OCCUPATIONAL HEALTH SERVICES IN JAPAN
Policy and Legislation
In Japan, the sole administrative body of occupational health is the Ministry of Labour, and the core law is the Industrial Safety and Health Law enacted in 1972 (this law will be termed “the Health Law” for the purposes of this article). The Health Law and its enforcement orders specify the employer’s responsibility to provide occupational safety and health services, including the appointment of an occupational health physician (OP), according to the size of the workplace. It is a requirement that all workplaces employing 50 or more workers appoint an OP (a full-time OP for workplaces that employ 1,000 or more workers). In addition, all workplaces, regardless of employee number, are mandated to provide health examinations for their workers. The mandatory health examinations include pre-employment and periodic general health examinations for full-time workers and specific health examinations for full-time workers engaged in activity described as “harmful work”. Compliance with the above legal requirements is generally good, although a gradient in compliance rate exists according to workplace size.
Organization and Service Provision Models
Organization and service provision models vary considerably according to the size of the workplace. Large-scale workplaces often embody full-size occupational health units, such as a health administration department, a department of health promotion or a clinic/hospital on the premises. These functional units may take the form of independent institutions, especially if they emphasize curative activities, but many are units subordinate to departments such as the labour department or the general affairs department. In some cases, the occupational health unit is run by a corporate health insurance union. The full-time OP is very often appointed to a directorial position of the unit, sometimes nominally matching a managerial post within the corporate hierarchy. The co-medical staff may consist of a variable combination of general nurses, occupational health nurses and x-ray and/or medical technologists.
In contrast, many small-scale workplaces lack the human and facility resources to carry out occupational health functions. In this sector, part-time OPs are recruited from among private general practitioners, hospital- or university-affiliated physicians and independent or non-independent occupational health practitioners. The part-time OPs engage in a variable range of occupational health activities depending on the needs of the workplace and the physician’s expertise. An occupational health organization (OHO), which is defined as an organization delivering occupational health services on a profit-earning basis, have played an essential role in the provision of occupational health services to small-scale workplaces. Services purchasable from OHOs cover provision and follow-up of various health examinations, implementation of environmental measurements and even the dispatch of OPs and nurses. Many small-scale workplaces appoint a part-time OP and contract with an OHO to meet specific legal requirements imposed on the workplace.
Activities and Content
Nationwide questionnaire surveys focusing on the activities of full-time and part-time OPs have been conducted periodically by the Occupational Health Promotion Foundation, an auxiliary non-profit-making organization of the Ministry of Labour. According to the 1991 survey, to which 620 full-time OPs responded, average time allocation was longest for curative activities (495 hours/year) followed by periodic health examinations (136) and health consultations (107). Time allocation to workplace patrols averaged 26.5 hours/year. In the survey, 340 part-time OPs also responded; the average time allocated by part-time OPs was proportionately less than that of full-time OPs. However, a detailed observation reveals that the activities of part-time OPs vary widely in quantity and quality, depending on several inter-related factors:
1. size and characteristics of the workplace
2. main job and other appointments of the physician
3. work commitment.
There are no legal provisions on the qualifications of the OP: simply stated, the OP (whether full-time or part-time) can be appointed “from among physicians” (the Health Law). As of 1995, the total number of physicians is estimated to be 225,000, with an annual increase of about 5,000 (i.e., an increase of 7,000 qualifying from graduates of 80 medical schools in Japan and a decrease of 2,000 due to death). The estimated number of OPs as of 1991 was about 34,000 (2,000 full-time and 32,000 part-time), which was equivalent to 16.6% of the total number of physicians (205,000). In addition, an estimated several thousand nurses across the nation play an active part in the field of occupational health, although there is no legal definition of an occupational health nurse. A health supervisor, which is defined by the Health Law as a person who takes charge of technical matters related to health, is recruited from among the workers. The OP interacts closely with the health supervisor, to whom the OP may “give guidance or advice” under the Health Law.
Within the Ministry of Labour, occupational health is administered directly by the Industrial Safety and Health Department, which is subordinate to the Labour Standards Bureau. The Bureau’s functional units at the local level include the Prefectural Labour Standards Offices (of which there are 47) and the Labour Standards Inspection Offices (there are 347 of these) distributed nationwide and staffed by a total of about 3,200 “Labour Standards Inspectors”, 390 “Industrial Safety Expert Officers” and 300 “Industrial Health Expert Officers”.
The Ministry of Labour has been implementing consecutive five-year plans for the prevention of industrial accidents; the most recent of these (the eighth) was associated with the slogan “realizing a healthier and safer working life on both mental and physical aspects”. Accordingly, the Ministry is pursuing a Total Health Promotion (THP) plan. Under the THP plan, the OP prescribes an exercise menu for each worker based on health measurement data. Training programmes accommodating company representatives are organized by the government to develop necessary skills. The government also gives recognition to OHOs that are capable of providing services related to THP implementation.
When occupational health services are provided on the premises, as is the case in large-scale workplaces, they will often take the form of an intracorporate department and will thus be placed under the financial constraints of the employer. Another variation involves the presence of an affiliated but self-supporting unit (clinic, hospital or OHO) which employs an occupational health staff. In some cases, the unit is run by a corporate health insurance union. Many small-scale workplaces, lacking the human, facility and financial resources, but under the requirement to appoint a part-time OP, will often do so by contracting with general practitioners, hospital- or university-affiliated physicians and others. As stated previously, the part-time OP will engage in a variable range of occupational health activities depending on the needs of the workplace and the physician’s expertise. The requirements imposed on the workplace, such as provision of periodic health examinations to all employees, often exceed the time capacity and/or the willingness of the contracted physician. This creates a demand-supply gap which is often filled by OHOs.
The Japan Society for Occupational Health (JSOH) is an academic society comprising OPs, occupational health nurses and researchers. Its present membership exceeds 6,000 and is increasing at a rapid rate. The JSOH holds annual scientific meetings at national and regional levels and recently started publishing an English scientific periodical entitled Journal of Occupational Health. Some core research institutes are the National Institute of Industrial Health (periodical: Industrial Health, biannual, English), the Institute for Science of Labour (periodical: Journal of Science of Labour, monthly, Japanese and English), the Japan Industrial Safety and Health Association (publications: Industrial Safety Yearbook and so on) and the Institute of the Industrial Ecological Sciences of the University of Occupational and Environmental Health, Japan (periodical: Journal of UOEH, bimonthly, Japanese and English).
The Ministry of Labour recently launched a comprehensive plan aimed at disease prevention and health promotion for the nation’s workers. It plans to establish government-subsidized occupational health centres (OHCs) at prefectural and regional levels throughout the country within an eight-year plan. Prefectural OHCs are planned to be established for each of the 47 prefectures, and each will be staffed by about 15 personnel, including one administrative full-time physician and three or four part-time physicians. Their primary function will be the provision of training and dissemination of information to OPs working within the vicinity. Regional OHCs are planned for 347 sites nationwide in affiliation with the local divisions of the Japan Medical Association (JMA). They will focus on providing occupational health services to the under-served sector, that is, workers in small-scale industries. The initial budget for the fiscal year 1993 was 2.3 billion yen ($US20 million) for the establishment of six prefectural and 50 regional OHCs. The prefectural and regional OHCs will function interactively as well as with the administration, the JMA, the workers’ hospitals and so on. Collaboration between these various institutions will be the key to the success of this plan.