Japan Needs to Prioritize a “Population Health” Approach
Ryo Kubota (Acucela Inc.) argues that to improve its healthcare outcomes Japan should prioritize population health and medicine. Dr. Kubota sees opportunities for Japan’s innovative life science industry in this area.
Japan’s population is both aging and declining at a faster rate than any other in the world. As a result, the country’s government, academic research institutions, and life science industry are highly incentivized to leverage Japan’s notable history of technical innovation to ease the aging burden. They are doing so with gusto, and the world is watching. The government has prioritized health and healthcare innovation as it relates to aging-related diseases, among many other programs and policies. But one of the lowest-hanging and highest-impact fruits for how Japan can improve its healthcare outcomes remains unharnessed—prioritizing population health and medicine.
WHAT IS POPULATION HEALTH?
“Population health” is often confused with “public health,” but the two ideas are not quite the same. Public health focuses on which drugs, vaccines, or large-scale campaigns can treat or prevent a disease. By contrast, population health focuses on understanding why some people are more likely than others to get sick in the first place, and then seeks to identify the targeted, group-specific interventions that can reduce the odds that those individuals will need to turn to hospitalization or pharmaceutical intervention. Specific groups could be those who live in a specific area or city, those with certain education or income levels, those of a certain age, or those with certain dietary behaviors. For example, elderly individuals—the most rapidly expanding age demographic in Japan—are particularly vulnerable to chronic, lifestyle diseases and are among the most likely to suffer catastrophic health consequences if such diseases are not detected and managed early on.
By its very design, population health has a strong proactive prevention component, calling for action and resource allocation to overcome the more entrenched problems that drive poor health conditions. Health equity—the preventable differences in health between unique groups within a population—is a core part of understanding this paradigm. As part of this, population health advocates believe that successful initiatives require taking into strong account the societal structures, attitudes, and behaviors that influence individual and group health.
The complex influences on health mean that a range of interventions and approaches—from national spending and legislation around food, housing, education, employment, and immigration to social networks and collective action at the local community level—are needed for population health. In other words, population health has undeniable exponential benefits for health and healthcare, but its implementation can also be a policy nightmare, given that no one organization can truly be accountable for all these actions as they relate to the overall health of the population.
Nevertheless, Japan is arguably supremely equipped to deal with complex policy arrangements, made easier by its long history of practicing and encouraging healthy lifestyles (i.e., a nuanced understanding of the importance of social determinants on health embedded in cultural practices). Moreover, this is another opportunity for Japan to lead the world in innovative health system approaches, already having established the gold standard for universal health coverage.
HOW WOULD POPULATION HEALTH BENEFIT JAPAN?
Consider diabetes and dementia, two major health and economic challenges in Japan, which are set to rapidly increase as the population continues to age. In 2016, Japan’s Ministry of Health estimated that ten million Japanese adults had diabetes, and dementia has been diagnosed in more than five million Japanese. The government estimates that dementia diagnoses will increase to seven to eight million, or 6% to 7% of the total population, by 2030.
Symptoms that definitively point to someone having dementia or diabetes often do not emerge until significant damage is done. Yet from what we know about both illnesses, they are indisputably influenced by socioeconomic and environmental factors and have a chronic, progressive development. Moreover, diabetes patients are at significantly higher risk of developing all types of dementia, including Alzheimer’s disease. Successful management of population health starts with better early identification and tracking of these trends. And yet while some small studies exist, there is a paucity of data in Japan on the prevalence of both diabetes and dementia, and how those trends are affected by social determinants.
This is exactly the research that a country-wide approach to population health would make possible. Results would benefit health and science and improve longevity (or quality of life), not only in Japan but also worldwide. Japan’s innovative life science industry could capitalize on the trends that an approach prioritizing population health reveals in order to develop cutting-edge prevention and treatment strategies.
WHAT WOULD A POPULATION HEALTH APPROACH REQUIRE?
In addition to an empowered chief medical officer, as I have argued for elsewhere, a population health approach in Japan would require the creation of a school (or schools) of population health in the country’s academic and clinical training centers. Japan’s future medical practitioners and health policy leaders will need to learn to understand, follow, and treat individuals and designated groups of individuals, while having an eye toward the larger public. Existing academic programs cover public and global health but not population health. Importantly, creating a Japanese school of population health would require the integration of science and healthcare studies with health economics and population and social policy.
In addition to training future practitioners and leaders, Japan’s health system must move away from its doctor- and pharmaceutical-centric systems and toward a model that empowers nurse practitioners and community health providers. In other words, there must be a power shift in healthcare. Many doctors may resist such a shift, feeling a threat to their livelihoods. There is certainly strong resistance from many Japanese doctors to delegating more tasks to non–medical school graduates. Younger doctors, however, may welcome such a shift, which would alleviate their daily case burden (many doctors see more than one hundred patients per day, with little time for proper communication and relatively low pay) and allow them to provide better care for those they do treat, relying less on a barrage of tests. While Japan spends roughly half as much on healthcare as a percentage of GDP as the United States does, the Japanese health system spends about twice as much on drugs as a percentage of total healthcare costs. If young doctors are trained in a system that embraces a more affordable and effective distribution of tasks, the focus can shift to population health and away from power and ego.
In terms of policy, prevention must be prioritized in practice and not just on paper. For example, vaccination—the most tangible, most innovative prevention tool of modern medical science—lacks vocal champions in Japan. As I have argued elsewhere, Japan’s Ministry of Health, arguably the government body with the greatest mandate and authority to champion this essential tool for the Japanese population, is notoriously silent on the need for and benefits of vaccination. This silence is all the more disturbing given the loud voice of the country’s anti-vaccine movement, whose statements and claims have all been firmly debunked.
The lack of attention to population health in Japan is ironic given its history of successful post–World War II public health and sanitation programs—programs that form the foundation of many World Health Organization programs today. It is time for the country to marry its historical skills in these areas with a deliberate focus on population health.
WHAT COUNTRIES ARE DOING THIS ALREADY?
Numerous, primarily Western, developed countries are making concerted efforts to integrate population health approaches into their health systems and policies. No one country is doing this perfectly; all are grappling with mandate and ownership—an admittedly daunting task with no clear solution. But cases from the United Kingdom, the United States, and Australia show how and where to begin. That explicit intention pushes these countries far ahead of the curve in terms of health system advancement and commitment to the health of their people.
The UK’s National Health Service acknowledges that it has an important role to play in improving population health. The focus on population health can be seen through numerous initiatives, such as a government-run hospital operating a domestic charity to provide peer support to people living with HIV. Additionally, in Somerset a new model of care is being developed for people with three or more long-term conditions, which coordinates health and care services to meet the needs of these individuals and their families. Furthermore, general practitioners in Derbyshire work with the Citizens Advice Bureau to offer information on benefits, employment, immigration, and many other issues in primary care. 
In the United States, major population health determinants like healthcare, education, and income remain outside public health authority and responsibility, and current resources provide inadequate support for traditional—let alone emerging—public health functions. However, the U.S. Center for Disease Control (CDC) itself features two explicit population health strategies on its website: the 6|18 Initiative for healthcare purchasers, payers, and providers and the Health Impact in 5 Years (HI-5) initiative focused on community-level changes.
Australia offers the most comprehensive integration of population health. It has an explicit focus on research in major academic institutions, as evidenced by University of Technology Sydney’s Australian Centre for Public and Population Health Research. Additionally, the government recognizes the value of intentional research networks, such as the Population Health Research Network, which enables existing health data from around the nation to be collated and made available for vital health research purposes so that engaged partners can respond more effectively to the changing needs of the Australian population. Finally, the Department for Health and Wellbeing coordinates a survey called the Population Health Survey Module System, which is a multifaceted service available to the government and NGOs to obtain data on a range of population health issues.
The UK, U.S., and Australian models exhibit varying degrees of prioritization and implementation of population health approaches. Yet, regardless of degree, they all share an explicit government focus on population health. Japan can and should introduce intentional legislation, research, and programs, whether in one distinct community like the UK’s Somerset program, through narrow but focused national strategies such as the U.S. CDC strategy, or through a more comprehensive approach like the one seen in Australia that combines national research networks and surveys with academic, NGO, and government partnerships. Most important for Japan is to start this process and lay the groundwork for efforts that will directly improve the human and economic health of its population over the long term.
Japan’s demographic and economic challenges require healthcare policies that ease (or at least do not exacerbate) the financial burden and increase the quality of life for the country’s rapidly aging and declining population. Effective implementation of these policies will require more domestic experts with an in-depth understanding of population health. The introduction of such expertise at scale will require the creation of a school, or dedicated programs within multiple existing schools, focused on this concept. The absence of such expertise unfortunately ensures that any Japanese effort to improve the healthcare system will fall short—possibly addressing key issues for unique groups on paper but failing in practice to address the underlying issues of the group as a whole.
Perhaps most importantly, Japan cannot afford not to do this. Government debt is higher than ever, and GDP growth is very modest. This economic reality, combined with a declining labor population due to the rapid aging of Japanese society, the resulting skyrocketing healthcare and welfare costs, and the rising prices for cutting-edge therapies like novel cancer drugs or regenerative medicine demanded more and more by older populations, means that Japan can no longer spend whatever is needed for healthcare. The country has the highest number of MRI and CT scanners (per one million people) in the world, and three times as many outpatient visits as in the United States; hospital stays in Japan are likewise three times as long as in the United States.  Life science innovation alone will not solve these problems.
 “What Does Improving Population Health Really Mean?” King’s Fund, March 29, 2019, https://www.kingsfund.org.uk/publications/what-does-improving-population-health-mean.
 Tomoko Otake, “Japan’s Buckling Health Care System at a Crossroads,” Japan Times, February 19, 2017.
Ryo Kubota is Chairman, President, and CEO of Acucela Inc., a subsidiary of Kubota Pharmaceutical Holdings. He is also a member of the Board of Directors at the National Bureau of Asian Research and a visiting professor at Keio University School of Medicine. Dr. Kubota holds an MD and a PhD in medicine from Keio University.