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Health promotion policies in the Republic of Korea and Japan: a comparative study
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References (contd.)
Kosulwat, V. (2002). The nutrition and health transition in Thailand. Public Health Nutrition, 5(1A), 183-189. Likitmaskul, S., Kiattisathavee, P., Chaichanwatanakul, K., Punnakanta, L., Angsusingha, K., & Tuchinda, C. (2003). Increasing prevalence of type 2 diabetes mellitus in Thai children and adolescents associated with increasing prevalence of obesity. Journal of Pediatric Endocrinology and Metabolism, 16(1), 71-77. Lucero, K., Hicks, R. A., Bramlette, J., Brassington, G. S., & Welter, M. G. (1992). Frequency of eating problems among Asian and Caucasian college women. Psychological Reports, 71(1), 255-258. Martz, D. M., Sturgis, E. T., & Gustafson, S. B. (1996). Development and preliminary validation of the cognitive behavioral dieting scale. International Journal of Eating Disorders, 19(3), 297-309. Mo-suwan, L., & Geater, A. F. (1996). Risk factors for childhood obesity in a transitional society in Thailand. International Journal of Obesity and Related Metabolic Disorders, 20(8), 697-703. Popkin, B. M. (1994). The nutrition transition in low-income countries: an emerging crisis. Nutrition Reviews, 52(9), 285-298. Popkin, B. M. (2001). Nutrition in transition: the changing global nutrition challenge. Asia Pacific Journal of Clinical Nutrition, 10 Suppl, S13-18. Psujek, J. K., Martz, D. M., Curtin, L., Michael, K. D., & Aeschleman, S. R. (2004). Gender differences in the association among nicotine dependence, body image, depression, and anxiety within a college population. Addictive Behaviors, 29(2), 375-380.
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Sakamoto, N., Wansorn, S., Tontisirin, K., & Marui, E. (2001). A social epidemiologic study of obesity among preschool children in Thailand. International Journal of Obesity and Related Metabolic Disorders, 25(3), 389-394.
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Eun Woo Nam, Toshihiko Hasegawa, John Kenneth Davies and Nayu Ikeda
Abstract: Health promotion strategies have been developed and implemented in some Asian countries, particularly in the Republic of Korea (Korea) and Japan. It would help to understand features of health promotion in each country to compare health promotion strategies between them. In this study, using categories developed by HPSource.net, we conducted a comparative analysis of health promotion strategies between Korea and Japan to understand features of health promotion in each country and contribute to the improvement of population health.
One of the goals of Health Plan 2010 is to assess its achievements with numerical targets, which is also the case in Japan. One of the important discussion points involves a decision on the optimal number of targets for evaluation.
There is a major difference in the funding of health promotion activities between Korea and Japan. They are financed through the general account in Japan, while in Korea a foundation for health promotion has been established and the income from tobacco tax is ringfenced for this fund.
The database and methodology of HPSource needs adaptation for global use. We encountered some disadvantages in using its current framework for comparing and analysing information on health promotion in Korea and Japan.
It has been recognised that HP-Source could influence the development and implementation of health promotion strategies in other parts of the world. Health promotion tools can help decision makers, planners and researchers to formulate and enhance comprehensive plans.
In this study we learned many lessons in expanding policy tools outside of one region to aid the global development of effective health promotion policy and practice.
This manuscript was submitted on December 21, 2004. It received blind peer review and was accepted for publication on September 29, 2005. The authors gratefully acknowledge the support of Jackie Green received through the peer plus system, as part of the Health Promotion Journals’ Equity Project (HPJEP).
Background and purpose of study
Over the last few decades industrialised nations have placed renewed emphasis upon strategies to maintain and promote health and prevent illness in line with the philosophy of New Public Health (NPH) (Ashton and Seymour, 1998; Goraya and Scambler, 1998). The World Health Organization (WHO) has been proactive in stimulating health promotion and encouraging its member states to embrace NPH since the declaration of ‘Health for All by the Year 2000’ at the Alma-Ata Conference on primary health care in 1978 (WHO, 1978). This has been maintained in its more recent Health 21 strategy (WHO 1999). The Ottawa Charter for Health Promotion was presented at the First WHO International Conference on Health Promotion held in Ottawa on November 21, 1986 for actions to achieve ‘Health for
Table 1 Socio-economic status and health insurance
Korea Japan Population (thousand, 2003)* 47,700 127,654 GDP per capita (Intl $, 2002)* 19,523 26,860 Life expectancy at birth (male/female, years, 2003)* 73.0/80.0 78.0/85.0 Total health expenditure per capita (Intl $, 2002)* 982 2,133 Total health expenditure as % of GDP (2002)* 5.0 7.9 Type of health insurance NHI1 NHI1 Coverage of health insurance (%) 100 100
Source: World Health Organization (2005)
1 NHI denotes National Health Insurance.
All by the Year 2000 and Beyond’.1 This conference was primarily a response to growing expectations for a new public health movement around the world. Discussions focused on the needs in industrialised countries, but took into account similar concerns in all other regions. It built on the progress made through the Declaration on Primary Health Care at Alma-Ata, the World Health Organization’s Targets for Health for All document, and the recent debate at the World Health Assembly on intersector action for health.
Health promotion strategies have been developed in some Asian countries. In particular, in the Republic of Korea (Korea) and Japan, national health promotion initiatives are currently in their implementation phases. These two neighbouring countries share some
Eun Woo Nam Professor Department of Health Administration College of Health Sciences Yonsei University Wonju, Republic of Korea Email: koreahealth@hotmail.com
Toshihiko Hasegawa Director Department of Policy Sciences National Institute of Public Health Wako, Japan
John Kenneth Davies Director International Health Development Research Centre Faculty of Health University of Brighton Brighton, United Kingdom
Nayu Ikeda Research Resident Japan Foundation for Aging and Health Chita, Aichi Prefecture, Japan
commonalities in culture and values with each other, and comparisons of health promotion strategies between them would help to understand features of health promotion in each country, identify similarities and differences and to derive strategies for further improvement. However agreed criteria are needed to sort out such complex contextual factors surrounding health promotion in each country.
HP-Source.net is a pioneering initiative in this context. It is an attempt to establish a dynamic Internet-based data base for capacity mapping of health promotion at the national level in Europe.2 Aiming at the maximization of efficiency and effectiveness of health promotion policies, infrastructures and practices, HPSource.net collects qualitative and quantitative data through a international voluntary collaboration of researchers, practitioners and policy makers. It is developing a structurally uniform system for collecting information, creating a database and communication strategies for easy access to information for a wide range of stakeholders in health promotion, analysing this database to generate models, actively imparting this information and knowledge, and advocating the adoption of models of proven effectiveness and efficiency throughout Europe. The construction of this database was funded by the European Commission and initially coordinated at the London School of Hygiene and Tropical Medicine. The second (current) phase of the project began in 2004 and is coordinated at the University of Bergen in Norway. Data on political, economic and practical aspects of health promotion were provided by relevant correspondents from all 15 member states of the European Union before 1 May 2004, plus Norway, Iceland, Latvia, Switzerland, and the Czech Republic. In the study reported here, the authors conducted a comparative analysis of health promotion strategies between Korea and Japan which included the categories of data collection developed by HP-Source.net. The paper seeks to make a contribution to the improvement of population health through systematic investigation of various dimensions of health promotion strategies in these two countries.
Methods
1. Subjects This study compares health promotion policies between Korea and Japan. Their basic indicators are as shown in Table 1.
There are three administrative tiers in Korea. The highest tier includes seven metropolitan cities and nine provinces. Designated metropolitan cities are those urban areas with a population of over one million inhabitants. At the second level, provinces are subdivided into cities and counties, and metropolitan cities are subdivided into districts. The lowest units are dong in cities and ri in counties.. Provincial governments, although they have to some extent their own functions, basically serve as an intermediary between the central and municipal governments. Highly centralised governments have been a strong tradition in Korea, extending back more than six hundred years to the establishment of the Joseon Dynasty (1392-1910). Thus, even with the advent of decentralisation and popularly-elected local governments, there is a long way before local autonomy is achieved to the extent that is practiced today in advanced countries.
The affairs of local government are conducted at two levels in Japan (i.e. prefectures and municipalities). As of April 1, 2004, there are 47 prefectures, which consits of 3123 municipalities, including 23 wards within Tokyo. Since the Comprehensive Decentralization Law came into force in April 2000, the consolidation of municipalities has been promoted to strengthen their
Keywords
•health promotion •HP-Source •Korea •Japan
administrative foundations. Local government has established an equal and cooperative relationship with the national government, and is expected to carry out their administration independently in accordance with individual local circumstances.
2. Data and analysis Following the structure of the database of HP-Source.net, data was collected for health promotion capacity mapping in Korea and Japan. HP-Source.net includes data in 9 areas in each country –overview of health promotion, formulation of policy, evaluation of policy, monitoring and research, implementation, professional workforce development, professional associations, and funding. Data in eight of these areas were reviewed, excluding professional associations due to insufficiency of data. Qualitative and quantitative data from published and unpublished literature and from the internet websites of relevant official agencies, were collected and inserted into comparative tables. The data from each country is then described item by item for comparison.
Results
1. Overview of health promotion
Although health promotion strategies in Korea originally adopted definitions proposed in the Ottawa Charter, they did not establish long-range policies (see Table 2). The Health Promotion Act of 1995 embodied tobacco control strategies, including the imposition and collection of tobacco taxes, limitations on the advertisement and sponsorship of tobacco companies, the designation of smoking areas in public places, and other regulations. The Korea Health Promotion Fund (KHPF) was established in 1996 as a source of funding support for national health promotion programmes. Clause 22 of the 1995 Health Promotion Act is the legal basis of its provision of funding. The Ministry of Health and Welfare (MHW) launched its Health Plan 2010 strategy for the improvement of population health. In 2004 the healthy city movement started in Korea when four healthy cities joined the WHO Healthy City Alliance (http://www.alliancehealthycities.com,2005.7.18). A Field Management Training Programme (FMTP) began in sixteen local government areas for officers responsible for health promotion. In addition, the Korean government posted young physicians from the army to serve as health promotion practitioners for a mandatory period of 2.25 years.
National health promotion policies in Japan have already been operating for 30 years. The Japanese government advocated the development of an infrastructure for health promotion through the First-Phase Measures for National Health Promotion in 1978, and the Second-Phase Measures for National Health Promotion in 1988. These two initiatives developed infrastructures for for example health checkup systems, facilities, human resources and fitness guidelines. Despite their successful contribution to health promotion, the evaluation of outcomes was difficult because numerical standards had not been set in advance. In addition, due to further decentralisation encouraged by the Decentralization Promotion Act of 1995, prefectures and municipalities became responsible for the development of health promotion strategies in their local areas. The central government then launched in 2000 the third initiative for health promotion called the National Health Promotion Movement in the 21st Century (Healthy Japan 21). Based on concepts of health promotion advocated in the Ottawa Charter, Healthy Japan 21 emphasises the importance of societywide support, as well as individual efforts, for people to become proactively involved in health promotion activities. Moreover, specifying the roles of stakeholders at national and local levels, Healthy Japan 21 pursued promotion of healthy lifestyles, mandatory segregation of smoking, and coordination of health screening conducted under different schemes. In addition, the initiative adopted the management with numerical goals and targets, which was in line with Healthy People 2000 of the United States (U.S. Department of Health and Human Services Public Health Services,2005). The Health Promotion Act came into force in 2002 as a legal basis for the initiative (Japan Public Health Association, 2005). The Healthy City movement started in the mid 1990’s, and eleven healthy cities enrolled in the WHO Healthy City Alliance.3 Thus health promotion initiatives have been developed in Japan for a longer time than in Korea. Based on the Ottawa Charter, current health promotion initiatives were launched in 2000 and will be implemented until 2010 in both countries. Health promotion initiatives have a legal basis in Japan and financing of health promotion initiatives has a legal basis in Korea. Decentralisation is a key theme for health promotion initiatives in Japan, while in Korea the administrative system is still centralised.
Healthy People 2010 emphasises that prevention saves lives, improves the quality of life and can be cost effective in the long run. It has 28 focus areas, 467 specific objectives and 10 leading health indicators. The first focus area includes access to quality services, the second includes arthritis, osteoporosis and chronic back conditions, and the third includes cancer.4
2 Overview of health promotion Table 2
Korea Japan Background Ottawa Charter National measures Health Promotion Act 1995 in 1978 & 1988 KHPF* in 1996 • Infrastructure developement •Lack of numerical standards Decentralization Current initiatives Health Plan 2010 Healthy Japan 21 Healthy Cities Project Health Promotion Act 2002 FMTP (Field Management Healthy City Project Training Program)
*Abbreviation for Korea Health Promotion Fund.
2. Formulation of Health Promotion Policy
1) National level
(a) Publication and actions (Table 3) In 2003, the MHW published a report entitled Health Plan 2010 in Korea (KIHASA and MHW, 2000), which is electronically available on their website.5 Key policy recommendations for the initiative have been highlighted by KIHASA. The initiative in practice seeks to create public awareness of
2 National health promotion policies Table 3
Contents Korea Japan Publication Published by MHW Published by JHPFF* Title of document Health Plan 2010 Healthy Japan 21 Status of document Report Report Key policy •extending life expectancy •Reducing premature death recommendations/ •Reducing cancer •Extending healthy life statements •Reducing tobacco smoking expectancy •Reducing alcohol consumption •Improving QOL Practice •Creating public awareness •Emphasis on primary recommendations/ of responsibility in health prevention statements •Strengthening public sense •General improvement to of value in health support health promotion •Goal settings & evaluation •Effective implementation through inter-organizational cooperation Levels and sectors National National: of actions •Bureau of Health Promotion, •Health Service Bureau, MHW MHLW Sub-national Sub-national: •Metropolitan cities, provinces, •Prefectures and cities, and counties municipalities •Public health centres •Public health centres •Other relevant organizations •Other relevant organizations
*Abbreviation for Japan Health Promotion and Fitness Foundation.
responsibilities for health and to strengthen the public’s sense of value in health. The initiative proposes that actions should be taken by the Bureau of Health Promotion of MHW at the national level, and by metropolitan cities, provinces, cities, counties, public health centres, and other relevant organisations at the sub-national level. A report entitled “Healthy Japan 21: National Health Promotion in the 21st Century” was published in 2000 by the Japan Health Promotion and Fitness Foundation (JHPFF). This document was written in Japanese only and a brief introduction in English is available at the website of the Ministry of Health, Labour and Welfare (MHLW).6 JHPFF is a foundation, financed through subsidies and private donations, working in close coordination with the central government for diffusion of information and education on health promotion, fostering leadership, and carrying out surveys and research on relevant aspects of health sciences. The basic premise of Healthy Japan 21 is to create a vibrant society in which the whole nation is healthy and spiritually rich through the reduction of premature deaths, the extension of healthy life expectancy, and the improvement of quality of life. The initiative therefore emphasises primary prevention through making general improvements to support health promotion, setting numerical goals for evaluation, and initiating cooperation and partnerships working among relevant organizations, such as the mass media, health insurers, healthcare providers, and volunteers. Actions are proposed at both national and sub-national levels: Health Service Bureau of MHLW at the national level; and prefectures, municipalities, public health centres, and other relevant organisations at the subnational level. The Korean Health Plan 2010 established fourteen goals which related to health expectancy, smoking, drinking, exercise, nutrition, mental health, dental health, reproductive health, hypertension, cerebrovascular disease, arthritis, diabetes mellitus, cardiovascular disease, and cancer. Thirty-eight objectives were specified: one objective each on exercise, hypertension, cerebrovascular diseases, arthritis, diabetes mellitus, and cardiovascular diseases, two each on health expectancy, drinking and nutrition, three objectives on dental health, four each on smoking, mental health and reproductive health, and eleven on cancer.
Healthy Japan 21 established nine goals, i.e. smoking, drinking, exercise, nutrition, rest and mental health, dental health, diabetes mellitus, cardiovascular diseases, and cancer. Then seventy objectives were specified in total: four objectives on smoking; three on drinking; six on exercise (three each on adults and the elderly); fourteen on nutrition (five on nutritional status and intake, six on knowledge, attitude and behavior, and three on environment); four on rest and mental health (one each on stress and suicide, and two on sleep); thirteen on dental health (three each on infants, school children, and the elderly, and four on adults); eight on diabetes mellitus; eleven on cardiovascular diseases, including those on health checkup, hypertension and stroke; and seven on cancer.
Twice as many objectives have been set up in Japan as those in Korea (see Table4). Lifestyle modification is common to both countries. Health expectancy and reproductive health are still important goals in Korea. Curative service and management of arthritis is peculiar to Korea. Many targets have been set on cancer in Korea.
2 Goals and targets of national health promotion policies Table 4
Number of objectives Goals Korea Japan* Life expectancy 2 NA Anti-tobacco (smoking) 4 4 Alcohol consumption 2 3 Exercise 1 6 Nutrition 2 14 Mental health 4 4 Dental health 3 13 Reproductive health 4 NA Arthritis 1 NA Cancer 11 7 Diabetes mellitus 1 8 Cardiovascular diseases 1 11† Hypertension 1 NA Cerebrovascular diseases 1 NA Total 14 goals & 38 objectives 9 goals & 70 objectives
NA denotes «Not Applicable». * Source: http://ml-www.kenkounippon21.gr.jp/kenkounippon21/ugoki/houkoku/pdf/0410mokuhyou_zanteiti.pdf (in Japanese) † Including targets on hypertension and stroke.
2) Sub-national level Some health promotion policy documents at the provincial level in Korea were published in 2000, such as those in Kyungnam Province 2001, Ulsan City 2001 and Changwon City 21. These documents refer to the five priority areas identified by the Ottawa Charter, i.e. building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. The Department of Health of each provincial government is generally responsible for the formulation of these documents.
It is discretionary on local government whether or not to develop and publish local health promotion policies in Japan. All prefectures completed the formulation of health promotion policies by March 2002, and 40% of municipal governments (1222/3123) did so as of July 2004. Health promotion strategies of the 627 municipal governments are under development and are due to be completed by March 2006.7 References to some local policy documents on health promotion are electronically accessible at the official website of Healthy Japan 21.8
3. Monitoring, survey and research on health promotion and public health (Table 5) The Korean Institute of Health and Social Affairs (KIHASA) is responsible for the development of theory and research in health promotion. They also conduct and report every 3 years systematic monitoring of health promotion policies by the Health and Nutrition Survey. The Korean Centre for Disease Control and Prevention (KCDC) has recently been established to review the development and practice of health promotion programmes. The Korean Health Industry Development Institute (KHIDI) is responsible for carrying out a nutritional survey.
In Japan, surveys and research on health promotion and the development of relevant databases are conducted by JHPFF, the National Institute of Health and Nutrition (NIHN) and the National Institute of Public Health (NIPH). JHPFF not only conducts but commisions research to academic researchers at universities and other relevant institutions. NIHN is an independent policy corporation responsible for implementing National Nutrition Survey (NNS) and research on the maintenance and promotion of health, nutrition, diet and lifestyle. NIPH was established in April 2002 through the merger of the former National Institute of Public Health and the National Institute of Health Service Management, and focuses on the training of experts and research on public health, healthcare, and social welfare.
National data on public health such as Vital Statistics, Patient Survey, NNS, National Livelihood Survey, Health and Welfare Survey have been regularly collected for the monitoring of public health. NNS is the most useful in the context of Healthy Japan 21, because it emphasizes the prevention of lifestylerelated diseases (Kawaminami, 2001). The survey involves approximately 15,000 people from 5000 households in randomly selected 300 local units in Japan. The data consists of food and nutritional intake, diet, and physical status such as height and weight, blood pressure, blood biomarkers, exercise, and medication to control blood pressure, cholesterol and blood sugar. The 2002 Health Promotion Act stipulates NIHN as a responsible body for compiling NNS.
Prefectures conduct surveys on health, nutrition and diet concurrent with NNS. They are similar to NNS in the questionnaire formats and methods of compilation and analysis.
2 Monitoring, survey and research Table 5
Responsible bodies Responsibilities Korea Japan Theory & research KIHASA 1) •JHPFF, NIHN, HIHN† •Universities Systematic monitoring Health and Nutritional survey •National: NNS, Vital & reporting of public health by KIHASA, KCDC 2) Statistics, Patient Survey, and KHIDI 3) etc. by MHLW •Local: Nutrition surveys by prefectures
1) KIHASA denotes Korean Institute of Health and Social Affairs. 2) KCDC denotes Korean Center for Disease Control and Prevention 3) KHIDI denotes Korean Health Industry Development Institute † Abbreviations for Japanese Health Promotion and Fitness Foundation, National Institute of Health and Nutrition, and National Institute of Public Health, respectively.
4. Implementation at national and subnational levels (Table 6)
1) Korea implementation of Health Plan 2010 (Health Korea 2010). They are involved in planning health promotion and supporting national and local bodies in carrying out health promotion programmes. It is unclear which bodies are responsible for the implementation of health promotion at regional and local levels. (2) Facilitation of Better Quality Health Promotion Practices The bodies in charge of facilitation of better health promotion practices are the following: KIHASA and KCDC in the health sector; Korean National Health Insurance Cooperation in other public sectors; Korean Anti-Smoking Association, Korean Association of Public Health Administration, Korean Association of Family Health, and Korean Association of Health Promotion; graduate schools of public health, faculties of public health and preventive medicine, medical schools, and nursing schools of universities; and Korean Health Industry Development Institute as a research centre.
(3) Creation of Health Promotion Materials Materials on health promotion are produced through various sources, including the Health Promotion Development Centre (HPDC) of KIHASA and health centres in the health sector, and NGOs such as the Korean AntiSmoking Association. Universities prepare study materials for students.
(4) Health Promotion Networking The implementation of health promotion programmes require close collaboration between the Health Promotion Development Centre (HPDC) of KIHASA, health centres, and NGOs.
(1) Implementation of National Health Promotion Policy MHW is responsible for the (5) Planning and Implementing Health Promotion Programmes KIHASA and MHW are planning and
implementing health promotion programmes at the national level; also, KCDC and Korea Food and Drug Agency (KFDA) together with the Regional Health Promotion Fund, which has been supporting programmes from 2005. Public health centres are responsible for health promotion at the local level and sub-health centres also implement the programme. NGOs including the mass media, have supported these efforts on a more local level.
(6) Implementation at the Local Level Korea is a centralised country and the implementation at the local level depends on local capacity. It depends on specific resources and politics, how much freedom local bodies have in setting priorities for local implementation of the national health promotion policy.
2) Japan
(1) Implementation of National Health Promotion Policy MHLW is responsible for the implementation of Healthy Japan 21 at the national level. The central health authority is responsible for facilitating the nationwide implementation of the initiative, the dissemination of information and education through diverse channels, the provision of technical support for the development of local plans, the implementation of surveys and research, securing of adequate human resources, and the coordination of health programmes.
(2) Facilitation of Better Quality Health Promotion Practices Three organisations were established for the effective implementation of the health promotion initiatives at the national level. Firstly, the Headquarters for the Promotion of Healthy Japan 21 was established in MHLW to facilitate the inter-departmental implementation of measures for the initiative. Secondly, the National Council for Promotion of Healthy Japan 21 was launched as a central organisation for the efficient and continuous implementation of Healthy Japan 21. Representatives from national and local levels meet and exchange opinions and information four times a year. Thirdly, organisations approving the initiative created the National Liaison Council for Promotion of Healthy Japan 21 as the core for dissemination of information to the public and
Responsible bodies Responsibility Korea Japan Implementation MHW MHLW of national HP policy MCHP of KIHASA Facilitation of better • National: KIHASA*, National: HPHJ21, HP practices other public sectors NCPHF21, NLCPHF21‡ •Universities and colleges •NGOs Creation of HP materials • National: HPDC†, KHPF, • National: MHLW KCDC • Local: prefectures, public • Local: MCHP††, health centres, municipalities, public health centres JHPFF¶ • NGOs • Universities and colleges Networking • National: MCHP, HPDC, Local: prefectures, public KIHASA health centres, municipalities, • Local: MCHP, public health JHPFF centres, healthy city networks, healthy lifestyle advisory groups • NGOs Planning and running • National: KIHASA, MoHW • National: MHLW programmes and • Local: MCHP, city governments • Local: prefectures, public campaigns (e.g. Seoul, Wonju and other health centres, municipalities ‘healthy cities’, public health centres • NGOs
* MCHP denotes Management Centre for Health Promotion under the Korean Institute for Health and Social Affairs(KIHASA). † HPDC denotes Health Promotion Development Center under KIHASA. ÅıÅı RMCHP denotes Regional Management Center for Health Promotion under MCHP ‡ HPHJ21, NCPHF21, and NLCPHF21denote Headquarters for Promotion of Healthy Japan 21, the National Council for Promotion of Healthy Japan 21, and the National Liaison Council for Promotion of Healthy Japan 21, respectively. ¶ Abbreviation for Japanese Health Promotion and Fitness Foundation
strengthening of mutual collaboration through the exchange of information. Academic bodies contribute to the facilitation of better quality health promotion practices; for example NIPH, medical and nursing schools, and academic societies in health promotion such as the Japanese Public Health Association,9 the Japanese Society of Health Education and Promotion,10 and the Japanese Society for Health Promotion and Welfare Policy.11
(3) Health Promotion Networking Prefectures play a central role in networking of municipalities, health insurers, school health workers and occupational health nurses. Moreover, prefectures and municipalities are required to formulate local health promotion plans in harmonisation with other existing local health plans and in turn, integrate local plans within the existing comprehensive plan. Public health centres function as the base for health promotion activities in their jurisdiction. Their responsibilities not only include networking between relevant organisations, but include the collection and analysis of health data, and the provision of technical support for municipalities. (4) Planning and Running Health Promotion Programmes and Creation of Materials MHLW is responsible for the development of a strategic master plan for Healthy Japan 21 at the national level. The plan formulates overall philosophy and goals to provide the long-term direction of efforts in health promotion for local governments. MHLW facilitates and supports the development of local plans by holding seminars and distributing information to stakeholders. They further implement national health promotion programmes by encouraging the nation through the mass media, developing support systems, and establishing a health information system.
Prefectures formulate more concrete strategic plans and action plans aligned with the national master plan and focus on the choice of measures and resource allocation for the efficient and effective implementation of strategies. Prefectures also develop health promotion plans for secondary health areas, which are geographical units stipulated by Medical Service Law for the provision of comprehensive health and medical services ranging from health promotion
Korea Japan Single responsible body •National: MHW • National: MHLW •Local: RHPF •Local: Local governments National level To be conducted in To be conducted in 2005 & 2010 2005 & 2010 Development of tools KIHASA and MHW Panel set up by MHLW
2 Degree programmes in health promotion Table 8
Courses Korea Japan Bachelor NA NA Master Yonsei University NA Doctorate NA NA Postgraduate non-degree KHEA* NA Non-academic KIHASA†,MCHP, KHRDL Health fitness instructors/
* KHEA denotes Korean Health Education Association. † KIHASA denotes Korean Institute of Health and Social Affairs. . MCHP denotes Management Center for Health Promotion under the MoHW KHRDI denotes Human Research Development Institute under the MoHW
Financial source Level/Nation Korea Japan National Tobacco Tax General taxation Local Tobacco Tax General taxation
to treatment and rehabilitation. Public health centres play a central role in collecting and analyzing health data at this level. Moreover, prefectures support municipalities in developing and implementing their plans through the dissemination of prefecture plans and the provision of health statistics data. Healthy Japan 21 recommends that municipalities proactively formulate and implement health promotion plans and programmes, because they directly provide local residents with services in maternal and child health and in geriatric health. They are expected to disseminate health promotion, network relevant organisations, support voluntary community participation, and evaluate municipal plans through community involvement.
5. Evaluation of health promotion policy, programmes, campaigns and projects (Table 7)
MoHW in Korea will evaluate Health Plan 2010 in 2005 and 2010. The midterm evaluation (2005) is currently underway and will most likely result in redefining the national objectives by the Management Centre for Health Promotion (MCHP) under the KIHASA, and in formulating more concrete strategies to support the implementation process at the provincial and local level by the Regional Management for Health Promotion (RMCHP). The tools for the evaluation of health promotion programmes are being developed under initiatives from the MCHP. Pilot projects for demonstration and research are evaluated every year by the MCHP.
The MHLW and local governments are responsible for the evaluation of Healthy Japan 21 at national and local levels. Healthy Japan 21 will be evaluated in 2005 and 2010 with evaluation tools developed by a panel which MHLW formed in 2002. Their interim report is electronically available on the website of MHLW. Some of health promotion interventions at the local level started later and will be evaluated later.
6. Professional education in health promotion (Table 8)
Academic qualifications in health promotion are available only at Master’s level in Korea. There is a Master’s course in health promotion at the Department of Health Promotion, Graduate School of Public Health, Yonsei University in Seoul. Postgraduate non-degree courses are offered by the Korean Health Education Association and non-academic courses are available at KIHASA and KCDC. The MHW has launched a FMTP for staffs in public health and health promotion at the local level from 2005. Korea has 17 academic courses in health sciences at the undergraduate level and more than 28 MA or MPH courses. Furthermore, more than 10 Ph.D. courses in health sciences fields are offered by universities. Although there is no academic institution in Japan which offers a degree specifically in health promotion, many degree programmess in relevant fields such as those in public heath and nutrition include lectures on health promotion as a part of their courses. Training courses for instructors and programmers of health fitness are also available at universities, colleges, and at the Japanese Health Promotion and Fitness Foundation.
7. Funding (Table 9)
Financial sources for health promotion programmes are divided into two types; Korea has a health promotion fund from the tobacco tax and general taxes are used in Japan. In Korea, the KHPF is the primary source of finance for health promotion programmes at national and local levels. Table 10 shows recent changes in the health promotion fund. The fund is financed through income from tobacco tax collected from tobacco companies and importers. The tax rate was 150 Won per pack of cigarettes in 2000 and rose to 354 won per pack of cigarettes in February 2005. Three percent of collected tobacco tax is earmarked for the fund and the remainder goes into National Health Insurance in 2000. This rate recently was increased to 17.7 percent to the health promotion fund.
Healthy Japan21 is financed by national, prefecture, and municipal budgets through a specified fund. Table 11 shows the transition of national budgets for health promotion from 2001 to 2004. The exact budget for Healthy Japan21 is however unknown because the initiative is implemented with other programmes such as those for elderly health (MHLW, personal communication, 2004). Kawahara (2001) described that in 2001 most of the budget of 1,069 million yen for health promotion had been allocated for the comprehensive implementation of Health Japan21 within existing programmes in addition to other health programmes, while projects for the diffusion of specific initiatives had accounted for 0.6% of the budget.
2 Change in the Health Promotion Fund by Tobacco Tax Table 10 in Korea (Unit: hundred million won)
Year Source 1997 2000 2004 HP Fund 18,688 30,539 91,349 Ratio 1.0 1.63 4.89
MoHW, National Health Promotion Budget, each year. The base year 1997.
2 National budget of policies relevant to health promoTable 11 tion in Japan (Unit: million yen)
Year 2001* 2002* 2003† 2004‡ Budget 106,925 92,623 92,919 93,406
* Source: http://mhlw.go.jp/topics/2002/bukyoku/kenkou/2.html † Source: http://mhlw.go.jp/topics/2003/bukyoku/kenkou/2.html ‡ Source: http://mhlw.go.jp/topics/2004/bukyoku/kenkou/2.html
Most of the programmes in health education and health promotion in Japan are organised under the framework of health services for the elderly financed by sickness funds, and maternity and child health services delivered by local governments. Although sickness funds can denote the amount of funds to be put into health services for the elderly, decisions on resource allocation largely depend on political circumstances. Moreover, programmes by local governments have experienced substantial changes. Administrative tasks in programmes of maternity and child health have been decentralised to local governments from prefectures municipalities and their local branches.
Discussion
Having applied the European HP-Source tool for the analysis of health promotion policies, the first comparative study between Korea and Japan identified a number of issues that reflected similarities and differences in health promotion policies between these two countries.
Current political interests in health promotion in Korea and Japan
At present in many countries particularly in Europe, there is a major focus on providing ‘evidence’ of successful interventions and programmes in public health and health promotion and relating this to good practice. The European Commission has provided financial support to a Multi-Network Project entitled ‘Getting Evidence into Practice’ (GEP) and the 6th IUHPE European Conference on Quality and Effectiveness of Health Promotion, which was held in June 2005, continues the theme, “Evidence for Practice: Best Practice for Better Health”.
One of the goals of Healthy Japan 21 is to use evidence-based numerical targets as indicators for evaluating the status of public health. The same trend can be observed in Korea. An important discussion point involves deciding on the optimal number of targets for evaluation. Healthy Japan 21 has twice as many targets as those of Health Plan 2010. Is it too many or too few? Should the Korean list of objectives be reduced to the equivalent of those of the Japanese, particularly by merging hypertension, cardiovascular diseases and cerebrovascular diseases into one category?
There is a major difference in the funding of health promotion activities between Korea and Japan. Japanese health promotion policies and programmes are financed through the general account, while in Korea a foundation for health promotion has been established and the income from tobacco tax is ring-fenced for this fund. This Korean system follows those in some other countries such as Australia and Finland. One of interesting issues arising from the growth of health promotion foundations with ring-fenced funding is the shift in the perception of health promotion from just health (services) to include cultural and sports sponsorship. However it cannot be said that this is the main-stream method for health promotion financing yet, and there still remains much room for discussions on the efficiency of earmarked funds from taxes. For instance, successive British governments have refused to ear-mark or ring-fence income in the public sector as expenditure. This means that the financing of health promotion or public health depends on the National Health Service, whose political priorities are reducing hospital waiting lists and meeting the demands for treatment from patients. How can health promotion move forward within a global environment?
The HP-Source data base and methodology need to be adapted for global use. Some disadvantages arose for comparing and analysing information on health promotion in Korea and Japan using the database’s current framework. Firstly, administrative units of ‘regional’, ‘provincial’, and ‘local’ are not applicable to all countries. For example, the Japanese system consists of local prefectures and municipalities under the national government, while in Korea there are only the provincial level of municipalities and wards under the national level. Terminology and definitions of administrative units are thus diverse among nations and cannot be straightforwardly interpreted. Secondly, evaluation questions could not be compared because Korea and Japan are at the early stage of the development of health promotion initiatives and their evaluation tools are still under discussion. Questions should therefore be created in the data base to account for health promotion policies that are under development. Thirdly, some questions in the database overlap, causing some confusion to respondents. Terminology regarding the stages of health promotion such as policy, programmes, projects and interventions should be determined and clearly defined, so that each question clearly reflects the appropriate meaning in that stage of implementation and evaluation.
The benefits resulting from HP-Source pioneering efforts in Europe are recognised as potentially influencing the development and implementation of health promotion strategies in other parts of the world. Health promotion tools, such as those in the HP-Source can help decision makers, planners and researchers to formulate comprehensive plans and identify deficits.
Limitations
This study compared health promotion policies in Korea and Japan using the health promotion tool HP-Source.net. The
HP Source instrument was developed and to date has been applied by using country-based named researchers to ascertain and enter information into the database from a variety of country sources in Europe. But, in this study subjects of comparison were used for the first time in Asia and limited to Japan and Korea, rather than drawing on the full current HP-Source database for 25 European countries. There are nevertheless many lessons to be learnt from expanding policy tools such as HPSource outside of one region to aid the global development of effective health promotion policy and practice.
1. http://www.who.int.org (accessed on July 18, 2005) * Corresponding author: Eun Woo Nam
Tel 82-33-760-2413 Fax 82-33-762-9562 e-mail ewnam@dragon.yonsei.ac.kr #234-1 Maejiri
Heungup-myun Wonju-city Korea. 2. http://www.hp-source.net 3. http://www.alliance-healthycities.com, accessed on 2006.1.30. 4. http://www.healthypeople.gov/healthfinder, accessed on 2005.7.18. 5. http://www.mohw.go.kr (accessed on March 20, 2004) 6. http://www.mhlw.go.jp/english/wp/wphw/vol1/p2c6s4.html (accessed on April 17, 2004) 7. http://www.kenkounippon21.gr.jp/kenkounippon21/ chihou_keikaku/sakutei/index.html (in Japanese) 8. http://www.kenkounippon21.gr.jp/kenkounippon21/ chihou_keikaku/jireisyu/index.html (in Japanese) 9. http://www.jpha.or.jp/jpha/english/index.html 10.ttp://www.onyx.dti.ne.jp/~health (in Japanese) 11.http://gakkai.umin.ac.jp/gakkai/gakkai/2003/A01560.htm (in Japanese)
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