Making sense of the Japanese medical system

Health - June 19th, 1998
tokyoweekender_Dr. Fujii

Staying Healthy in Japan

by Elyse Rogers

Learning the mysteries of Tokyo can be challenging for new expats. To introduce foreigners to their new home, and to answer questions, ev­ery year the Tokyo American Club Women’s Group puts on a three-day orientation program called “Tokyo Here & Now.” This year it was under the direction of Marjorie Blizzard. The program is jammed-packed with demonstrations, panels, a book sale and other “get acquainted” sessions.

During the years I lived in Tokyo, I spoke to that group many times about obtaining medical care in Tokyo. When I moved back to the States in 1987, I suggested that I pass the baton on to Dr. Koichi Fujii from the Tokyo Medical Surgical Clinic. And Dr. Fujii has been ably introducing new expats to all things Japanese in the medical area ever since. I had the pleasure of hearing his medical presentation in Octo­ber when I was in Tokyo, and even had the opportu­nity to serve on a panel with him and two others to answer questions posed about medical care.

What surprised me was that the questions asked were almost identical to the ones I fielded more than a decade ago. So, with Dr. Fujii’s kind assistance, I’d like to present a primer on the Japanese medical/ hospital system and the emergency care system (in my next two columns) for those of you who either are not familiar with it, or have been here so long you need a refresher course.


There are seven ways in which medical care is delivered:

1. Clinics—which are small (usually private) medical facilities that mainly cater to outpatients but do have some beds for in-patient care. Bed count in most cases is under 20 beds. There are 85,000 clinics in Japan.

2. Hospitals—run by the government, non profits or other organizations. There are 8,000 of these nationwide and they provide pretty much all kinds of medical care, including in-patient, out-patient and specialties. Most are affiliated with a medical school or university.

3. Physical exam offices (docks). Believe it or not, you can get a complete physical in Japan by going to a special center that does only physical examinations. It may or may not be connected to a hospital or clinic, but they must have licensed physicians to do the exams.

4. Pharmacies. It seems that “nothing is simple in Ja­pan,” and pharmacists are no exception. There are actu­ally three types—drug stores, prescription pharmacies and hospital dispensaries.

• Drug stores sell over-the-counter drugs such as cold medicines, Band-Aids, foot powders and all the “extra items” most drug stores in the States carry. In addition, they sell other wares such as cosmetics, toilet tissues, etc. The only thing Japanese drug stores do not sell is real drugs. In other words, you can’t get a pre­scription filled there.

• Prescription phar­macies do fill prescrip­tions and are required by law to have a registered pharmacist on board. The pharmacy part of the store, however, is usually small, since most pre­scription drugs are actu­ally dispensed by the physicians or hospital prescribing them.

(An interesting note: the government wants to do away with this hospi­tal/doctor dispensing system as a means of cost-sav­ing, however, so look for more outside pharmacies in the future.)

• Hospital dispensaries are usually big pill-dispens­ing emporiums as Japanese citizens have the highest per capita consumption of drugs in the world. In the 1980s, the common “joke” with Japanese patients was that if you went to the doctor and he didn’t give you a “shopping bag full of drugs,” he wasn’t doing his job.

(Receiving a “shopping bag full of medicines” cre­ated its own dilemma. Human nature being human nature, many patients didn’t want all the drugs pre­scribed. But, being very polite (this is Japan, after all), they would accept them and simply not take them or toss them down the toilet. Good for the bottom line of Japanese pharmaceutical companies, but one of the reasons the cost of health care skyrocketed from ¥6.5 trillion in 1975 to ¥27.2 trillion in 1995.)

5. Nursing Homes. There are private nursing homes in Japan, and special “custodial care” homes for the aging who are bedridden. The “custodial care” facilities are government supported and limited in number. Families pay about ¥60,000 per month and the govern­ment covers the remaining costs—estimated at more than ¥3 million per year. In 1993, 270,000 older people (or 1.6 percent of the population aged 65 or older) lived in some type of government-supported housing.

There are also other types of government-subsi­dized housing besides custodial care ones: 1) homes for the aged with low incomes, and 2) low-cost homes for the aged with low incomes. (I gather the difference is that the first type of home provides more assisted care, while the second is simply cheaper housing.)

The government is looking carefully at all facilities for the aged because of the growing elderly population and the high cost of provided housing and care. For many years, elder care wasn’t a problem in Japan because fami­lies assumed the role of caregivers. But with more younger families preferring nuclear-family living arrangements, and retirees preferring the freedom and in­dependence that separate housing provides, the old tra­ditions for elder care are breaking down. In the year 2020, it is predicted that Japan’s population make-up will consist of more than 25 percent older than 65, and more than 14 percent over 75. This will make Japan the most aged nation in the world.

The rules for admission to custodial care homes are specific and strict, and will probably get stricter; there is already a movement to make the elderly pay a higher percentage of the cost of care (and some costs have been increased already).

6. Hospices. Hospices provide services to the dy­ing, either at home or in special centers. Currently these centers are mostly church-sponsored, although some hospitals and clinics will take on the home care of dying patients, even though they do not necessarily call it a “hospice.” Hospice (in the home-care sense) is a growing program in the U.S.—many are affiliated with the Visiting Nurse Associations, and I predict that such programs will grow in Japan as well. Actually Visiting Nurse Programs have already made inroads here.

7. Public Health Offices (hokenjo). The govern­ment provides for the public health of its citizens, as it does in the U.S. and many other countries. This in­cludes a wide range of services including epidemiol­ogy studies, water and environmental regulations and programs, well-baby clinics, wellness screening and even disease treatment programs for a limited num­ber of specific diseases.

The good news is that the Public Health Depart­ment provides some services expats might like to use that are either free or for a nominal fee, but the bad news is that very little English language help is avail­able. So, although health check-ups (that include blood pressure monitoring and basic tests) immunizations and well-baby clinics are offered, you’ll need a Japa­nese neighbor or friend to accompany you if you want to take advantage of these services (unless, of course, you’re fluent yourself).

Water testing is another service the Public Health Ser­vice provides, and that’s fairly straightforward (albeit, all in Japanese). But if you bring water samples of your drinking water to them, they’ll test it and let you know (in Japanese) if it’s safe or if there are any problems.

If you are fortunate to live in a “ku” that has a large foreign population, such as Minato-ku, you’ll probably find a great deal of English-language help available. Not so in many of the other “kus” or in outlying regions.