Japan's Evolving Role in Global Health
What role has Japan historically played in the global health arena and what influences Japan’s involvement today? Dr. Kenji Shibuya and Mr. Rayden Llano (The University of Tokyo) discuss the key challenges and recommend reforms to help reposition Japan as a prominent leader in the global health field, regardless of the disaster the country suffered in March.
Origins and Successes
In the aftermath of World War II, Japan made international peace and development the focus of its foreign policy objectives, both on the basis of humanitarian considerations and its own self-interests.  For many years following, Japan’s efforts were centered on peace building and achieving political stability.  Realizing, however, that economic and human development also requires attention to social factors, Japan refocused its foreign policy around the concept of human security, of which global health became an integral part. 
Over the last 30 years, the Japanese people have shown remarkable leadership in global health on many occasions. In 1980, for instance, the eradication of smallpox was achieved under the leadership of Dr. Isao Arita while he was Chief of the World Health Organization’s (WHO) Smallpox Eradication Unit.  In addition, the successful worldwide implementation of the DOTS strategy to treat tuberculosis (TB) in the 1990s was due in large part to Dr. Arata Kochi, who for ten years oversaw the WHO’s TB initiatives. 
The Japanese government has also played a major role in raising the profile of global health issues at two recent Group of Eight (G8) Summits in Kyushu-Okinawa and Hokkaido-Toyako. Most notably, Japan’s efforts in the G8 Summits greatly facilitated the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has already committed U.S. $21.7 billion to fight these three diseases in 150 countries. 
Key Issues and Challenges
Japan can claim great successes in global health. In a continuously evolving global health landscape, however, the country now faces significant challenges that must be addressed if it is to remain a key global health player. First, Japan’s global health policymaking is markedly characterized by government fragmentation that significantly hinders progress. At present, while consensus-building is necessary between the Japanese Diet and the Ministries of Foreign Affairs, Health, and Finance, as well as with Japan’s bilateral development agency, Japan International Cooperation Agency (JICA), there is no formal coordination mechanism in place. How can Japan effectively and efficiently set global health policies in the face of such fragmentation? The following section offers recommendations on how the country can overcome this barrier.
An even greater challenge is the overwhelming dominance of the government itself in global health issues and the correspondingly weak involvement of Japan’s nongovernmental organization (NGO) sector. Despite the increase in the number of global health NGOs in the last 30 years, Japan’s civil society is still small and largely dependent on government funds.  Further adding to this situation, the contributions of Japan’s for-profit sector, with the exception of a few innovative initiatives discussed in the next section, have been limited as well. This is due at least in part to a lack of tax-exemptions for charitable contributions and a fundamental unawareness of global health issues among an increasingly inward-looking Japanese public. This disengagement from the outside world leads to limited media coverage of global health, which in turn, in a vicious cycle, serves to further reinforce Japanese society’s lack of global health awareness.
The weak involvement of Japan’s NGO and private sectors has major implications for Japan’s continuing role in global health. First, the country will remain unable to substantially increase its financial commitment to global health. Currently, government funding accounts for an overwhelming 99.2% of development assistance for health ($652 million in 2008).  This represents essentially all of Japan’s financial investments in global health, and yet it only accounts for 0.013% of Japan’s gross national income—far below the global average of 0.05% in the Organisation for Economic Co-operation and Development (OECD) countries. In addition, insufficient global health engagement by independent academic institutions has resulted in a severe lack of research capacity that will increasingly hinder Japan’s ability to assess global health needs and set priorities according to evidence-based research and evaluation.
Despite these challenges, Japan has great potential to overcome these barriers and become a more effective global health contributor by implementing several key recommendations.
First, the Japanese government should establish a high-level global health committee. The committee should include all major stakeholders; namely, policymakers, bureaucrats, and academics, as well as civil society and private sector representatives. This consolidation would significantly increase coordination and communication between the different ministries and other key global health actors, thereby facilitating efforts to increase Japan’s financial commitments and expand its research capacity (as discussed below).
Second, the Japanese government should promote greater engagement by its NGO and corporate sectors in the global health arena, which will require substantial inter-ministerial coordination. Already, new pioneering initiatives are emerging in Japan. In 2003, Sumitomo Chemical transferred its Olyset bed net technology to a company in Tanzania in the hopes of making inroads in the fight against malaria. Since then, the company has steadily intensified its efforts, creating thousands of local jobs and resulting in the annual production of 29 million long-lasting insecticidal nets.
New civil society organizations are also arriving on the scene, such as Table for Two (TFT), a Japanese NGO that aims to promote health globally by “simultaneously address[ing] hunger in the developing world, and obesity and other lifestyle related diseases in the developed world.”  Every time one of TFT’s partner companies serves a healthy meal in Japan, that company donates $0.20 to TFT, which in turn puts the donation toward providing school meals to undernourished children in developing countries. Since its inception, TFT has enlisted more than 130 Japanese corporations, universities, and government offices. In 2008, TFT expanded its network to the United States.
Many more NGO sector initiatives like TFT are needed. They can be encouraged through greater global health awareness among the Japanese public, policymakers, and the media, as well as by granting tax-exempt status to civil society organizations, a recommendation that the Ministry of Finance has not yet agreed to implement. 
Lastly, crucial to Japan’s efforts to ramp up its involvement in global health is the need to increase scientific and health policy research capacity. To do this, Japan needs to make greater investments in global health leadership programs within universities to increase the stream of qualified Japanese students and young leaders working in global health, as well as to set up an external evaluation agency similar to the U.S. Institute of Medicine. Through these efforts, Japan’s capacity for evidence-based policymaking will significantly increase, thereby facilitating an effective Japanese response to the newly emerging and ever-changing health needs of the global community.
Looking to the Future
On March 11, 2011, the most devastating earthquake to ever strike Japan was accompanied by a destructive tsunami that washed away entire cities, killing and injuring tens of thousands of people and displacing more than 200,000 others. With no time to react, much less respond to the devastation, the country was also met head-on with the worst nuclear crisis since Chernobyl—an ongoing emergency that has sent shockwaves throughout the entire world as fears of radiation leakage continue to abound.
Amid reports that this may be one of the world’s costliest natural disasters, many might assume that Japan, already facing economic decline, is not in a position to reposition itself as a leader within the global health community. This opinion could not be further from the truth.
Now, more than ever, Japan is reminded of how closely interconnected we all are and of the importance of working in solidarity to address the world’s global health challenges. The ongoing nuclear crisis has fuelled considerable anxiety around the world over the potential health effects of leaked radiation reaching many countries. Witnessing firsthand how national problems can affect the health and well-being of others in the international community, Japan is more determined than ever to transform its global health involvement and leadership. In fact, there are already powerful signs of change. Seeking to help mitigate the impact of the disasters, we have seen unprecedented numbers of Japanese youth rushing to care for disaster victims. Using Japanese social media networks such as Mixi and GREE, which each have over 20 million users, many young Japanese have effectively mobilized substantial financial resources through donation campaigns and gathered support for projects targeting the identified needs of the victims. Some might argue that the present engagement of Japanese youth is only temporary, but we posit that the deep-rooted solidarity created by this unprecedented disaster is sustainable and has the potential to reshape Japan’s role in global health if reforms are initiated on the basis of our recommendations.
About the Authors
Rayden Llano is a 2010–11 Henry Luce Scholar working within the Department of Global Health Policy in the School of International Health at The University of Tokyo Graduate School of Medicine. Graduating in 2010 from Stanford University with a BA in Human Biology, he has also spent part of his tenure as a Luce Scholar at the WHO Regional Office for the Western Pacific.
Kenji Shibuya is Professor and Chair of the Department of Global Health Policy in the School of International Health at The University of Tokyo Graduate School of Medicine. Dr. Shibuya is founding Vice President of Japan’s Institute for Global Health. Previously, he worked with the WHO’s Global Program on Evidence for Health Policy and coordinated its Health Statistics and Evidence Unit. Dr. Shibuya serves on both the WHO’s Global Burden of Disease 2005 Project and the Advisory Committee for WHO Health Statistics.
 Ministry of Foreign Affairs of Japan, Japan’s Official Development Assistance Charter, 2003; and Ministry of Foreign Affairs of Japan, Japan’s ODA Annual Report, 1994.
 Dennis Trinidad, “Japan’s ODA at the Crossroads: Disbursement Patterns of Japan’s Development Assistance to Southeast Asia,” Asian Perspective 31, no. 2 (2007): 95–125.
 Corinna Konrad, “The Japanese Approach: Tracks of Human Security Implementation,” Human Security Perspectives 1, no. 3 (2006): 22–38; and United Nations Commission on Human Security, Final Report of the Commission on Human Security (New York: Commission on Human Security, 2003), chap. 1.
 Frank Fenner, Nature, Nurture and Chance: The Lives of Frank and Charles Fenner (Canberra: Australian National University Press, 2006), chap. 10.
 M.S. Murali and B.S. Sajjan, “DOTS Strategy for Control of Tuberculosis Epidemic,” Indian Journal of Medical Sciences 56, no. 1 (2002):16–18.
 Michael Reich, Keizo Takemi, Marc J. Roberts, and William C. Hsiao, “Global Action on Health Systems: A Proposal for the Toyako G8 Summit,” Lancet 371, no. 9615 (2008): 865–69.
 David Arase, “Public-Private Sector Interest Coordination in Japan’s ODA,” Pacific Affairs 67, no. 2 (Summer 1994): 171–99.
 Rayden Llano, Sayako Kanamori, Osamu Kunii, Rintaro Mori, Teiji Takei, Hatoko Sasaki, Yasuhide Nakamura, Kiyoshi Kurokawa, Yu Hai, Lincoln Chen, Keizo Tekemi, and Kenji Shibuya, “Reinvigorating Japan’s Commitment to Global Health: Challenges and Opportunities,” Lancet (forthcoming).
 “Sumitomo Chemical Announces Expansion of Olyset Net Plant in Tanzania,” Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria, August 3, 2009, http://www.gbcimpact.org/itcs_node/2/0/news/2015; and “Olyset Manufacturing in Africa,” Sumitomo Chemical, http://www.olyset.net/olysetnet/manufacturinginafrica.
 Table for Two, http://www.tablefor2.org/en/abt_whoweare.html.
 Julie Gilson and Phillida Purvis, “Japan’s Pursuit of Human Security: Humanitarian Agenda or Political Pragmatism?” Japan Forum 15, no. 2 (2001): 193–207.