in place in 1883, there was a long time lag between the establishment of a health care system and that of a pension system in Japan. This is partly because, unlike the health insurance system, there had been relatively less pressing need to initiate a public pension system (due to the short life expectancy of the population (around 47 years old for males at that time), as well as to the existence of traditional form of financial support by families), and partly due to the technical complexity of a pension system as a form of long-term insurance system.
Point 2) has more significance. Non-employed workers (such as farmers, fishers and foresters, as well as self-employed workers) usually live with and look after their elderly family members. In addition, the job participation rate of the elderly in non-employed workers’ households is high since they are allowed to work as long as they want to with no mandatory retirement age in place. That is why non-employed workers do not require a formal pension system to the same extent as employed workers. Nevertheless, there is no substantial difference between an employed worker and a non-employed worker in terms of the need for health care services. Thus, both groups of workers need to be treated equally in this regard. Therefore, point 2) reflects the difference between employed workers and nonemployed workers in terms of their need for health insurance and pensions.
This could be generalized in the following way. As discussed in Chapter 1, a formal social security system is basically designed to replace or supplement an informal mutual assistance mechanism (maintained mainly by family members) that becomes weakened or attenuated along with industrialization. The order of priority of each social security system is determined based on the degree of difficulty that individual families have in dealing with a certain situation, as well as on the level of need, which varies depending on changes in social factors (such as the population structure). The order is generally as follows:
Health care ^ Financial support for the elderly (= Pension) ^ Long-term Care for the elderly
It is generally rational to develop health care first, then pensions. However, as indicated in Figure 2.1, the time lag between the development of health care insurance and the development of pension schemes was too great in the case of Japan. This is due to the following reasons:
1) Japan had had a large non-employed worker population for a relatively long time, which had allowed a traditional mutual assistance mechanism to continue functioning and suppressed the demand for a pension system up to a certain point.
2) After the postwar economic growth and industrialization reached a certain point, Japan’s population started to age rapidly due to the sharp decline in the birthrate that had occurred in the early stage of that period of economic growth and industrialization. This phenomenon brought about a drastic increase in the amount paid by the government for pensions, which had been further exacerbated by the revision of the payment levels (the index-linked pension payment system was introduced in 1973).
The above two points could apply to developing countries.
Another issue needs to be taken into account regarding the development of Japan’s social security system. Although it is relatively common for non-employed workers and their families to financially support their elders, some of them (for example, unmarried elderly females) cannot expect such support. It is necessary to validate from the viewpoint of fairness and equality whether Japan’s social system was properly functioning to ensure the security of a livelihood for these people.
3. Comprehensive Evaluation of Japan’s experience. Japan’s experience as a whole is unique and was not seen in the West. In addition, it provides models of either success or failure, or both strong points and weakness, especially for developing countries regarding: (1) how to design a social security system in latecomer nations, and (2) how to deal with the rapid aging of the population that starts from a certain stage of economic development.
Major characteristics of Japan’s experience concerning point (1) above, which have particular significance for the present developing countries, are as follows:
(a) Japan was the first nation to have made active efforts to develop its social security system when the country still had a huge informal sector population (farmers/self-employed workers);
(b) Japan promoted a government-led social security system in which the government itself became the insurer for employed workers as well.
The National Health Insurance as a community health insurance for farmers as well as the Government-Managed Health Insurance for employed workers in small and medium-sized companies are considered to serve as models for developing countries as original and nonWestern forms of systems.
Moreover, Japan established a universal insurance framework based on the above systems at a relatively early stage of economic development, which consequently contributed substantially to its subsequent economic growth. This fact also offers important implications for developing countries, since the promotion of a social security system is generally regarded as a «burden» that hinders economic growth and is left unresolved as it requires government spending.
At the same time, it should be noted that Japan’s social security system is inseparably linked to its postwar national consensus and national integration for achieving economic development, its administrative, economic and political systems, the Japanese-style employment practices of its private corporations, and its close public-private partnership at the national level which prompts people to refer to the nation as «Japan, Inc.» Therefore, the actual feasibility of each social security system must be further studied from the viewpoint of the relationship between the social security system in question and a broad range of other systems of each country.
The above point (2) sheds light on the problem that latecomer countries, including Japan, tend not to recognize the impact of the aging of the population until a certain point in time. In this case, as pointed out by the World Bank, they are highly likely to substantially increase their pension payment levels (specifically, by using reserves) based on «financial misunderstandings». Japan made this mistake in the operation of its public pension system, leading the nation to continue to take corrective action until today, that is, a substantial reduction in payment levels in the name of «reforms». Besides, in Japan, these corrective actions have been taken in a repeated and incremental manner, deepening people’s anxiety about the pension system. Such a mistake inevitably requires latecomer countries, including Japan, to take corrective action on a large scale over a quite short period of time as the aging of the population and the population transition advance at a high rate in these countries. Therefore, the levels of payments for public pensions should not be increased when the country’s population is not so gray. This is an important implication from Japan’s negative experience.
As for health care and welfare, it is important to start early to prepare for the third health transition stage (see 1-3) by improving the quality of services (in order, for example, to prevent «hospitalization for social reasons») as well as its cost effectiveness, through the establishment of an elderly care policy focusing on health care rather than welfare, as well as through the scaling up of welfare services.
Conclusion. Challenges ahead and prospects for the realization of a Eurasian Welfare Network and a Sustainable Welfare Society on a global scale. In this report, starting from the provisional grouping of Asian countries, we have discussed the basic factors requiring consideration in a review of social security systems in developing countries, followed by an evaluation of Japan’s experience in social security.
Although there are a number of points and issues to be addressed this report could only cover a part of them regarding such themes as social security in Asia or economic development and social security in developing countries17, so we would like to refer to several topics that have not been mentioned in the main body of this report.
Firstly, we would like to touch on a few issues regarding the environment and environmental policies in the context of social security. If social security issues can be defined as issues of the distribution of wealth, environmental issues could be defined as issues of the scale (or growth) of wealth. Both social security issues and environmental issues are closely intertwined in the dynamic process of economic development, as well as social changes. This perspective is related to the inverted-U curve hypothesis for environmental pollution (an empirical hypothesis claiming that, as an economy develops, environmental pollution first worsens and then gradually improves), which is now being considered as a parallel to the already-mentioned Kuznets inverted-U curve hypothesis explaining the relationship between economic growth and income distribution18.
Thus, economic development, social security and the environment must be studied with an integrated approach, and such an approach should be further nurtured taking into account the growing environmental problems in Asian countries brought about by their rapid economic development, as well as Japan’s experience concerning social security and environmental issues.
We also need to direct our attention to a broad range of subjects with regard to the relationship between the progress of globalization and the consolidation of domestic social security, or more broadly, between development and culture. As to the former, although discussion in this report has been mainly from the viewpoint that a social security system is a domestic system, Asian countries are destined to be exposed to globalization in the course of
17 For details, see Hiroi and Komamura (2003): Social security in Asia.
18 For details, see Hiroi (1999).
establishing their social security systems. This is, in fact, the most significant feature of the circumstances now facing these countries in terms of social security19.
Meanwhile, it is also critical to create a future vision of social security in Asian countries not only on the nation state scale, but also on a supra-national scale with views on economic cooperation and income redistribution between the nations in the region, although these may take on a different shape from the case of the EU.
Such a vision ultimately leads to the theme of a welfare state on a global scale, and also overlaps with the concept of human security. Furthermore, considering the environmental issues mentioned above, there needs be a vision and the realization of a «sustainable welfare society» in Asia and on a global scale for the 21st century.
For this purpose, the first major challenge will be to establish an Asian (or «Eurasian») welfare network aimed at promoting mutual cooperation and collaboration among Asian and European countries regarding social security, as well as to envision the concept of a crossborder welfare block in the region.
On the other hand, despite their moves to establish a closer and more integrated relationship, as suggested in the theme of development and culture, not all countries are uniformly seeking industrialization. Each of them is developing (or maintaining its traditions) in its own way with its indigenous culture and traditional social structure still intact. This perception raises a question of how the concept of social security itself - which, in a sense, derives from Western historical experience - can be applied as it is to Asian countries. The subject of the social security in Asia is always required to be examined with an awareness and understanding of such cultural and regional diversity.
Lastly, we would like to confirm the following two points regarding international cooperation in social security, a keystone of this report.
(a) In the context of social security, this theme has often been assigned a low priority in Japan’s social security research, which has primarily been focused on learning from the West.
(b) In the context of international cooperation, this theme had not attracted much attention as an item of cooperation since Japan’s assistance activities for developing countries have been implemented mainly in the field of infrastructure development through construction projects.
As a result, international cooperation in social security was an unexplored field in Japan. However, it has come to the fore as one of the most important tasks to be addressed by the country along with the tightening relationship between Japan and other Asian and European countries including Russia, deepening understanding of the significance of consolidating social security in relation to each country’s economic development, as well as the growing recognition of intellectual support based on the evaluation of Japan’s experience.
Now our major challenge is to expand communication with each Eurasian region through mutual feedback between research studies on social security adopted by all countries and regions in the world, as well as the evaluation of Japan’s experiences in the field of social security.
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Important notice
This article is an excerpt with some technical revisions from the following publication with the permission from Japan International Cooperation Agency (JICA):
Institute of International Cooperation, Japan International Cooperation Agency. Development of Japan’s Social Security System An Evaluation and Implications for Developing Countries. June 2004.
