Section 2.Review of Health and Welfare Measures for People with Disabilities

(1) The current situation of people with disabilities

In Japan, the total number of people with disabilities is currently projected to be 5.76 million, out of which 3.18 million are people with physical disabilities, 0.41 million are mentally disadvantaged persons and 2.17 million are people with mental disorders.

According to the Survey on the Actual Status of People With Physical Disabilities in 1996, people with physical disabilities living at home accounts for 2.93 million, out of which people with severe physical disabilities (Class 1 and 2) accounts for 43.2%, up from 40.1% in the 1991 Survey. People with multiple disabilities also on the rise, accounting for 6.1%. On the whole, disabilities of these people seem to have become more severe and multiple. Recently, people with disabilities with the age of 65 and over have accounted for more than half or 54.1% and are further increasing.

Regarding mentally disadvantaged persons (0.3 million living at home), those who are less than 18 years old are decreasing, while those who are 18 years old and over are increasing. In addition, people with the severest and severe mental disadvantage account for more than 40%, and 18.2% own physically disabled persons' certificates. Disabilities of mentally disadvantaged persons seem to be more severe and multiple.

Regarding people with mental disorders, inpatients account for 0.34 million and those who live at home account for 1.82 million. The average length of stay for hospitalized patients is 331 days and much longer compared with America and European nations. According to the Patient Survey in 1996, patients who are hospitalized for five years and more account for 46.5% (45.7% in the same survey in 1993), which shows that their social rehabilitation has not progressed.

Column 1996 Survey on the Actual Status of People with Physical Disabilities The Survey on the Actual Status of People with Physical Disabilities is conducted once in five years for the purpose of grasping the situation of people with physical disabilities' type, degree and cause of disabilities as well as daily life and for the purpose of obtaining basic materials that are necessary to promote future welfare measures for people with disabilities. The latest Survey was conducted as of November 1, 1996 targeting people with physical disabilities living at home with the age of 18 and over who live in the selected areas for survey throughout the country, and its results were made public in January 1999. According the 1996 Survey, the number of people with physical disabilities living at home is estimated at 2.93 million throughout the country. Regarding people with physical disabilities who need personal care for all or part of their daily living activities, 7.9% of all the people with disabilities need personal care when "having a meal," 11.4% for "excretion," 19.5% when "taking a bath" and 26.3% when "going out." The percentages of people who need personal care when taking a bath and going out is increasing. In addition, the percentage of people with physical disabilities who have gone out for the past one-year is 86.2% of all and increasing compared with the previous survey (85.8%). On the other hand, regarding things which annoy them when they go out, people with physical disabilities point out the "inconvenience in using transportation" (30.3%) and "poor equipment of buildings which they use" (28.0%). As welfare services which are demanded by people with physical disabilities, the "improvement in securing incomings including pensions and allowances," the "reduction in the burden of medical expenditures," the improvement of public transport and public buildings and houses and the improvement of in-home services are listed. Compared with the previous Survey, an increasing number of respondents demand the environment where people with physical disabilities can live easily and comfortably.

(2) Promotion of the Government Action Plan for Persons with Disabilities

1 The Government Action Plan for Persons with Disabilities

The Government Action Plan for Persons with Disabilities was formulated by the Headquarters for Promoting the Welfare of Disabled Persons in December, 1995, as an implementation plan of priority measures to further promote the "New Long-Term Program for Government Measures for Disabled Persons" formulated in March, 1993. The Action Plan is a seven-year strategy from fiscal 1996 to fiscal 2002 and includes not only health and welfare measures, but also the measures for people with disabilities as a whole, such as housing, education, employment, communication and broadcasting.

As basic concepts, the Government Action Plan for Persons with Disabilities is based on a concept of rehabilitation that aims for the restoration of rights as a full citizen in all stages of their lifetime, as well as a concept of "normalization" that aims for a society in which people with disabilities live their lives and are active the same as people without disabilities. The Action Plan strives to promote measures on a priority basis from the following seven viewpoints: 1 To live together in the community; 2 To promote social self-sufficiency; 3 To promote barrier-free access; 4 To aim to improve quality of life; 5 To ensure safe livelihood; 6 To eliminate mental barriers; and 7 To promote international cooperation and exchange suited to Japan.

2 Promotion of Measures Based on the Government Action Plan for Persons with Disabilities

As the budget related to the Government Action Plan for Persons with Disabilities for the fiscal 1998, the Ministry of Health and Welfare included about 237.8 billion yen in the initial budget and about 12.7 billion yen in the first and third supplementary budgets, in order to improve measures for in-home welfare to help people with disabilities live in their communities and to build custodial care homes for people with physical disabilities to aim to reduce the number of people who are waiting for the placement. The Ministry is determined to continue to further improve measures to achieve concrete numerical targets for each measure mentioned in the Action Plan.

To materialize the Government Action Plan for Persons with Disabilities, it is necessary for local governments, which are the self-governing bodies that are closer to residents, to make a plan for people with disabilities with concrete numerical targets and to systematically promote measures. Prefectures and municipalities are obliged to make efforts to formulate plans for people with disabilities based on the Fundamental Law for People with Disabilities, and all the prefectures and designated cities have already made the plans. Regarding municipal plans for people with disabilities, a survey by the Prime Minister's Office shows that as of the end of March, 1998, 59.0% of all the cities and 26.4% of all the towns and villages have already made plans for people with disabilities and that local governments with smaller population are more delayed in making plans. The survey also indicates that out of the municipalities that have already made plans for people with disabilities, only 29.7% include numerical targets in their plans. To utilize the Government Action Plan for Persons with Disabilities in supporting the life of people with disabilities who live in their communities, it is important for municipalities, which are the closest to them, to make plans for people with disabilities. In order that many municipalities will make plans for people with disabilities incorporating numerical targets as soon as possible, the Ministry of Health and Welfare will continue to give support through a project to promote the health and welfare service area plan for people with disabilities which will be conducted in 1999.

Table 4-2-1. Purposes (by the End of 2002) of Measures Related to the Ministry of Health and Welfare in the Government Action Plan for Persons with Disabilities and the Budget for Fiscal 1999

2. Future Directions of Health and Welfare Measures for People with Disabilities

(1) Discussions at the three councils related to people with disabilities and offering of opinions

Japan's health and welfare measures for people with disabilities are promoted based on the Government Action Plan for Persons with Disabilities. In order to generally review the measures as a whole based on the discussions concerning the introduction of the public long-term care insurance system and the basic structural reform of social welfare services, various discussions were made at the jointly planned subcommittee of the three councils for people with disabilities (the Welfare Council for People with Physical Disabilities, the Committee on Welfare for People with Disabilities of the Central Child Welfare Council, and the Committee on Health and Welfare for People with Mental Disorder of the Council on Public Health) which were established in October, 1996. In December 1997, the subcommittee released an interim report.

The interim report made the following three proposals as the basic idea of the health and welfare measures for people with disabilities: 1 To support people with disabilities' self-sufficiency and participation in social economic activities; 2 To respect people with disabilities' identity and choice; and 3 Mutual support in the community. The report also made the following five proposals as the direction of the basic measures: 1 To improve measures to support people with disabilities' life in community; 2 To promote comprehensive measures beyond the type of disabilities; 3 To ensure technical capabilities to deal with the characteristics of disabilities; 4 To deal with the aging as well as severer and more multiple disabilities of people with disabilities; and 5 To protect the rights of people with disabilities and promote their participation in planning.

In order to further deepen discussions concerning the proposals given in this interim report, the jointly planned subcommittee began discussions in March, 1998, focusing on new service use systems, while especially respecting the idea of the basic structural reform of social welfare services and the direction of concrete reforms as important subjects which are common to the health and welfare measures for people with disabilities. On January 19, 1999, the subcommittee offered its opinion on the "Future Course of Health and Welfare Measures for People with Disabilities."

In addition, the Welfare Council for People with Physical Disabilities and the Committee on Welfare for People with Disabilities of the Central Child Welfare Council made discussions concerning the comprehensive review of in-home and institutional services, from the standpoint of supporting people with disabilities' self-sufficient life in their communities. Both councils offered their own opinions on January 25, 1999.

Based on these offered opinions, the Ministry of Health and Welfare is now making concrete discussions concerning the necessary review of the related systems.

(2) The outline of the offered opinions

1 "Future Course of Health and Welfare Measures for People with Disabilities" (offered by the jointly planned subcommittee)

According to the opinion offered by the jointly planned subcommittee, regarding welfare services, it is necessary to ensure users' right of choice in order to realize "normalization" and the idea of self-choice. It is also necessary to establish a new service use system for the twenty-first century based on the user-oriented principle, which attaches importance to the indignity as individuals by establishing the equal relationship between service users and providers. Specifically, regarding the in-home and institutional services for people with physical disabilities and mentally disadvantaged persons as well as services which households with children with disabilities use at their own houses, which are decided based on the sochi-seido (the system that municipalities judge and decide the type of welfare facilities which people with disabilities are placed and the type of in-home services to be provided, according to type and severity of disability for each person with disabilities), such as the use of home helper service and the placement of rehabilitation facilities, it is proper to shift to a new system. In the new system, basically individual users choose services by themselves and use them by concluding contracts with service providers. The costs for these services are subsidized by public money according to the content of provided services taking each user into consideration.

As the premise to the above-mentioned shift, it is necessary to comprehensively satisfy the following conditions.

a. Conditions to ensure users' right of choice

• Improving the comprehensive consultation system for people with disabilities living in their communities

• Offering information concerning in-home and institutional services provided by the administrative agencies and service providers

• Establishing the supply basis for welfare services for people with disabilities

• Systematizing the mechanism to support self-choice by mentally disadvantaged persons

b. Conditions to ensure the direct and equal relationship between service users and providers

• Requiring service providers to accept applications for the use of services

• Establishing the system to handle complaints about welfare services

• Promoting measures to ensure that service users and providers conclude proper contracts

The jointly planned subcommittee also proposed to maintain the level of services, to protect users, and to promote participation by people with disabilities.

2 "Future Course of Health and Welfare Measures for People with Disabilities" (offered by the Welfare Council for People with Physical Disabilities)

a. Strengthening the consultation and support systems

• Systematizing the municipal living support program for people with disabilities which supports the use of in-home welfare services for people with disabilities living at home and conducts consultation for the parties concerned

b. Improving in-home welfare services

• Systematizing the social rehabilitation service which provides walking training and other training necessary for social life including braille and sign language

• Regarding the Day Service Program, considering the possibility to provide functional training by visit

c. Promoting social participation

• Expanding and improving the role and function concerning the communication support at information service facilities for people with visual and hearing disabilities

• Considering the possibility to clearly systematize the services to support communication of persons with visual and hearing disabilities, such as the interpretation of sign language and summary note-taking

• Diffusing and improving the fostering project of guide dogs for the blind

d. The ideal system of facilities for people with disabilities

• Regarding rehabilitation facilities, considering the abolishment of the classification of facilities for people with severe disabilities and general facilities as well as the establishment of an adding-up system of disability's severeness paying attention to each person with disabilities

• Promoting the shift of small-scale workshops to legal facilities by easing the necessary conditions for the quota of commuting sheltered workshops

• Promoting the acceptance of people with severe and multiple disabilities by custodial-care homes

3 "Future Course of Measures for Mentally Disadvantaged Persons and Children with Disabilities"
(offered by the Central Child Welfare Council)

a. Community-based life support

• Clearly systematizing the support program for community-based education and care for children (adults) with disabilities

• Regarding the home helper service for mentally disadvantaged persons, considering the possibility to ease the necessary requirements for the severeness of their disabilities

• Offering places to live for mentally disadvantaged persons by easing working requirements of group homes and welfare homes for mentally disadvantaged persons

b. Offering places for working and day-time activities

• Promoting the improvement of sheltered workshops (commuting) for mentally disadvantaged persons including the eased requirement for the fixed number

• Clearly positioning the day service program for mentally disadvantaged persons by law

• Promoting the shift of small-scale workshops to legal facilities and projects

c. Reviewing the function of facilities for mentally disadvantaged persons

• Reinforcing the function to promote facility residents' shift to community life

d. Transferring the administrative work to accept residents to facilities for mentally disadvantaged persons to municipal governments

(1) The history of review

With regard to Japan's health and welfare measures for people with mental disorder, the Supplementary Provisions of the "Law to Make a Partial Amendment of the Mental Health Law" in 1993 provides that the Law shall be reviewed in about five years after the enforcement of the amended law. The interim report released by the jointly planed subcommittee of the three councils for people with disabilities in December 1997, also requested a review of medical care for mental diseases.

Based on these, to review the Mental Health and Welfare Law, the Special Committee on the Mental Health and Welfare Law was established at the Committee on Health and Welfare for People with Mental Disorder of the Council on Public Health in March 1998 and published a report in September 1998. In addition, based on the report, the Committee on Health and Welfare for People with Mental Disorder of the Council on Public Health made discussions concerning the review of the Mental Health and Welfare Law. In January 1999, a statement of the Council on Public Health's views ("Future Health and Welfare Measures for People with Mental Disorder"), which shows the direction for the review of the Mental Health and Welfare Law, was released.

(2) The background and necessity of the review

1 Increase in the number of people with mental disorders

According to the Patient Survey in 1996, the number of people with mental disorders who stay in mental and other hospitals or commute to hospitals is estimated at 2.17 million and is rapidly increasing from 1.57 million in the same survey in 1993. Along with the recent increasingly complicated society, it becomes necessary to consider the health and welfare measures for people with mental disorders as an issue for all the people.

2 Relapse of infringement cases of human rights of people with mental disorders

Since the amendment of the Mental Hygiene Law in 1987, the protection of human rights of people with mental disorders has been one of the most important issues of the health and welfare measures for people with mental disorders. Recently, however, infringement cases of human rights occurred, such as the Yamatogawa Hospital case where seeing patients was unfairly limited and the Saigata Hospital case where patients died while they were unfairly bound. Thus, it is required to expand and improve the measures to protect human rights of people with mental disorders.

3 Decline in family members' capability to support people with mental disorders

Recently, due to the changing family style, the aging of family members, and an increase in the number of people with mental disorders who live alone, it has become more and more difficult to depend on family members for daily life support to people with mental disorders. Thus, measures to support people with mental disorders in the communities familiar to them are required.

4 The issue of long-term hospitalization and social rehabilitation facilities to accept inpatients

According to the 1996 Patient Survey, regarding inpatients of mental hospitals, patients who have been hospitalized for five and more years account for about 46.5% (45.7% in the same Survey in 1993), which shows the social rehabilitation of people with metal disorders has not progressed. Thus, it is necessary to further promote social rehabilitation measures.

(3) Law to Make a Partial Amendment of the Law on Mental Health and Welfare for People with Mental Disorders

Based on the statement of views by the Council on Public Health, the Ministry of Health and Welfare considered and submitted a bill on "Law to Make a Partial Amendment of the Law on Mental Health and Welfare for People with Mental Disorders" on March 10, 1999. This bill was approved on May 28, 1999 and was proclaimed on June 4.

The outline of this law is as follows.

The Outline of the Law to Make a Partial Amendment of the Law on Mental Health and Welfare for People with Mental Disorders (1) Matters concerning the provision of medical care paying attention to the human rights of people with mental disorders 1 To abolish the restrictions on the number of members for the Examination Committee on Medical Care for Mental Diseases and vest the Committee with authority to report and collect 2 To review the system for designated physician of mental health, such as the expansion of the responsibility to write medial records and the establishment of the punishment of suspending the performance of duty 3 To clearly write that those who are in involuntary hospitalization for medical care and protection are judged to be unable to enter a hospital based on their consent due to their mental diseases 4 To strengthen guidance and supervision to mental hospitals, such as the establishment of an order to restrict in-hospital medical care (2) Matters concerning the transfer of people with mental disorders who urgently need hospitalization Regarding people with mental disorders who need urgent hospitalization, but are judged to be unable to enter a hospital based on their consent due to their mental diseases, establishing a system to transfer them to proper hospitals under the responsibility of prefectural governors. (3) Matters concerning guardians 1 To delete the provision of supervising obligation to prevent self-inflicted acts of harm and other harms 2 Regarding guardians of people with mental disorders who receive medical care of their own free will, exempting the guardians from their obligation to make their people with mental disorders receive medical care (4) Matters concerning the improvement of the health and welfare service for people with mental disorders 1 To strengthen the function of the mental health and welfare service centers so that they will conduct the administrative work of the Examination Committee on Medical Care for Mental Diseases and judge whether or not the medical expenditures to commute to hospitals are covered by public money as well as whether or not the Health and Welfare Handbook for People with Mental Disorders is issued 2 To designate by law the community life support centers for people with mental disorders which provide consultation and advice service concerning daily life as social rehabilitation facilities for people with mental disorders 3 To designate by law the home helper service and short stay service, which will be conducted as the living support program along with the current community life support service (group home) by each municipality 4 The service to provide consultation and advice concerning the use of welfare services which has been traditionally conducted by health centers, will be mainly conducted by municipalities. (5) Other amended matters 1 To abolish the provisional hospitalization system 2 To abolish the accordingly applied provisions concerning chronic addicts of stimulant drugs, and to clarify that people dependent on drugs are included in people with mental disorders.

Column Reviewing the Term "Seishin-Hakujaku (Mental Retardation)" Regarding the term "seishin-hakujaku (mental retardation)," guardians and welfare facility-related persons have strongly demanded that "mental retardation" should be replaced by "chiteki-shogai (intellectual disability)" which can express the situation of disorders in a neutral manner, because "mental retardation" sounds like having some defect in one's character as a whole and because "retardation" has a strong negative nuance. "Seishin-hakujaku (mental retardation)" is a literal translation from Schwachsinn (German) or feeble mindedness (English). At present, these expressions are not used in America and European countries, and the expression "intellectual disability" is widely used. In Japan, the expression "chiteki-shogai (intellectual disability) has already spread and been firmly established in the mass media. Regarding "mental retardation" as the term provided by law, in response to the recent demand by the related organizations and the fact that the review of the term "mental retardation" was stated in the Government Action Plan for Persons with Disabilities, the bill on "Law to Make a Partial Amendment of Related Laws to Arrange the Wording "Mental Retardation" which was proposed by the chairman at the Committee on Public Welfare, the House of Councilors, was submitted to a plenary session. This bill was approved at the 143rd Diet, proclaimed on September 28, 1998 and came into force on April 1, 1999.