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WhyJapaneseAreNotSatisfiedwithTheirHealthCareSystem:

FromtheISSPSurveyonHealthandHealthCare1

July2015

MURATAHirokoARAMAKIHiroshi

PublicOpinionResearchDivisionNHKBroadcastingCultureResearchInstitute

1ThispaperisbasedonthearticlepreviouslypublishedinHosoKenkyutoChosa[NHKMonthlyReportonBroadcastResearch]:日本人はなぜ医療に満足できないのか~ISSP国際比較調査「健康」から~“Nihonjinwanazeiryonimanzokudekinainoka:ISSPKokusaiHikakuChosa‘Kenko’kara”[WhyJapaneseAreNotSatisfiedwithTheirHealthCareSystem:FromtheISSPSurveyonHealthandHealthCare](byHirokoMurataandHiroshiAramaki,November2014).TheoriginaltextinJapanesecanbeaccessedat:http://www.nhk.or.jp/bunken/summary/research/report/2014_11/20141104.pdf

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Abstract

TheNHKBroadcastingCultureResearch Institute isamemberof theInternational Social Survey Programme (ISSP), a cross‐national surveycollaborationprogram.Thispaper features the2011SurveyonHealthandHealth Care. The authors report on the comparison of findings from 31countries or regions and explore the satisfaction of Japanese with theirhealthcaresystem.

Japan’suniversalhealthcaresystemgivesusersaccesstohigh‐qualityhealth care at relatively low cost. Users are also assured of free access tomedical institutions of their choice. Against this backdrop, Japan had thehighest doctor consultation rate among the 31 countries or regions.However,54percentrepliedthat“peopleusehealthcareservicesmorethannecessary,”afigurenotashighasinothercountries.Butdespiteeasyaccesstohealthcareproviders,someyoungandmiddle‐agedpeoplesaidthatthey“did not get the medical treatment they needed” because they “could nottakethetimeoffworkorhadothercommitments.”

Those who were satisfied with the medical treatment they receivedaccountedfor70percentoftheJapanesesurveyed,and62percentansweredthatdoctorscanbetrusted.However,thesepercentagesarenotashighasintheotherparticipatingcountriesorregions,indicatingthatJapanesedonotnecessarilyhaveahighestimationofdoctors.

Furthermore,only43percentaresatisfiedwiththehealthcaresysteminJapan.Astrongcorrelationwasfoundbetweenevaluationsofdoctorsandsatisfaction with the health care system. Countries where people have ahigher estimation of doctors were more satisfied with their health caresystem.A correlationwas also observedbetweenwhether people find thehealthcaresystem in theircountryefficientand theirsatisfactionwith thesystem.TheresultssuggestthatJapan’slowsatisfactionwithitshealthcaresystemisrelatedtolesspositiveestimationsofdoctorsandofthesystem’sefficiency. The survey indicates that implementing measures to enhancetrustindoctorsandefficiencyinthehealthcaresystemwillbeeffectiveforboostingsatisfactionwiththehealthcaresystem.

1. Introduction

The International Social Survey Programme (ISSP), a cross‐national surveycollaborationprogram,ofwhich theNHKBroadcastingCultureResearch Institute is amember,conductedasurveyonhealthandhealthcarein2011among31countriesorregions.Thisarticle compares the resultsof thesurveyandreportson the featuresofhow Japanese feel about their health care system. Research organizations fromapproximately50countriesorregionsaremembersoftheISSP,whichconductsayearlysurveyamongitsmembersonaparticulartopic,usingacommonquestionnaire.ThisisthefirsttimethattheISSPdealswithhealth,thetopicofthe2011survey.Thetopicwas

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selected to probe attitudes toward health and health care against the background ofaging populations and increasing health care spending due to advanced health care,issuesfacingmanycountries.Datacollectedfromthe31countriesorregionssurveyedwasreleasedin2013.

The year of the survey, 2011, coincided with the 50th anniversary of theintroduction of universal health care coverage in Japan. Universal coverage not onlyprovidesqualityhealthcareforrelativelymodestfeesbutalsoallowsusersfreeaccesstowhicheverhealthcareprovidertheychoose.UnlikeJapan,manyothercountries,forexample the U.K., regulate access to care by requiring a referral from a generalpractitionerorprimarycarephysician. It isalsonotcustomaryforpeople incountrieslike Germany, France, or Sweden to freely consult doctors in large hospitals.１ In theUnited States, the Affordable Care Act was passed in 2010, making enrollment in ahealthinsuranceplancompulsorysince2014.Untilthen,theUnitedStateshadnopublichealthinsurancescheme,exceptforprogramscoveringseniors,personswithdisabilities,orlowincomeearners,andmanypeoplewereenrolledinexpensiveprivatehealthcareplans. This iswhy nearly 50million Americans, some 15 percent of the population,２wereuninsured,and thepresenceof sucha largenumberofpeoplewithoutaccess tohealthcareincaseofinjuryorillnesshadbecomeamajorsocialissue.

In Japan, meanwhile, quality health care is available for modest fees, but areJapanesereallysatisfiedwiththesystem?Thispaper,usingdatafromtheISSPsurvey,probeshowJapanese feelabouthealthcare, comparingattitudes towarduseofhealthcare,satisfactionwiththehealthcaresystem,andotherissues.Thispaperanalyzesthedatafrom10outofthe60questionsinthequestionnaire.

While the Organisation for Economic Co‐operation and Development (OECD)publishes numerous health and health care statistics, such as average life expectancy,frequency of doctor consultations, and so forth, for its 34member countries, and theWorldHealthOrganization(WHO)alsopublishesdataonillnessandhealthissues,thereare few cross‐national surveys that allow comparisonof attitudes towardhealth care.This makes the ISSP survey, which probes these attitudes among a representativesampleofthepopulation,areliablesourceofvaluabledata.

Regarding regions, in the case of Germany, the research data consist of twoseparatedatafilesfortheformerWestGermanyandEastGermany,andinBelgium,forthe Flanders and Wallonia regions. Therefore these regions were treated as distinctwhendatawasanalyzed.Detailsonsurveymethodologyforeachcountrycanbefoundonp.21.

To facilitate identifying answer trends in each country, analysis was conductedexcludingansweroptionslike“can’tchoose”and“noanswer.”３

2. DifferencesinHealthCareUsageandAttitudesHighestDoctorConsultationRateinJapan

According to 2011 OECD statistics,４ the number of doctor consultations percapita in Japan is 13.1 a year, secondonly toKorea (13.2) in frequency.The fact thatboth Japan and Korea have universal coverage, and that users have direct access tomedicalspecialists,isafactorhere.

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Theyearlydoctorconsultationrate(veryoften+often+sometimes)５ intheISSPsurveyis64percentforJapan,thehighestamongthe31countriessurveyed(Figure1).Koreaalsohasacomparativelyhighdoctorconsultationrate,atrendthatisconsistentwiththeOECDstatisticsquotedabove.

Figure 1. Doctor Consultation Rate

Byagegroup, thedoctor consultation rate ishigh inall countriesamongpeopleaged55andover.InJapan,theconsultationratefortheolderpopulationsegmentis76percentcomparedto54percentforbothyoung(aged34andunder)andmiddle‐aged(aged 35–54) people. But comparing data internationally, older Japanese have thehighest doctor consultation rate among all countries and young and middle‐agedJapanese the second‐highest rate, indicating that regardless of age, Japanese consultdoctorsfrequently.

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Very often

Often

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Frequency ofconsulting a doctor  :

Japan 64％

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JapaneseDoNotBelieveTheyUseHealthCareServicesMorethanNecessary

AndhowdoJapanesefeelabouthavingahighdoctorconsultationrate?OverhalftheJapanesesurveyed,54percent,answeredthat“peopleusehealthcareservicesmorethan necessary” (strongly agree + agree) (Figure 2). But compared to countries likeSwitzerland (80 percent) and France (71 percent), this figure is not especially high.AlthoughJapanesehaveahighdoctorconsultationrate,awarenessthattheyusehealthcareservicesmorethannecessaryisnothigh.

Byagegroup,49percentoftheyoungagegroup(aged34andunder),53percentof themiddle‐aged(aged35–54),and56percentof theolderagegroup(aged55andover)believethatpeopleusehealthcareservicesmorethannecessary,andexceptforaslightly lowerpercentageamongtheyoungagegroup,theagegroup‐basedfiguresarerelativelysimilar.

Figure 2. Do People Use Health Care Services More than Necessary?

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SwitzerlandFrance

PhilippinesTaiwanKoreaU.K.U.S.

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Strongly agree AgreeNeither agree nor disagree DisagreeStrongly disagree

％

Japan

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AccesstoHealthCareDifficultDuetoWorkorOtherCommitments

Factors such as “high treatment fees” or “a long waiting list” for consulting adoctor or other reasons for not being able to receive health care are indices formeasuringaccess tohealthcareor, inotherwords,howeasily thehealthcaresystemcan be used.６ In the ISSP survey, four reasons for not being able to “get themedicaltreatment you needed”were presented, and peoplewere askedwhether each reasonhadappliedduringaone‐yearperiod.Amongthese,excludingtheuser‐relatedreasonofnotbeingabletoaccesshealthcareduetoworkorothercommitments,Figure3showsdataforthefollowingthreereasons:“youcouldnotpayforit[medicaltreatment],”“thetreatmentyouneededwasnotavailablewhereyouliveornearby”and“thewaitinglistwas too long.” Ratios for each were calculated based on the denominator excludingthosewhoansweredtherewasnoneedformedicaltreatmenttobeginwith.

Figure 3. Reasons for Lack of Access to Health Care

Notes: Arranged in descending order in terms of the combined total of the percentages of “could not pay,”

“treatment not available nearby,” and “long waiting list.” Taiwan is excluded from the analysis here

because the reasons did not include “treatment not available nearby.”

In Japan, only 4 percent each of people surveyed gave “could not pay” and“treatmentnotavailablenearby”asreasonsfornotbeingabletoaccesshealthcare.Thisismostlikelybecausewithuniversalcoverage,userscanbasicallyaccesshealthcareforaco‐paymentof30percent,andthehealthcaresystemofferseasyaccess tocareandtreatment.

In Scandinavian countries like Norway and Sweden, many people gave “thewaitinglistwastoolong”asareasonforlackofaccesscomparedto“couldnotpay.”InFinland,17percentsaidthat“thewaitinglistwastoolong.”InScandinavia,healthcareis financedthrough taxation,and treatment isofferedaccording toprioritiesbasedontype and severity of illness.７ This is supposedly why the wait time issue arises, andpatients with chronic diseases sometimes have towait severalmonths to get care. A

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similarissueexistsintheU.K.InJapan,bycontrast,usershavefreeaccesstohealthcare.Evenso,7percentof Japanesegive “thewaiting listwas too long”asa reason fornotgettinghealthcare,andalthoughthewaittimeissueisnotasseriousasinScandinaviaortheU.K.,itmaybebecauseJapanesepatientsoftenhavetowaitlongatahospitalorclinic—the situation sarcastically described as “a three‐hour wait for a three‐minuteconsultation.”

The other reason—“you could not take the time off work or had othercommitments”—isgivenby21percentofJapanese,thefourthhighestratioamongthe31countries(Figure4).

Figure 4. Unable to Access Health Care Due to Work or Other Commitments

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Byagegroup,only5percentofolder(aged55orover)Japanesepeoplesaythatthey cannot access health care due to work or other commitments, compared to 41percent of young (aged 34 and under) and 33 percent of middle‐aged (aged 35–54)people,bothratesbeingthehighestamongallcountriessurveyed(Figure5).Althoughaverage total yearly work hours in Japan have dropped since the revised LaborStandardsLawwentintoforcein1988,８ peopleinJapancontinueworklongerthaninother economically advanced countries, which is probably why many Japanese wereunabletoaccesshealthcare.

Figure 5. Unable to Access Health Care Due to Work or

Other Commitments (by Age Group)

3. SatisfactionwithDoctorsandMedicalTreatment

RelativelyLowSatisfactioninJapan

Figure6detailstheratioofpeoplesatisfied(completelysatisfied+verysatisfied+fairlysatisfied)withrecentmedical treatment.As inFigure3, theratiowascalculatedbased on a denominator excluding thosewho said theyhadnot received anymedicaltreatment.Inallcountries,overhalfofallpeoplesurveyedsaidtheyweresatisfiedwithtreatment,indicatingagenerallyhighlevelofsatisfactionoverall.

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Figure 6. Satisfaction with Treatment

InJapan,70percentsaidtheyweresatisfied,butevensothisratiowasthefourthlowest among all the countries surveyed. By age group, older people in all countries,includingJapan,tendedtobesatisfiedwithtreatment.

In response to the statement “doctors discuss all treatment options with theirpatients,” 36 percent of Japanese agreed (strongly agree + agree), a somewhat lowpercentage compared to the other countries (Figure 7). Meanwhile, a relatively largeproportion of Japanese, 42 percent, disagreed (strongly disagree + disagree)with thestatementthat“themedicalskillsofdoctorsarenotasgoodastheyshouldbe.”Inotherwords,whileJapanesebelievethatdoctorsaregenerallycompetent,manyofthemfeelthatcommunicationwithdoctorsisinadequate.

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Completely satisfied Very satisfiedFairly satisfied Neither satisfied nor dissatisfiedFairly dissatisfied Very dissatisfiedCompletely dissatisfied

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Figure 7. Evaluation of Doctors

Insomecountries,morethan80percentansweredthatdoctors“canbetrusted”

(stronglyagree+agree)(Figure8).Allthehigher‐rankedcountriesareinEurope,whereit is common for patients to see their local doctor,whowill then refer the patient tospecialistsifnecessary.PeopleinEuropemaythusfeelthatdoctorsarereliablebecauseoftrustbuiltupthroughfrequentinteractionwiththesamedoctor.

InJapan,62percentsaythatdoctors“canbetrusted,”asomewhatlowpercentagecomparedwiththeothercountries.Thislowfigurecanperhapsbeattributedtoseveralincidents involving doctors that shook the public’s trust. In the 2000s, for example,reportswererepeatedlymadeofdoctorsfoundguiltyofoperatingonthewrongpatient,liableforlaparoscopicsurgerythatwentwrong,oraccusedoffalsifyingmedicalcharts.Therewasalsoanincidentinthenewsaroundthetimeofthesurveyin2011whereitwasreportedthatdoctorshadbeeninvolvedinthesellingofhumanorgans.

Byagegroup,ineverycountrysurveyed,theolderagegrouptendedtofeelmoretrustindoctors.

Taiwan 73 Taiwan 57Philippines 68 Switzerland 54SouthAfrica 64 Israel 53Switzerland 57 CzechRepublic 52Turkey 57 Belgium(Flanders) 49Belgium(Wallonia) 56 Slovenia 44Belgium(Flanders) 54 Japan 42U.K. 54 Slovakia 42Germany(East) 53 Netherlands 41Denmark 51 U.K. 40France 51 Germany(East) 39CzechRepublic 51 SouthAfrica 39Australia 50 Belgium(Wallonia) 38Korea 48 France 38Germany(West) 47 Denmark 38Netherlands 45 U.S. 38Slovenia 44 Turkey 38Israel 44 Croatia 38Portugal 43 Australia 36U.S. 42 Germany(West) 35Croatia 39 Sweden 33Japan 36 Portugal 33Poland 35 Lithuania 32Lithuania 34 Finland 31Slovakia 34 Norway 28Sweden 34 Korea 25Finland 31 Chile 22Chile 29 Poland 21Russia 29 Bulgaria 19Bulgaria 29 Philippines 16Norway 26 Russia 14

"Doctorsdiscussalltreatmentoptionswiththeirpatients"

Disagreethat"themedicalskillsofdoctorsarenotasgoodastheyshouldbe"

(Stronglyagree+agree) (Stronglydisagree+disagree)(%) (%)

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Figure 8. Trust in Doctors

4. AttitudestowardtheHealthCareSystem

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Strongly agree Agree

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4. AttitudestowardtheHealthCareSystem

JapaneseFeelOnlyWeakSatisfaction

Satisfaction (completely satisfied + very satisfied + fairly satisfied) with healthcare systemsamongpeople in the countries surveyedshowedwidevariation, rangingfrom93percentinBelgium(Flanders)to22percentinChile(Figure9).InSwitzerland,where86percentreportsatisfaction,thedensityofphysiciansper1,000populationis3.8persons,rankingthecountryeighthamongthe34OECDcountries,whilethedensityofnursesper1,000populationis16.6persons,thehighestintheOECDcountries.９

In Japan, a comparatively low43 percent expressed satisfactionwith the healthcare system. According to a 2004 survey of Japan, Korea, the U.S., and France by theJapanMedicalAssociationResearch Institute,１０ 27percentof Japaneseweresatisfiedwith thehealthcaresystem,versus65percent in theU.S.and74percent inFrance,atrendsimilartothefindingsoftheISSPsurvey.Intermsofphysiciandensity,Japanhas2.2 physicians per 1,000 population, ranking the country 29th among the 34 OECDcountries,incontrasttoSwitzerlandmentionedabove.DensityofnursesinJapanis10.0per1,000population,alsonotespeciallyhighcomparedtoothercountries.Otherfactorsnegatively affecting satisfaction of Japanese with the health care system will bediscussedinsections5and6. Examiningsatisfactionbyagegroup,olderpeople(aged55andover)weregenerally

satisfiedwiththehealthcaresystemintheirrespectivecountries(Figure10)However,differences between age groups were not prominent in European countries, wheresatisfactionwiththehealthcaresystemwasgenerallyhigh.Ontheotherhand,inJapansatisfactionamongyoungerpeople(aged34andunder)was35percentcomparedto53percentamongtheoldergeneration(aged55andover),showingawidegap. In Japan’s health insurance system, health care for the older population ismaintainedbyhealthinsurancefeespaidbytheyoungeractivepopulation.Theburdenon younger people continues to increase as the population ages and the birthratedeclines, and todaynearlyhalf of totalexpenditureonhealth is consumedbypersonsaged 70 and over.１１ When the Japanese ISSP survey was conducted in 2011, theDemocratic Party of Japan was in power and mulling whether to increase theco‐paymentratefrom10percentto20percentforusersbetweentheagesof70and74,an issue that attracted considerable attention. Intergenerational unfairness, that is,greaterconsumptionofhealthcareresourcesbyolderpeople,maybeonereasonwhyyoungerandmiddle‐agedJapanesearedissatisfiedwiththehealthcaresystem.

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Figure 9. Satisfaction with the Health Care System

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19 

20 

25 

22 

11 

8 

16 

18 

9 

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19 

8 

9 

9 

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9 

4 

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3 

5 

51 

49 

54 

43 

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57 

50 

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45 

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57 

59 

49 

34 

53 

48 

37 

37 

49 

42 

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36 

43 

31 

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33 

27 

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23 

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16 

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9 

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0 

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2 1 

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9 

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1 1 

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Belgium(Flanders)

Switzerland

Belgium(Wallonia)

Denmark

Netherlands

Finland

Philippines

U.K.

Sweden

Norway

France

Taiwan

Australia

Turkey

Slovenia

Germany(West)

South Africa

Israel

Germany(East)

Korea

Czech Republic

U.S.

Portugal

Croatia

Lithuania

Slovakia

Bulgaria

Russia

Poland

Chile

Completely satisfied Very satisfied

Fairly satisfied Neither satisfied nor dissatisfied

Fairly dissatisfied Very dissatisfied

Completely dissatisfied

Japan

14

Figure 10. Satisfied with the Health Care System

(Completely Satisfied + Very Satisfied + Fairly Satisfied) (By Age Group)

TheHealthCareSystemis“Inefficient”

Comparedtopeopleinothercountries,moreJapanese,51percent,believethat“Ingeneral, the health care system in this country is inefficient” (strongly agree + agree)(Figure11).

In the OECD statistics, total expenditure on health as a percentage of grossdomesticproductisoftenusedasanindexforhealthcarecosts(Figure12).IntheU.S.healthcarecostsaccount for17.7percentofGDP,muchhigher thanelsewhere.OthercountrieswherethisfigureishigherthantheOECDaverageof9.3percentincludetheNetherlands (11.9 percent), France (11.6 percent), and Switzerland (11.0 percent).HealthcarecostsinJapanare9.6percentofGDP,slightlyabovetheOECDaverage,butlow compared to the U.S. or the Netherlands. Considering Japan’s aging population,healthcarecostsarerelativelylow.

Japan’shealthcarecostshavebeencontainedduetotightcontrolofreimbursementthrough a nationally uniform fee schedule, which means that administrative andoperationalcostscanbekeptlow.１２ Additionally,thenumberofphysiciansandnurseswhotreateachhospitalizedpatientisverylowcomparedtoothercountries.Somesaythatthismeansanoverlyheavyworkloadformedicalpersonnel,butthesituationdoescontributetoefficiencyofthesystem.Thus,Japan’shealthcaresystemcanbesaidtodorelativelywell on a cost‐performance basis, and it ranks first among theworld’s 191countries as far as WHO’s measuring of “overall goal attainment’ is concerned.１３Nevertheless, many Japanese, compared to people in the Netherlands, France, orSwitzerland,believethattheirhealthcaresystemis“inefficient.”(Figure11).

92 85 

80  78 80 

76  77 

67 70 

67  69  67 59  62  65  60 

50  50  55 64  60 

43 52 

47  44 35 

27 33  35 

24  21 

90 84  81  80 

77  75  75  72  70  69 69 

67  63  62  61  59  58  57  56 53  52  49  48  45 

37  36 31  27 

24 23  18 

97  88  86 78 

86 

75 

86  76  85 79  79  78  77  74 

66  64  64  65 70 

61  54 64 

52  43 

34 

53 

35  39 25  35 

30 

Aged 34 and underAged 35‐54Aged 55 and over

（％）

15

Figure 11. The Health Care System Is Inefficient

30 

31 

18 

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Poland

Bulgaria

U.S.

Chile

Russia

Philippines

South Africa

Slovakia

Australia

Turkey

Germany(East)

Korea

Norway

Lithuania

Czech Republic

Germany(West)

U.K.

Taiwan

Netherlands

Portugal

Slovenia

Sweden

Croatia

Denmark

Finland

Switzerland

Belgium(Flanders)

Israel

France

Belgium(Wallonia)

Strongly agree Agree

Neither agree nor disagree Disagree

Strongly disagree

％

Japan

16

Figure 12. Ratio of Health Care Costs to GDP in OECD Countries

Source:OECDHealthStatistics2013.Notes:Incountriesforwhichtherewasnodatafor2011,

thedatafromthemostrecentyearisshown. ShadingindicatescountriesforwhichISSPdataexists.

Country 2011orMostRecentYear

U.S. 17.7Netherlands 11.9France 11.6Germany 11.3Canada 11.2Switzerland 11.0Denmark 10.9Austria 10.8Belgium 10.5NewZealand 10.3Portugal 10.2Japan 9.6Sweden 9.5U.K. 9.4Spain 9.3Norway 9.3Italy 9.2Greece 9.1Iceland 9.0Finland 9.0Australia 8.9Ireland 8.9Slovenia 8.9Slovakia 7.9Hungary 7.9Israel 7.7Chile 7.5CzechRepublic 7.5Korea 7.4Poland 6.9Luxembourg 6.6Mexico 6.2Turkey 6.1Estonia 5.9OECDaverage 9.3

%

17

5. FactorsInfluencingSatisfactionwiththeHealthCareSystem

WhereDoctorsareWellRegarded,HealthCareSystemSatisfactionisHigh

Thissectiondiscussesfactorsthatmaybeinfluencingsatisfactionwiththehealthcaresystem.Letusfirstlookattherelationshipbetweenhowpeoplefeelaboutdoctors,and theirsatisfactionwith thehealthcaresystem.Thecorrelationcoefficientbetweensatisfactionwithtreatmentandsatisfactionwiththehealthcaresystemis0.831,whilethecorrelationcoefficientbetweentrustindoctorsandsatisfactionwiththehealthcaresystemis0.899.Thetwofiguresindicateastrongcorrelation(Figures13,14).Inotherwords, countries with large numbers of people satisfied with treatment and wherepeoplebelievethatdoctorsaretrustworthyarealsocountrieswheremanypeoplearesatisfied with the health care system. In Japan, the ratio of people satisfied withtreatmentandpeoplewhotrustdoctorsarebothlow,andthosesatisfiedwiththehealthcaresystemarealsofew.

Figure 13. Satisfaction with Treatment and Satisfaction with the Health Care System

Satisfaction with treatment

(%)

Satisfaction with

 health

 care system

18

Figure 14. Trust in Doctors and Satisfaction with the Health Care System

PerceptionsofHealthCareSystemEfficiencyandSatisfactionLevels

Thereisanegativecorrelation(‐0.692)betweenthepercentageofpeoplewhosaythat“thehealthcaresystemisefficient”andsatisfactionwiththesystem(Figure15).Inotherwords, themore people believe that their health care system is inefficient, thefeweraresatisfiedwiththesystem.InJapan,manypeoplebelievethatthehealthcaresystemisinefficient,andtheirsatisfactionwiththesystemisnotstrongeither.

One factor in Japan is that people have direct access to the hospital or clinic oftheirchoiceforaconsultation,andmanytendtogotoamajorhospitalfromtheoutset.Somesaythatthistrendinterfereswithemergencycare,andabilltoraisethecurrentcharge for patientswho go direct to a large hospitalwithout a referral from a familydoctor is being discussed. Various measures are being implemented to raise theefficiencyofthesystem,suchasutilizingelectronicpatientrecordsandreimbursementbreakdownstoenableadministrators tozero inonoverconsumptionofhealthcareoroverprescribingofdrugs.Ifthesemeasuresareeffectiveforimprovingefficiencyandthepublicbecomesmoreawareof themeasures, theymayexpressmoresatisfactionwiththehealthcaresysteminthefuture.

Trust in doctors

Satisfaction with

 health

 care system

(%)

19

Figure 15. “The Health Care System Is Inefficient” and Satisfaction

with the Health Care System

Satisfaction with

 health

 care systemHealth care system is inefficient

(%)

AU Australia PL PolandBG Bulgaria PT PortugalCL Chile RU RussiaTW Taiwan SK SlovakiaHR Croatia SI SloveniaCZ Czech Republic ZA South AfricaDK Denmark SE SwedenFI Finland CH SwitzerlandFR France TR TurkeyIL Israel US U.S.JP Japan BE-FLA Belgium(Flanders)KR Korea BE-WAL Belgium(Wallonia)LT Lithuania DE-W Germany(West)NL Netherlands DE-E Germany(East)NO Norway GB U.K.PH Philippines

20

CorrelationbetweenPoorAccesstoHealthCareandSatisfaction

Lastly, to determine the relationship between access to health care andsatisfactionwith the health care system, correlation coefficients for the percentage ofthose who answered “could not pay,” “no health care available nearby” and “a longwaitinglist,”andsatisfactionareshowninFigure16.Amongthese,thereisacorrelationof‐0.434between“alongwaitinglist”andsatisfaction,demonstratingatrendtoweaksatisfactionwiththehealthcaresystemincountrieswherepatientshavetowaitalongtimetoseeadoctor.

Datashowed thataccess tohealthcarewasalsorelated tosatisfaction,althoughthecorrelationwasnotasstrongasforsatisfactionwithhealthcareandtrustindoctors.

Figure 16. Correlation between Lack of Access to Health Care and

Satisfaction with the Health Care System

Reasonsfornotbeingabletoaccesshealthcare

Couldnotpay Nohealthcareavailablenearby Longwaitinglist

Satisfactionwithhealthcaresystem ‐0.231 ‐0.394 ‐0.434

(Pearsonproduct‐momentcorrelationcoefficient)

6. Conclusion

Findingsof the ISSPsurvey for Japan indicate thatdespitegoodaccess tohealthcare, fewpeoplearesatisfiedwith thehealthcaresystem.Satisfactionwith thehealthcare system may be influenced by factors like trust in doctors, satisfaction withtreatment,andperceptionsofthehealthcaresystem’sefficiency.Therefore,improvingsatisfaction with treatment and the efficiency of the system may help improvesatisfactionwiththehealthcaresystem.

During Japan’s rapid economic growth in the 1950s and 1960s,many privatelyfundedhospitalswerebuiltthroughoutthecountry.Althoughaccesstohealthcarewassecuredinthisway,someholdthatimprovingthequalityofhealthcarewasputonthebackburner.１４ WithrevisionstotheHealthCareLawin1997,theconceptofinformedconsent—thoroughly explaining treatment topatients inorder toestablish agreementbetweenpatientanddoctor—wasintroducedasawayofimprovingthequalityofhealthcare. But beginning in the 2000s, reimbursement rates were cut in order to reducehealth care costs, while doctors were expected to spendmore one‐on‐one time withtheirpatientsatthesametime.

The Japanese public’s expectations are continually rising, as they desirebetter‐qualityhealthcareanddoctorconsultationsthatrespectpatientsasindividuals.Despite this, it seems that doctors and the health care system are failing to respondadequatelytousers’expectations,asevidencedbytheshortageofdoctorsinspecialtieslikeobstetrics,pediatrics,andsurgery.１５ Dissatisfactionwiththehealthcaresystemis

21

likelyduetothegapbetweenexpectationstowardhealthcareandeverydayhealthcarereality.

Inthisstudy,peoplewereaskedwhethertheywouldbeinfavorofhighertaxesinorder to improve health care standards. Data for Japanese people showed that thosewhowere satisfied andwho did notwant to paymore tax accounted for 43 percent.Meanwhile, those who were dissatisfied and who did not want to pay more taxaccounted for55percent.This indicates thatpeoplewhoweredissatisfiedweremorelikelytofeelnegativelytowardanincreasedtaxburden.Improvingsatisfactionwiththehealth care system is essential formaking health care expenses feel less burdensomeandultimately,forensuringthesystem’ssustainability.Constructivediscussionsshouldbe continued to achieve an efficient, sustainable health care systemensuringpeople’sgoodhealth.

Outline of Survey in Participating Countries

Year ofSurvey

No. of ValidResponses

SurveyMethod

U.S. 2012 1,550 Face‐to‐face

U.K. 2011 936 Self‐completion with interviewerinvolvement

Israel 2011–12 1,220 Face‐to‐face

Australia 2012 1,946 Self‐completionbymail

Netherlands 2011 1,472 Self‐completionbymail

Korea 2011 1,535 Face‐to‐face

Croatia 2011 1,210 Face‐to‐face

Switzerland 2011 1,212 Face‐to‐face

Sweden 2011 1,158 Self‐completionbymail

Slovakia 2012 1,128 Face‐to‐face

Slovenia 2011 1,082 Face‐to‐face

Taiwan 2011–12 2,199 Face‐to‐face

CzechRepublic 2012 1,804 Face‐to‐face

Chile 2011 1,559 Face‐to‐face

Denmark 2013 1,388 Internet

Germany(West) 2012 1,117 Self‐completion with interviewerinvolvement

Germany(East) 2012 564 Self‐completion with interviewerinvolvement

Turkey 2011–12 1,559 Face‐to‐face

22

Japan 2011 1,306 Self‐completion with interviewerinvolvement

Norway 2012 1,834 Self‐completionbymail

Philippines 2011 1,200 Face‐to‐face

Finland 2011 1,340 Self‐completionbymail

France 2011 3,319 Self‐completionbymail

Bulgaria 2011 1,003 Face‐to‐face

Belgium(Flanders) 2011 1,210 Self‐completion with interviewerinvolvementandbymail

Belgium(Wallonia) 2012 1,873 Self‐completionbymail

Poland 2013 1,115 Face‐to‐face

Portugal 2012–13 1,022 Face‐to‐face

SouthAfrica 2011 3,004 Face‐to‐face

Lithuania 2011 1,187 Face‐to‐face

Russia 2011 1,511 Face‐to‐face

１ KenjiShimazaki,2011.Nihonno iryo:Seidotoseisaku [Japan’sHealthCare:SystemandPolicies],TokyoDaigakuShuppankai.２ U.S.DepartmentofCommerceCensusBureau,2011.StatisticalAbstractoftheUnitedStates2011.３ For countries with weighted data, tabulation was conducted using the weighted figure. Whenanswerswere tabulated by totaling up answers tomultiple answer options, actual numberswereaddedandpercentagescalculated;therefore,insomecasesfiguresdonotcoincidewiththeadded‐uppercentages.４ OECD,2013.OECDHealthStatistics2013.DataforJapanisfrom2010.５ Frequencyofseeingadoctorwasqueriedona5‐pointscaleof“veryoften,”“often,”“sometimes,”“seldom” and “never.” Answers “very often,” “often,” and “sometimes” were grouped together asaffirmativeandanalyzedonthoseterms. ６ OECD,2011.HealthataGlance2011:OECDIndicators. ７ Shimazaki2011,Nihonnoiryo.８ Japan Institute for Labour Policy andTraining, 2013.Detabukkukokusai rodohikaku (2013nenban)[DatabookofInternationalLabourStatistics2013].９ OECD, 2013. FromOECDHealth Statistics 2013. Refer to data from 2011 or for the latest yearavailable.１０ NarumiEguchiandNaokoNumata,2004.“Iryonikansuruishikinokokusaihikaku—yonkakokunochihotoshinioite”[InternationalComparisonofAttitudestowardHealthCareinRegionalCitiesinFourCountries],inJMARIWorkingPaper,No.105.１１ MinistryofHealth,LabourandWelfare[Japan],2013.Heisei23‐nendokokuminiryohinogaikyo[EstimatesofNationalMedicalCareExpenditure,FY2011].１２ Hideki Hashimoto, Naoki Ikegami, Kenji Shibuya, Nobuyuki Izumida, Haruko Noguchi, HideoYasunaga,HiroakiMiyata, JoseM.Acuin,MichaelR.Reich,2011. “CostContainmentandQualityofCare in Japan: Is ThereATradeoff?”TheLancet, “Japan:UniversalHealthCare at 50Years,” JapanCenterforInternationalExchange.１３ WHO,2000.TheWorldHealthReport2000.１４ TakaakiKirino,2014.Iryonosentaku[ChoicesinHealthCare],IwanamiShoten.

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１５ Kenji Shibuya, Hideki Hashimoto, Naoki Ikegami, Akihiro Nishi, Tetsuya Tanimoto, HiroakiMiyata,KeizoTakemi,MichaelR.Reich,2011.“FutureofJapan’sSystemofGoodHealthatLowCostwith Equity: Beyond Universal Coverage,”The Lancet, “Japan: Universal Health Care at 50 Years,”JapanCenterforInternationalExchange.DatafilesISSPResearchGroup(2013):InternationalSocialSurveyProgramme:HealthandHealthCare—ISSP2011. GESISDataArchive,Cologne,ZA5800DatafileVersion2.0.0,doi:10.4232/1.11759URLhttp://www.gesis.org/en/issp