In the face of ageing population and in the light of statistical data showing that the rate of industrial accidents was still high in the age group 50-59 as well as of a growing trend of overall health problems in the working population, the labour administration of Japan developed and implemented a new health policy for workers based on the promotion of a "Total Health" approach. This policy designated as the Total Health Promotion Plan aims at making workers recognize personal responsibility with respect to their long-term health status and maintain a healthy physical and mental condition.

Accordingly, the policy required that total health promotion programmes be established at each workplace in order to introduce "health education" and "exercise guidance" into the everyday life of workers so that these principles become customary.

The administrative structure directly responsible for the implementation of the THP is the Industrial Safety and Health Division of the Ministry of Labour. The implementation strategy of the THP relies on the Japan Industrial Safety and Health Association and its network of industrial experts and professionals on the one hand, and the direct involvement of all workplaces with the support of a national network of 343 Local Labour Standard Inspection Offices. These two entities work under the overall guidance of the Ministry of Labour.

In 1979, the Ministry of Labour had developed and implemented an occupational health policy designated as the Silver Health Plan, for middle-age to elderly workers with the purpose of reducing the number of accidents. At that time, the total number of industrial accidents was over 1.1 million. Although, the overall number has been decreasing over the last two decades, statistics still showed that more than 600,000 workers experienced industrial accidents each year. Among these accidents, the number of service incurred deaths and injuries⁽²⁾ reached more than 160,000 out of which 2,000 were deaths.

An analysis of the statistics of industrial accidents rate by age group showed that although the age group 50-59 represented only 30% of total workers, it incurred the highest number of accidents and twice as much as the age group 30-39, and represented almost 50% of all service incurred deaths and injuries⁽³⁾. Given the demographic structure of the population, the labour administration estimated as high the probability that workers of this age group be victims of future industrial accidents, and gave the priority to the occupational safety and health practices such as the SHP to be the chief task of the occupational safety and health administration.

Other factors considered as leading to such statistical results were the ageing society, the lack of exercise and nutrition, and the increase of stress at the workplace. Statistics showed that numerous workers were ill because of unstable rhythm of life, and showed a growing trend with respect to the rate of remarks such as diabetes and high blood pressure, resulting from periodical health diagnoses. These remarks increased from 23.6% in 1990 to 38% in 1996.

In the face of these data the labour administration decided to amend the Industrial Safety and Health Act (ISHA) in October 1988 in order to elaborate policy measures aimed at the improvement of the overall health of workers. The Silver Health Plan was revised and replaced by a new plan designated as the Total Health Promotion Plan (THP). While the SHP focussed primarily on the maintenance and improvement of health conditions for elderly workers, the THP promotes "total health" for all workers.

The THP is based on an approach according to which workers must recognize the importance of self-responsibility with respect to their long-term health status and therefore maintain a healthy physical and mental condition. Therefore, workers should establish a healthy lifestyle based on the active and dynamic principle of "self-care", interpreted as the management of ones' body. Total Health Promotion programmes should emphasize the principle of "self-care" in the everyday life of workers. Hence these programmes should introduce "health education" and "exercise guidance", into the workers' everyday life in order for these principles to become customary, and a detailed health promotion programme for workers must be defined for each workplace.

According to the ISH Act, the implementation of this new approach must take into consideration the following elements:

development of the system that is necessary to ensure the implementation structure of "health check";
training and education of industrial doctors;
training and education of the leaders (corporate, administrative, and social) responsible for the promotion of total health;
preparation and establishment of the infrastructures or equipment needed for the promotion of total health.

The implementation of the THP is provided in the guidelines stipulated by the ISHA (Article 70.2, relating to the maintenance and promotion of occupational health at the workplace).

The THP is administered by the Ministry of Labour which is responsible for the formulation and planning of the policies and procedures necessary to the promotion of occupational safety and health. The administrative structure responsible for the implementation of the THP is the Industrial Health Division which is under the authority of the Industrial Safety and Health Department of the Labour Standard Bureau, Ministry of Labour.

This Division is responsible for the preparation of various policy measures and promotion programmes of the THP, along with the realization of overall objectives set out within the guidelines established and enforced by the Ministry of Labour. This central body, which plays a leader role, devolved the management of promotion activities of the THP to two entities, to which it provides support and guidance. The first entity participating in the strategy for the implementation of the THP is the Japan Industrial Safety and Health Association (JISHA). It is authorized by the Act of Industrial Accident Preventive Organizations. Within JISHA, the Division directly responsible for the implementation of the THP is the Industrial Health Promotion Department. The second entity participating in the strategy for the implementation of the THP is the workplace (company offices, factories, inventories, construction sites, etc.). As the main executing actor, workplaces establish detailed practices, arranged for their specific situations with guidance and regulation from the Ministry of Labour, and are executed for the improvement of workers' health conditions.

The Industrial Health Division works in close cooperation with the network of decentralized Prefectural Labour Standards Offices (PLSO) and their subordinate local agencies called Labour Standards Inspection Offices (LSIO). The latter are the main local authorities that promote occupational safety and health. Forty-seven PLSOs are established in each prefecture (equivalent to a state) and control the work of 343 LSIOs operating on projects related to labour administration and providing direct services to companies and offices throughout the country.

The Division relies also on its network of 347 Regional Industrial Health Centres (RIHC). These Centres which started operating in 1993 have been established on the basis of an amendment to the Industrial Safety and Health Act adopted in October 1996, for the purpose of promoting and providing industrial health services to workers and employers of small workplaces employing less than 50 workers (ISHA; Article 19, Clause 3). The RIHCs are run by the local medical doctors associations through a contract with the central government. Hence, a centre is located in each Office of the medical doctors association.

Finally, the Industrial Health Division of the Ministry of Labour has jurisdiction over to the services of the Prefectural Industrial Health Promotion Centres (PIHPC), established in a prefecture in order to provide support to the RIHCs, to industrial health personals, and to workplaces employing more than 50 workers. The PIHPCs work under the authority of a public institution, the Labour Welfare Corporation⁽⁴⁾, and in close cooperation with the prefectural medical doctors association of each Prefecture. These PIHPCs started operating in 1993 and by the end of March 1999, there are 29 such centers in the country. The Ministry of Labour is aiming at having them established in each prefecture.

At the Industrial Safety and Health Division of the Ministry of Labour

The Industrial Health Division is in charge of the work related to the standards of industrial health, to the registration and supervision of the health and working environment assessment institutions, to the procedures concerning the registration of Health Consultants, and to the administration and supervision of the Institute of Industrial Medical Science. An Industrial Environment Improvement Office was established within this Division to manage the work related to the improvement and development of working environment.

At JISHA

Means to promote and to establish THP at workplace as well as plans of research and surveys shall be discussed regularly at the "Meeting for the Maintenance and Promotion of Workers' Health⁽⁵⁾" taking place in JISHA in line with the "Guideline for the Maintenance and Promotion of Workers' Health at Workplace" mentioned in article 7, The Health Promotion Department of JISHA shall carry out plans for the promotion of THP, which it envisages according to the results os such discussions and after further consultation with the Industrial Health Division, Ministry of Labour.

Roles of JISHA for the promotion of THP are as follows:

backup for the health promotion activities in workplace;
training and education of health promotion personnel;
backup and registration of health promotion personnel;
authorization and registration of institutions which offer THP-related services to workplace;
promotion and research of THP.

Categories and roles of health promotion personnel are defined in the following according to the "Guideline for the Maintenance and Promotion of Workers' Health at Workplace" mentioned in Article 7.

Industrial physicians - Practice health measuring, and according to the results, make instruction sheets for each individual. Then give instructions to other personnel in charge of maintenance and promotion of health based on each instruction sheet.

Exercise trainers - Based on the results of health measuring make specific exercise program for each individual worker and give guidance upon carrying out such program. Also give instructive support by him or herself or by giving instructions to exercise leader for the practice of such program.

Exercise leaders - Based on exercise programs and according to the instruction of exercise trainers help each individual worker to carry out individual exercise program.

Psychiatric counsellor - According to the results of health measuring physicians's, and under industrial doctor's instruction, take care of mental health when necessary or when asked by the worker during medical consultation.

Industrial nutritionists - Give nutritional instructions according to the results of health measuring.

Industrial health leader - Give health guidance to each worker according to the results of health measuring.

Details of health promotion activities are defined in the following according to the "Guideline for the Maintenance and Promotion of Workers' Health at workplace" mentioned in Article 7.

Health measuring

In order to carry out measures for the maintenance and promotion of workers' health, it is necessary for each worker to have accurate knowledge and information about individual physical condition and to continue health control under the instructions of personnel directed by industrial physicians.

A "health measuring consists of various inspections of the life-style and physical condition of each worker to collect data on individual health condition in order to carry out, based on its results, guidance such as exercise guidance, mental health advise, nutrition guidance, health guidance, and it has different purpose from that of conventional medical check-up mainly for early detection of diseases. The health measuring shall be practised, in principle, under the leadership of industrial physicians and based on its results, instruction sheets shall be made for each worker according to individual physical condition, by which they will receive exercise guidance, health guidance and so on.

Practice and contents of health measuring

Health measuring shall be provided regularly for every worker in order to carry out various health guidance continuously and systematically. Health measuring consist of medical consultation, research on worker's life-style, medical check-up, medical observation and physical tests.

Instruction sheets

Industrial physicians evaluate the results of health measuring, medical examination and make out instruction sheets to carry out health guidance such as physical exercises, and instruct other personnel in charge of maintenance and promotion of health.

Exercise guidance

Based on the results of health measuring and the instruction sheet provided by industrial physician, exercise trainer makes advisable exercise program for each individual and gives guidance for the practice of such program. Exercise trainer and exercise leader physical shall help workers to practice such program. In such occasion, it is recommended for the personnel in charge to make each worker act positively and spontaneously.

Programming of physical exercises

When making physical exercise program, it is important to take into account the individual's life-style, favourite pastimes, what they want and other personal factors to make the type and content of exercises safe, joyful and effective.

Assistance for carrying out physical exercise program

When carrying out physical exercise, it is important to provide appropriate exercise for each worker and make it a constant activity at workplace so that they can establish a healthy everyday habit.

Mental health care

When it is judged that a mental health care is needed according to the results of health measuring or if the individual requires it during medical consultation, psychiatric counsellor should carry out mental health care in accordance with industrial physician's instruction. "Mental health care" mentioned in this guidance is for workers who actively seek healthy life and consists of assistance to detect potential stress or means to make them relax.

Nutrition guidance

When some kind of problems are found in worker's diet according to the results of health measuring, industrial nutritionist not only should give nutritional guidance but also should evaluate the eating habit and the diet of the worker to instruct them to improve them.

Health guidance

In order to solve health problems deriving from working condition or life-style, industrial health leader should give guidance and education in workplace life, according to the results of health measuring and the instruction of industrial physician for healthy life consisting of sleeping habit, habit of smoking and drinking, oral hygiene and so on.

Health promotion personnel working at workplace or institutions that offer THP services are required to have technical knowledge for the achievement of health and healthy life-style, JISHA gives training courses for specialized personnel in various fields such as industrial physicians, exercise mental health, nutrition and health as a training institute authorized by Ministry of Labour. It also takes charge of the promotion of THP by registrating trainees who finishes such courses and supporting their activities.

There are two types of institutions that give THP services:

one being authorized to practice health measuring and every kind of health guidance;
and the other one which is authorized to give only exercising practice within health measuring.

Those institutions provide direct support for the creation of health at workplace by sending health promotion staff, and so on.

JISHA in cooperation with the Industrial Health division of Ministry of Labour helps and instructs institutions which offer THP services.

At the decentralized level

The 343 Labour Standards Inspection Offices - working under the authority of the 47 Prefectural Labour Standards Offices - operate projects related to labour administration and provide direct services to companies and offices throughout the country. As for the promotion of safety and health, these offices provide guidance and support, with the help of Corporate Associations, for the prevention of industrial accidents.

These Corporate Associations organized within the same industry and operational area, make also independent efforts to motivate their members to improve the level of safety and health at the workplace by holding regular meetings, publishing periodicals, information bulletins containing mainly articles on amendment of laws and regulations, economic prospects and changes occurring within their industrial area and that of their members. These publications provide also several sets of statistical data including the number of industrial accidents.

In the case of Tokyo Metropolitan Area, for example, there seems to be a unique promotion practice for the THP. The Tokyo Prefectural Labour Standards Office has selected several enterprises or factories to become the future "excellent safety and health workplaces" - so called "model or guided workplace." These workplaces are required to make every effort, with the support provided by the 18 Labour Standards Inspection Offices in the Tokyo area, in order to achieve safety and good health conditions in line with the THP. The Tokyo PLSO then proceeds to an evaluation whereby it examines their implementation arrangements and annual results. If after analysis the results and improvements are considered to have reached a satisfactory level, they are publicized as "good examples". In addition to financial subsidies, those companies are granted some advantages in the insurance system for industrial accidents.

The purpose of this program is to widely disseminate those good practices and the results of the THP implementation. The Tokyo PLSO expects that other workplaces will follow suit and adopt the method used in those examples so that it expands to other prefectures or regions as a result.

At the RIHC

The RIHCs work in close cooperation with the Prefectural Labour Standards Offices and exchange information on a regular basis with the local Labour Standards Inspection Offices. The RIHCs main task is to promote occupational health for workers of companies employing less than 50 workers through the provision of: a) industrial health counselling service, b) individual industrial health guidance service at the workplace, and c) provision of information on occupational health. These services which are free of charge are funded by the government. The RIHCs provide to companies registered at the center information services consisting of the distribution of lists of experts and organizations dealing with industrial health services. Those lists contain of the names of industrial physicians, industrial health consultants, and the hospitals and other medical institutions which will accept the implementation of industrial health promotion programs such as regular health check. Most industrial physicians are approved by the Japan Medical Association and are members of regional medical (doctors) associations.

At the PIHPC

The PIHPCs help the RIHCs obtain information and provide them with consultations services on technical skills and know-how to smoothly carry out their industrial health promotion activities at the workplace.

At the Workplace

The second entity to which implementation of the THP has been devolved is the workplace (company offices, factories, inventories, construction sites). Detailed practices for improving workers' health conditions are arranged for the specific situation of each workplace on the basis of established regulations and guidance from the Ministry of Labour. Procedures at the workplace include health check which must be the precondition to the implementation of the THP, health guidance which contains exercise advice, nutrition guidance, mental counselling. These services are provided by external experts assigned to each workplace. The flow chart of the THP operation at the workplace is annexed in Figure 1 attached.

Where smaller undertakings have difficulties setting experts, they have the possibility of resorting to external institutions authorized by the Ministry of Labour for providing services in accordance with established standards. Those institutions are those institutions registered at JISHA. Beside providing the THP related services, these institutions provide also advice on documentation procedures needed for the application and claim concerning subsidies that workplaces are required to submit every year.

The promotion of the THP at the workplace is implemented in five different stages: (a) health check; (b) exercise guidance; (c) mental health care; (d) nutrition guidance, and (e) general health guidance.

Small undertakings that face difficulties in operating health promotion programmes are granted financial support by the administration. The criteria required for eligibility to financial subsidies are the number of full-time workers, i.e. less than 300 workers, the fact that compensation insurance for industrial accidents has already been applied, and that at least 3 of the five THP operations (i.e. health check, exercise guidance and health guidance) are implemented.

Workplaces with more than 50 workers have an obligation a) to establish a "health committee" in which detailed practices for the promotion and the maintenance of health should be discussed, and b) to elect and appoint an industrial doctor. This enforcement is regulated by the ISHA (Article 13, and also Article 5). Besides that, it is recommended that an "expert committee on promotion and maintenance of health" consisting of experts such as industrial doctors, be established at each workplace. An elaborate health guidance is then provided to each worker.

The Industrial Health Division of the Ministry of Labour is comprised of 18 civil servants, including 2 for THP operation and 5 for the Industrial Environment Improvement Office. Human resources for the PLSOs are determined by the Total Staff Number Law which establishes the number of civil servants in each public administrative body. The Tokyo PLSO, which is the largest in the country, the staff is comprised of 755 officials. This number includes all staff of the Office itself and that of the 18 LSIO in the Tokyo Metropolitan area. The number of staff at each LSIO in Tokyo may range from 8 to 66.

The JISHA, which Board includes several members who are former government officials, consists of approximately 310 employees. The Industrial Health Promotion Department of JISHA directly responsible for the implementation of the THP is composed of 20 employees including those who have transferred from the Ministry of Labour. In addition, there are several agents who have experience and attended some technical training/education programmes and achieved professional degrees and/or licenses necessary for THP promotion. They cooperate with external experts and professionals.

The Ministry of Labour and the JISHA have developed their home page on the World Wide Web. The contents of these home pages consist mainly of the organizational structure and the summary of main policies and operational services, including the promotion of the THP. The homepage of the Ministry provides rather policy and structure oriented information in relation to the THP, while that of JISHA gives more practical information and allows direct application for seminars and training programs.

The Labour Welfare Corporation has also developed a homemade on the Web. It presents the tasks and functions of RIHCs and PIHPCs. It also contains the address and phone number of each Center for the convenience of THP leaders and other workplace managers. In addition, several PIHPCs have installed some audio-visual equipment in their lounges for the visitors to learn about industrial safety and health implementation programmes.

The industrial doctor who is in charge of the health condition of a large number of workers at the assigned workplace tends to utilize computer devices constructing database in order to manage the results of consultations and diagnoses.

As mentioned above, the Industrial Health Division of the Ministry of Labour has conducted the policy making and operations of the THP in partnership with various organizations, including workers' and employers' organizations. As the local branches of the central Labour Standard Bureau of the Ministry, the PLSOs and LSIOs have cooperative relationship with the Division and receive direct instructions from the Division in order to promote the THP locally and enhance understanding of its importance.

As well as these central-local governmental partnership, the Division gives the direction to the Labour Welfare Corporation to administer the PIHPCs and to the medical associations to establish the RIHCs in order to help promoting industrial health at the workplaces.

In order for the Division to put its policies into practice, it works with the JISHA. It is in charge of actual promotion and support of the implementation of THP at the workplace cooperating with civil and public experts related to the THP. Finally, the workplace is the real enforcer or operator of the THP practices. The relationship between the Division and the workplace is rather principal-agent type than the partnership.

Financial resources for the implementation of the THP are totally funded by the Ministry of Labour. The structure of financial resources for the measures of industrial safety and health including the THP is generally divided into two types of accounts, i.e., the general account and the special account. In the general account, the 1997 budget for the industrial safety and health measures is 292.5 million yen. In the special account of industrial accident compensation insurance, on the other hand, the budget for the promotion of industrial health is 6.826 billion yen, and the budget for the guidance for the prevention of industrial accidents is 6.721 billion yen, and the budget for the subsidy/grant for industrial safety and health activities is 6.767 billion yen. The total amount of financial resources devoted to the implementation of the THP, therefore, comes from these various resources. In addition, the 1997 budget for the PLSOs in the general account is approximately 10.61 billion yen, and the budget for the LSIOs is about 18 billion yen.

The JISHA, on the other hand, has a total annual budget of approximately 16 billion yen. Out of this total, approximately 10-20 per cent are utilized by the Industrial Health Promotion Department which is responsible for the implementation of the THP.

There seems to be few evaluation standards or measurements of the THP implementation at the workplace provided by the central Government. It is the common understanding that the work of public administration, having the partnership with these related organizations, should be limited to only give support and guidance rather than to give inspections or supervision of each operation and management of the THP.

Therefore, the central government is only providing the evaluation measurement for implementing the THP by conducting a survey distributing a self-evaluation sheet to the workplace and by issuing a case study of good examples. These measurement is not directly conducted by the government but by those THP related organizations. A survey conducted by JISHA entitled "the survey on the health condition of workers", seems to be the sole tool measuring the effectiveness of the implementation of the THP at the workplace. In addition to that survey, the JISHA is indirectly evaluating the THP programs through the assessment of experts and trainers who support the improvement of industrial health at the workplace.

Government officials seem to recognize that effective implementation of the THP and then the betterment of industrial health at the workplace are a responsibility of the company or enterprise which runs the workplace and that the Total Health Promotion Plan itself is only a 'tool' to help the implementation.

The measurements for the evaluation of the implementation of these practices have been conducted by the Labour Welfare Corporation. The evaluation is based on the number of consultations at the Centres and/or the number of participants at seminars and conferences. However, the goal of the practices involving these Centres is not a decrease in the number of industrial accidents and/or unhealthy workers. It is more a matter of improvement in effectiveness of support and guidance towards those industrial health experts such as industrial doctors, health leaders, and managers of the workplaces. The central government, having received the evaluation report from the Corporation, seems to have recognized the necessity and the importance of this practice, therefore, it continuously provides the budget for further establishment of Centres throughout the country.

The roles of these Centres are, and may become more in the future, significant due to the fact that there are still a great number of small enterprises and workplaces making a great amount of efforts, and struggling for higher productivity under the condition of serious recessive economy. The review of the THP has brought to light the necessity of joint efforts by labour administration, companies, and workers in order to promote occupational safety and health at the workplace, and the advantage of such cooperation. The THP, together with the SHP, have been applied and practised for almost 20 years. They have been successful, and are now effectively implemented at each workplace where various partners are coordinating and cooperating in order to obtain adequate methods and procedures for carrying out the THP.

1. This case has been drafted on the basis of a study prepared by Jun Kumamoto.

2. Defined as requiring more than 4 days leave.

3. Idem.

4. The Labour Welfare Corporation is under the authority of the Workers' Compensation Administration Division of the Labour Standards Bureau of the Ministry of Labour.

5. Group of scolars and officials of relevant governmental agencies in charge of promotion and establishment of THP.

Good Practices in Labour Administration

Development and implementation strategies of the national occupational safety and health policy