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Part 3: Maintaining and improving the standards of child health care and medical service

1. Recognition of problems

Providing support for our children who will be born into a society with fewer children and an ageing society in the 21st century is a major task for the administration of child health and medical treatment. Even in Japan, where we have overcome a number of diseases and attained a high standard of pediatric health care and medical treatment services in the 20th century, we will need to make further efforts to improve standards by taking into account QOL perspectives and the sound development of healthy children. Due to the reasons discussed above, we will need to proceed with environmental improvement aimed at improvement in child health care and medical standards by positioning it as the major issue to be worked on in the 21st century.

In order to improve health care and medical standards, we need to provide protective support for children in the womb who are developing and waiting to be born. To this end, we will need to make further efforts to improve the perinatal and pediatric medical treatment systems. We will also need to prepare a continued care system for low birth weight infants who now have a much higher survival rate due to advances made in the medical treatment for newborns. Furthermore, we will need to deal with such issues to overcome the higher infant mortality rate as compared with other countries.

In regard to local public entities, the following problems are to be addressed: the reduced numbers of technical staff in charge of maternal and pediatric health at some agencies; the lower use of area wide contacts and adjustments in maternal and pediatric health duties at public health centers where special and technical functions have been strengthened, and lowered maternal and pediatric health activities due to a shift in the emphasis to the long-term care insurance section of municipalities. Accordingly, the maintenance of the level of maternal and pediatric health services at community level is emerging as a problem.

In the field of pediatric medical services, we have been witnessing a number of problems: lower standards of medical services caused by downsizing and the closure of pediatric wards due to non-profitability; lower standards of emergency medical treatment; and a reduction in the number of applicants for pediatricians. In particular, there are concerns that doctors in the areas such as those working in pediatric emergency medical treatment and pediatricians specializing in segmented areas may be in short supply. However, this problem cannot be solved in the short term by the establishment of a training system, and if no measures to address this issue long-term are put into place, it may lead to the collapse of the pediatric medical treatment system itself.

As discussed above, some situations are threatening the standards of pediatric health care as well as community health care services, which had reached the highest level in the world. Measures to maintain such levels are crucial.

Although our medical check-up system for infants is the most advanced in the world, recording a high examination reception rate, it has been pointed out that there is a major regional gap in terms of the accuracy of the check-ups and follow up treatment, and that existing measures taken by local public entities for improvement of QOL for mentally and physically disabled children and those suffering from chronic diseases are not sufficient. It has even been indicated that such initiatives have been entirely entrusted to individual institutions, facilities or individual efforts. Cooperation between child welfare and school health care is also posing a problem. Another problem, which must be addressed, pointed out is children who have various psychological and physical development problems.

Furthermore, we will also need to strive to realize a social environment in which families with children find it easy to live. People want a system that will make it easier for parents to take care of their children at home or in medical institutions when they are ill, and which supports a long-term in-hospital environment and home care.

2. Direction of the initiatives

(1) Community health care

The systematic maternal and child health care services offered by local public entities based on the Maternal and Child Health Law have maintained high standards following the division of tasks between municipalities and public health centers in 1997 and measures taken based on the maternal and pediatric health plans devised by local public entities. Although the health care standards appear high, in some cases, the appropriate volume of resources are not being injected in view of the importance of each scheme, such as in the case of nursing care insurance and measures for the elderly. Community health care initiatives tend to be neglected in comparison to other initiatives in terms of planning, implementation and injection of human resources. However, the need for maternal and child healthcare services is increasing despite the declining birth rate and it is causing numerous social problems.

If the expertise and experience of doctors, public health nurses and other professionals in this field and a cooperative system between the organizations involved in maternal and child health, pediatric medical treatment and child welfare are lost, it will take a long time before they can be recovered and reconstructed. Therefore, we need to establish a system to prevent ourselves from falling into this type of situation by obtaining the understanding of the personnel in charge of the respective local public entities and other involved parties.

A. Medical check ups

Our medical check up system for infants has maintained the highest level in the world. We will need to make efforts to maintain and improve the accuracy of medical check ups and the quality of follow-up treatment so as to detect and treat infants' diseases/disorders at an early stage.

We will also need to take advantage of medical check-ups to deal with parent-child psychological problems, and improve support for child rearing [See p36.3. (1). A].

In addition, we will need to take proactive measures such as conducting surveys and research on child issues, which have not been sufficiently dealt with through existing health care, medical, welfare, and education measures. Such issues include attention deficit hyperactivity disorder (ADHD), learning disorder (LD), and autism (not accompanying mental disorders, in particular).

B. Prevention of accidents

When we consider the child-rearing environment itself, we cannot overlook the problem of smoking and drinking by the people around children. In Japan, we have a particularly large smoking population among males and females in their 20's and 30's in comparison to other countries, and smoking by pregnant women and the people around them is possibly linked to premature delivery, low birth weight of infants, sudden infant death syndrome (SIDS), bronchitis and bronchial asthma. We have also observed cases of children mistakenly swallowing and eating cigarettes. We will need to publish information that discourages such child-rearing methods, urge women to stop smoking and encourage the people surrounding children to smoke in separate areas.

We will also need to give guidance in curtailing drinking during pregnancy as habitual drinking by pregnant women can increase the risk of causing stillbirth and low birth weight infants.

We have also seen large numbers of infant deaths from drowning in bathtubs at home and in traffic accidents involving school children. Therefore, the implementation of accident prevention measures for children in cooperating with households, schools and communities is essential.

C. Vaccination

The major issue here is to keep the high level of the vaccination rate, which has contributed to reducing the number of child deaths. Vaccination is considered to be highly effective in restraining the target infectious disease when roughly 95% or more of the residents in a target community are vaccinated.

It has been pointed out that an understanding of vaccination among the parties concerned is not sufficient, because the nature of the target diseases of vaccination are not fully known, and there is strong concern about the lack of safety information about side effects. We will need to study the effects and risks involved, pay close attention and seek the understanding of the parties concerned in order to fully utilize the results in this field, one from which we can expect the maximum effects of preventive medicine.

A low vaccination rate against rubella is observed among a certain age group. The target of vaccination was conventionally girls during their junior high school years. In 1994, however, vaccination against rubella became obligatory in infancy. When this change took place, an interim measure was taken so that children older than infants but younger than junior high school age in 1994 could be vaccinated against rubella. However, only about 50% of the target age group was actually vaccinated. In anticipation of this resulting in an increase in the number of babies born with congenital rubella syndrome, the necessity for measures to be taken is being indicated. If we take a closer look at measles, the death toll for the ten-year period from 1989 to 1999 was 230, of which approx. 80% were under the age of ten. This illustrates that measles is still a significant childhood disease that needs to be overcome. In recent years, measles in adults has become an international problem, which indicates the importance of proper vaccination in childhood

(2) Pediatric medical treatment

A wide range of activities in pediatric medical treatment is desired, not only simple diagnosis or treatment of diseases, but also assessment of infant development, consultation on child-rearing problems, prevention of diseases mainly by vaccination and providing solutions for health problems in homes and schools. As the declining birth rate trend continues, an increasing the number of parents are feeling uneasy about child rearing. Therefore, we can expect an increasing desire from parents to have greater access to medical treatment for their children including the above-noted activities. We will also need to respond to such demands.

On the other hand, we have concerns about the increasing incidence of downsizing and closure of pediatrics ward due to unprofitability of medical treatment for children. It is also pointed out that due to the unprofitability of medical procedures, severe duties, more frequent on-duty shifts compared with other departments and virtually no chance for increase in the number of patients due to the declining birth rate, the number of students in medical schools who are aiming to become pediatricians is decreasing.

Considering such specificity of the medical treatment for children, a systematic approach will be vital, which includes the economic issues of which may result in increases in medical treatment fees so as to assure a level of pediatric medical service, which is comparable to that in other departments. At the same time, efforts on the side of medical professionals will be necessary.

A. Emergency treatment for children

It has been pointed out that the existing emergency medical treatment system for children (primary, secondary, and tertiary) is not fully systematized. The problem, as seen by the parents, is that they cannot find reliable pediatricians in their neighborhood who can perform examinations during night hours. From the medical professionals' viewpoint, the current system creates excessive workloads for certain pediatricians due to the concentration of patients in particular hospitals, regardless of the seriousness of the condition of the patient. Elements contributing to such situation include the following: parents are becoming aware of abnormalities in their children later in the day due to increasing number of double-income families, the experience and knowledge of grandparents are not being utilized due to increasing numbers of nuclear families and parents tend to desire diagnosis, treatment and explanation from doctors specializing in pediatrics. Taking these elements into consideration, we will need to urgently improve the emergency treatment system for children.

B. In-hospital environment and home care for children

In order to improve QOL for children who are mentally or physically disabled or receiving long-term treatment, medical institutions will need to take comprehensive measures aimed at improving the in-hospital and home care environment for children. To do this, they will need to join hands with organizations involved in child welfare, medical treatment and education, and special education.

We will need to improve the living environment of hospitalized children, by considering the needs of different growth and development stages. We will also need to improve mental care measures for children who are hospitalized for long periods, and provide support for the families of these children. Furthermore, we will need to create a social environment in which parents can take time off without feeling constrained by the people around them when their children fall ill and need to be cared for at home or in medical institutions.

In addition, we will need to improve systems for home care services for children hospitalized for long periods in the NICU (Newborns Intensive Care Unit), high-risk pediatric patients who have overcome an acute phase and pediatric patients suffering from long term chronic diseases.

3. Specific initiatives

(1) Community health care

Because of the technical and highly specialized nature of maternal and pediatric health services, which provide health care services and assessment services from pregnancy and childbirth through infancy, we need to secure technical staff, including doctors, and provide enriched seminars for staff members who are specializing in this area.

In order to maintain our standards of maternal and child healthcare, which are among the highest in the world, we need to secure human resources for the municipalities who provide accessible services to their residents. This will prevent the degradation of maternal and child healthcare services which are offered in the form of health care consultations, guidance, home-visit guidance and medical check ups. This will include the employment of special professionals, such as midwives.

A. Medical check up

We must maintain and improve the quality of medical check-ups for infants by ascertaining the needs of residents concerning the accuracy of such check-ups and follow-up measures. We should also implore our support for disabled children through medical check-ups at an early stage and for other children who are likely to develop a psychological or physical disorder at a later stage as a result of conditions such as Attention Deficit Hyperactive Disorder ("ADHD"), learning disorders and autism. Toward this end, we should improve early discovery systems for such disorders, obtain proper informed consent for parents and devise an effective early medical treatment and education program. At the same time, we should improve the medical treatment and education networks and community functions so as to strengthen the support function for disabled children and their parents.

B. Accidents involving children

As most accidents involving children are preventable, we should take advantage of every occasion to provide information and learning opportunities to families and staff members of children's facilities about specific accident prevention methods for each of the development stages of children. In order for accident prevention measures to penetrate home and community levels, we should set up council meetings at the prefectural and municipalities levels, and make it a community objective to plan, devise, promote and assess accident prevention measures.

We should also set up accident prevention centers in public health centers. Such centers will illustrate examples of accidents to families and staff members of facilities for children, educate them on specific accident prevention measures and provide opportunities for learning about emergency treatment such as heart and lung resuscitation using an infant model. The centers will receive reports on accident cases involving children in the community from medical institutions on a regular basis in order to analyze the causes, and provide this information to concerned parties. As many of the accidents occur due to the physical environment such as structural problems of houses or facilities, we also need to devise measures to improve the physical environment. In addition, we should also make use of the media in our PR activities.

As a preventive measure for Sudden Infant Death Syndrome ("SIDS"), we should provide information for parents, and continue a national campaign (including November as the focal month for stepping up SIDS measures) using slogans similar to those adopted in Western countries: 1) encourage laying babies face up; 2) encourage breast-feeding; and 3) encourage parents not to smoke. In the future, we should expand these PR activities in cooperation with the media.

C. Vaccination

The basic measure for improving the vaccination rate is to change the information supply qualitatively so as to increase interest among the parties involved in vaccination. To be more specific, we should offer balanced information concerning the benefits and risks of vaccination, and help parents to understand the issues by utilizing the opportunities presented by infant check-ups to explain the issues in an easy to understand way.

We should move away from conventional PR, which focuses on medical information, and produce an easy to understand pamphlet using cartoons and animations targeted at young people in order to deepen their understanding of the nature of the diseases and the meaning of vaccination. We should also use the Internet and other forms of electronic media when conducting our PR activities. In addition, we should promote health education for vaccination in schools as well.

While working on the above, it is also important that the prefectural government, which plays the leading role in implementing the countermeasures for infectious disease at the community level, take appropriate measures to reduce the cases of infectious diseases among infants. They will need to increase the level of trust among parents by taking prompt measures in the event of a group infection. They should continue to periodically grasp the occurrence trends of infectious diseases at the community level based on related trend reports and vaccination rates by using medical check ups as an opportunity to provide necessary information and promote effective prevention measures.

(2) Child health care

A. Pediatric health care

In the field of pediatric health care, we should respond fully to the wide range of requests regarding consultation on diagnosis, treatment, child-rearing problems, prevention of disease and solutions to health problems at home and school.

With regard to the issue of guaranteeing a sufficient number of beds for pediatric patients, prefectural governments need to ascertain the actual status in the community, and take necessary measures while seeking the understanding of the parties concerned regarding the security of pediatric medical treatment systems.

Although we do not have any immediate measures for the procurement of pediatricians in the mid to long-term, we should study measures to enhance the work environment, including attractive levels of remuneration. Among other things, fulfilling the required number of medical professionals at each pediatric hospital is vital in order to avoid doctors being burdened with excessive workloads. In the field of medical education, we need to provide a style of education that appeals to students, which motivates them, and strengthen the training for staff members who are in charge of providing this education.

In the future, the percentage of female pediatricians is expected to increase. Considering the higher labor turnover rate of women, however, measures are urgently required. It is particularly important to establish a system that allows female doctors to work and bring up children. In the future, we need to create an system in which substitute staff can be secured to cover maternal and child care leave, in-hospital nursery schools and continuing care nursing facilities can be enhanced and babysitters can be arranged resulting in a smooth return to the workplace after childcare leave.

B. Emergency medical services for children

In order to construct a good system of pediatric emergency medical services in the community, it is necessary to implement measures based on an agreement between the parties involved in medical services and administrative organizations to support pediatric emergency medical treatment on a community-wide basis. Prefectures, which have the important task of establishing an emergency medical service system for children, are needed to implement medical service plans systematically.

To be more specific, in regard to the primary emergency medical service system, potential measures may include the strengthening of outpatient functions by securing pediatricians from across a wide area for emergency centers that are open on holidays and during night hours. In order to secure staffing levels, the introduction of an on-duty doctor system may be considered. With regard to secondary emergency medical service systems, improvements in the rotation system adopted by pediatric departments are urgently required. However, the introduction of the rotation system alone may not be sufficient to respond to serious cases: therefore an alternative suggestion would be to include the establishment of a tertiary emergency medical service system in the medical service plan under which, one medical institution heavily staffed with pediatricians be assigned for this specific purpose to individual communities with an area of roughly 1 million residents.

In order to establish the above-mentioned facility and secure the requisite manpower, it is important to build a support system among regional doctors' associations, university medical faculties and the hospitals concerned. Before building such system in the community, it is also necessary to set up council meetings specializing in the issue of emergency medical services for children, including other involved parties, i.e., fire-fighting institutions, and to consider these various measures in response to the actual needs of the community. Creating a system based on the needs of the users' assessment, which evaluates the emergency medical service system for children in the community and discloses its results, will also be important.

It is also vital to establish financial support systems for surgery and other purposes. Reforming medical treatment fees and governmental subsidies for surgical procedures will also be necessary for some time to come.

C. In-hospital environment and home care for children

We need to improve the in-hospital living environment for children, taking into account the specific needs of children who are in different stages of growth and development. In particular, we should secure space for parents to tend to their children in the sickroom, improve the support environment to for the daily activities of hospitalized pediatric patients, provide psychologists and in-hospital nursing professionals for the psychological care of children hospitalized over long periods, provide play rooms and offer learning opportunities by setting up in-hospital classes.

We should also provide sleeping accommodation adjoining the medical institutions for families of pediatric patients, and establish a system so that the families of long stay patients can freely consult doctors about their concerns. In addition, we should also create a social environment in which parents can take time off without feeling constrained by others when their children fall ill.

We should construct a system aimed at improving home-care services for [pediatric] patients hospitalized in the Neonatal Intensive Care Unit ("NICU") for long periods, high-risk pediatric patients who have overcome an acute phase and pediatric patients suffering from chronic diseases over long periods. We should also strengthen our coordination with education facilities including child welfare institutions and schools for physically or mentally disabled children in the community, and improve support systems for home care services, including home-visit nursing care stations and short-stay programs for pediatric patients.

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