Looking at child health in Japan
For two weeks in June I participated in the Royal College of General Practitioners (RCGP) medical exchange to Japan to experience life as Maham sensei (sensei is a Japanese title of respect given to professionals including doctors).
During my stay I was based at the Kawakita Family Medicine in Tokyo and became integrated with the Japanese general practice trainees; attending clinics, visiting hospital facilities and learning about medical training and the working lives of the doctors. As a paediatric SHO at the time working with CC4C, I could not help but take a look into child health in Japan and the links with primary care.
Japan has one of the most sophisticated healthcare services in the developed world, with one of the lowest child mortality rates of 2.1 per 1,000 live births (in comparison the UK rate is 3.9 per 1000 live births). However as I discovered just like its railway network (anyone who has tried navigating their way through Shinjuku station in Tokyo will know what I mean) it is one of the most complex.
There is a system of compulsory national health insurance financed through individual income-based premiums, employer contributions and taxes. Patients contribute on average 20-40 per cent of the cost depending on age and income. Coverage is practically universal with strict government control of healthcare financing, and a trend towards hospital-based fee-for-service practice. Care for infants is free with the Nyuyouji Iryoushou, a certificate of free medical care which parents are eligible to apply for under the national insurance scheme.
Early pioneers of linking good antenatal care and improved child health, the Japanese launched the first combined maternal health, delivery and child health handbook in 1948. The handbooks were officially legislated under the Japanese Maternal and Child Health Act 17 years later, and form the blueprint of many of the child health and development handbooks in existence today across the globe. Authors such as Nakamura attribute the maternal and child health handbook as an early example of connecting care for child health, which provided valuable continuity between antenatal check-ups, delivery, vaccinations and developmental progress amongst the myriad of healthcare providers involved. This alongside mandatory health checks for mothers and children, free healthcare for infants and a narrow socioeconomic gap are all reasons put forward as to how Japan managed to reduce its child mortality to one sixth over a 25-year period.
Today in Japan other positive determinants of child health are visible. Most noticeable are the schoolchildren walking to and from school, and the nursery children being taken for a walk by the nursery staff. This habit has been ingrained in Japanese society for over 50 years, and is thought to be a contributing factor to the low levels of childhood obesity in Japan compared to other developed countries. Additional contributing factors include the benefits of a Japanese diet, and anecdotally I have never come across so many children whose favourite food is sashimi (raw slices of fish)!
With such good standards of child health across the nation it is logical to assume strong relationships between primary and secondary care. However the structure of the Japanese healthcare system makes this difficult to achieve. The national health insurance system means patients have almost open access directly to hospital specialists and as a result paediatricians see the majority of children until 15 years of age. General practice is still a new specialty in Japan with the role of the general practitioner (GP) still undefined. Rising costs in healthcare have meant a shift to providing more community-based services. Complicating things further is that until recently one did not need special qualifications for general practice, and often paediatricians would extend their practice to include adults and work as a GP in the community. At Kawakita the GPs did see children, however this was mainly for vaccination administration and through routine home visits for children who were housebound through comorbidity and profound disabilities. As general practice training develops into a formalised scheme, the role of the GP is beginning to take shape. Paediatrics is part of general practice training at Kawakita, and as a result the new GP trainees will have skills and experience in managing children. It will be interesting to see how the links between the GPs, paediatricians and other healthcare providers develop over the next few years, as child health moves away from hospital-based practice towards a more multidisciplinary healthcare model in the community.
Dr Maham Stanyon, Academic GP ST3, Imperial College Department of Academic Primary Care