The iron triangle of Japan's health care

Medical associations around the world influence healthcare policies in their respective countries. Policy makers turn to professionals for guidance on complex issues, so it is only natural that medical associations exert their influence through their knowledge. However, expertise alone cannot explain the influence of the Japan Medical Association on healthcare policy in post war Japan. The association's post war foundation was built during the 25 year presidency of Taro Takemi from 1957 to 1982. Takemi's uncle-in-law, Shigeru Yoshida, was Japan's first post war prime minister. This connection gave Takemi and the association unrivalled access to Yoshida and his successors in the ruling party. Through its influence on the ruling party, the association forced Japan's Ministry of Health, Labour, and Welfare to take heed and dictated much of healthcare policy.

Building on the legacy that Takemi created, currently the association boasts a membership of 159 000, a budget of 16bn yen (£83.4m; $155m; €119m), and an annual political donation fund of 1bn yen.¹ The successful formula that Takemi created—linking the Japan Medical Association, the ruling party, and the bureaucrats into an iron triangle—worked well for the association until the Koizumi cabinet was formed in 2001. Iron triangles exist in sectors where the government can influence pricing and output—for example, public works, road construction, farming, and retail.

The association and the iron triangle that it controlled have been on the defensive ever since. The iron triangle is being attacked at all three corners.² Firstly, Koizumi has taken power away from the Ministry of Health, Labour, and Welfare, and has used his cabinet office to set the overall direction of healthcare policy. Committees of the cabinet office are now largely headed by private sector leaders who are outside the sphere of influence of the association. They have spearheaded major reforms to control public spending on health care, while introducing more private competition among providers—steps vigorously opposed by the association but implemented none the less.

Secondly, the ruling party has lost its control. Although a member of the ruling party himself, Koizumi has largely ignored party committees—including those for health care. The association's historical grip on key committee members has therefore become meaningless. Furthermore, pollsters suggest that politicians need to look beyond the iron triangle to win the support of voters and re-election. A recent cabinet survey shows that health care is the number one policy area that concerns people—above economic growth and employment, even after 10 years of recession in Japan.³ Another survey by a major newspaper shows that over 90% of the public is dissatisfied with the current healthcare system.⁴ Strong public discontent, critical media coverage, and a more powerful opposition have all added to politicians from the ruling party seeking a support base broader than the Japan Medical Association.

Thirdly, the association, which is primarily a general practitioners' organisation, is under attack from hospital doctors and other medical professionals. Historically, Japan's high rate of economic growth could support the ever increasing costs of health care. With the Japanese economy stagnating, the healthcare budget has been kept under reign (despite an ageing population and a growing burden of lifestyle related diseases), and this has caused a fight over allocation. The association has fought for a bigger share for general practitioners often at the expense of other medical professionals. As a result the association is seen within the profession to represent less and less the overall interests of the profession.

On 12 July 2004, when the results of the election for the upper house were announced, the decline of the association's clout became clear. Back in 1977 the candidate nominated by the association gathered 1.3 million votes, representing 19 votes for every general practitioner member.⁵ Such an ability to garner votes, coupled with political donations, gave the association unrivalled political influence. In 2004 the association could muster only 0.25 million votes for its candidate.⁶ With 83 000 general practitioner members, this accounted for only three votes per general practitioner member—less than a sixth of the votes gathered in 1977. Considering that most general practitioners would have family members and employees, this number implies almost no influence outside their closest circles.

The impetus for the association's decline was Koizumi's rise to power. However, the root cause is more structural and likely to outlive the Koizumi era. The narrow interests pursued by select general practitioners had not addressed broader interests that became more pronounced and vocal over the years.

More fundamentally the association's decline begs the question about the role of medical associations in influencing healthcare policies. For the Japan Medical Association to reinvent itself, it needs to broaden its membership to represent the whole medical profession. It then needs to transform itself from a lobby group to an academically grounded professional association that is engaged with and accountable to the general public. In effect it needs to win the trust of the people—as a guardian of professional standards in policy debate as well as in medical practice and research.

These lessons are just as applicable to other medical associations around the world.