PERSPECTIVES
Financing health promotion in Japan and Mongolia
Dorjsuren Bayarsaikhan1
Division of Health Sector Development, World Health Organization Regional Office for the Western Pacific, United Nations Avenue, Manila, the Philippines
Introduction
Health promotion is becoming a noticeable policy in both developed and developing countries facing a burden of both communicable and noncommunicable diseases. This paper discusses the focus of health promotion policy, financing arrangements and the perspectives of social health insurance to fund health promotion.
The population health status in Japan is among the highest in the world despite an increasing incidence of cancer, heart, cardiovascular diseases and diabetes. Communicable diseases such as HIV/AIDS and new types of influenza also pose threats to public health. In Mongolia, both communicable and noncommunicable diseases are a serious public health concern. Since 1995, cardiovascular diseases, cancer and injuries have been the leading causes of mortality. Tobacco and alcohol consumption, physical inactivity and unhealthy diet are common risk factors for many chronic diseases.
Japan
In 2000, Japan announced the National Health Promotion Movement in the 21st century, with the shortened name of Healthy Japan 21. This policy aims to encourage all citizens to be healthy and free of disease. It focuses on healthy dietary habits, promotion of physical activities, diagnostic tests and reduction of tobacco use. Traditionally, health promotion is regarded as a useful means to prevent disease and promote health among different social groups. Municipal governments, health centres and urban communities play a major role in implementing health promotion activities. Health promoting leaders have been identified and nominated by community members and trained to conduct health promoting activities in their communities. These include advocacy of healthy lifestyle, behaviour, attitudes, dietary habits, access to health-related information and improvement of health literacy and education at community level. Studies suggest that a community participation approach suited to the socioeconomic setting has been effective in improving health-related behaviour and promoting health in Japan.1
Mongolia
Since 2000, the government of Mongolia has approved 16 public health programmes with health promotion effects such tobacco control, health education, cancer and injury prevention, nutrition, population fitness activities, child and reproductive health. However, strong evidence is not available yet about whether these programmes have been successful in controlling and reducing risky behaviours among the population. Since 2002, there has been an increase in the reporting of unsafe sex practices. There is an increasing trend in tobacco consumption, especially among young people. It is estimated that about 65% of males and 20% of females consume tobacco, which is higher than the respective averages in developing countries. The 2006 STEP survey on the prevalence of noncommunicable disease risk factors estimated that 9 of every 10 people surveyed had at least one risk factor and 1 in 5 people had three or more risk factors for developing a disease.2
Currently, the public health programmes in Mongolia are implemented at population level but other country experiences show that the effects of health promotion can be increased through action at the community and individual level. There is an acute lack of funding support for the public health programmes in Mongolia. Although the central government budget is referred to as the main funding source, no specific budgeting tools and guidelines are provided. The 2005 national health accounts estimated that the level of spending on public health services was less than 5% of total health expenditure.3
Financing promotion schemes
In Japan, local governments assumed the main responsibility for financing health promotion. In practice, the availability of local revenues to implement health promotion activities varied among the country's 47 prefectures. Therefore, the financial adjustment policy was implemented in the form of financial assistance from the national to local governments. The policy aimed to balance revenues of local governments and ensure that a minimum level of public health services was provided equally across the country. It had positive impacts on health improvements in the rural prefectures and reduced the disparity in death rates among all prefectures.4 In April 2008, a decision was made to finance disease prevention with Japan's social health insurance scheme that aims to help individuals to have control over their own health. This is a fundamental policy shift that is expected to intensify the implementation of Healthy Japan 21.
The Japanese and Mongolian experiences provide interesting observations for discussion. In Japan, successful implementation of health promotion activities can be attributed to policy decisions informed by evidence, strong government support and regulation of financing. Policy-wise, Mongolia approved several important public health programmes but their implementation needs improvement with necessary funding support.
The two countries use different financing methods to fund health promotion. In principle, a central government budget seems to be an appropriate financing method for health promotion at the population level. However, in the absence of appropriate guidance and budgeting tools, health promotion may not receive adequate funds. Local government budget and community participation played an important role in funding and implementing health promotion activities at the community level in Japan. Now, social health insurance will support health promotion at the individual level. It is important to note that all three levels of health promotion and their respective financing methods aim to encourage all people to pursue a healthier lifestyle and have adequate health literacy regardless of their socioeconomic status.
The universality of social health insurance coverage is an important factor for Japan. It will ensure that every insured member has access to, and benefits from, health promotion together with other preventive, curative and rehabilitative health care as required. Social health insurance also facilitates effective integration of health promotion into health service delivery and financing arrangements, which is essential for attaining and maintaining universal health-care coverage.
Financing health promotion with social health insurance is relatively new.5 In the past, health promotion has rarely been included in contributory health insurance benefits because it was considered to be for the public good and so was provided free to the population. In 2004, health promotion and social insurance experts met under the auspices of WHO and the International Social Security Association and agreed to joint efforts to strengthen health promotion and disease prevention within social security and social health insurance systems.6 The 2007 World Security Forum also addressed the issue of strengthening health promotion in social health insurance systems.7
As more is learned about health promotion and social health insurance, there are many stimuli for social health insurance to focus on health promotion. Compared to other financing methods, social health insurance has the greatest potential to address individual people's health needs and influence their behaviour through various incentives and special relations with contributing members and service providers.
It will be an interesting option for Mongolia to explore health promotion financing with social health insurance for two reasons: first, to increase available funds for health promotion and, second, to broaden the effects of health promotion across the population. The country introduced compulsory health insurance in 1993 and achieved near universal coverage in 1996 with a government subsidy for low-income and vulnerable populations. Currently, health insurance is well-accepted and practised in the country. The issue is whether the health insurance administration is interested in expanding insurance benefits, whether it is financially viable and whether the contributing members are willing to pay for health promotion benefits.
In 2005, a survey was undertaken to examine people's opinion on health, their health needs and overall perception of health promotion (unpublished research, D Bayarsaikhan and K Nakamura). It indicated that the contributing members largely support health promotion as part of health insurance benefits, even if it requires additional contributions. One possible explanation is that the current insurance benefits focus entirely on curative care. Therefore, actively contributing members received insurance benefits only when they became sick and hospitalized. The survey suggests that people's needs and demands are changing and they have become more concerned about their health. The survey also revealed that the Mongolian people lack adequate health knowledge, literacy and skills to act competently to monitor their own health and health-related problems.
A hypothesis was developed from the survey results that incorporated personal health-related information, education and professional health advice into the current insurance benefits. Hypothetical benefit packages were simulated in terms of health insurance expenditure and revenue. The simulations demonstrated that the expansion of health insurance benefits to include health promotion is financially viable at the current contribution level. This is one of the possible options to enhance health promotion effects with appropriate financing methods in Mongolia.
Conclusion
Observations in Japan and Mongolia show that secure and adequate financing is necessary for successful implementation of health promotion policy and programmes. Government intervention and funding support are needed to translate health promotion policies into effective action. Health promotion financing may have multiple funding sources suited to different levels of implementation, ranging from central and local governments to communities and individuals. Social health insurance is one of the potential funding sources to encourage health promotion at the individual level. The initiative to finance health promotion with social health insurance is relatively new, but there is interest and potential to expand insurance benefits. Country specific studies, cost effectiveness analyses and evidence on health promotion will encourage social health insurance organizations to take proactive action to promote health among their insured members. Eventually, health promotion benefits will shift the focus of insurance from illness to maintaining good health and will add strategic value to social health insurance development paradigms in today's complex socioeconomic situation. 
Competing interests: None declared.
References
1. Yajima Sh, Takano T, Nakamura K, Watanabe M. Effectiveness of a community leaders' programme to promote healthy lifestyles in Tokyo, Japan. Health Promot Int 2001;16:235-43. PMID:11509459 doi:10.1093/heapro/16.3.235
2. Mongolian STEP survey on the prevalence of noncommunicable disease risk factors 2006. Manila: WHO Regional Office for the Western Pacific; 2006.
3. Mongolian National Health Accounts Report. Ulaanbaatar: Ministry of Health; 2005.
4. Takano T, Nakamura K. The national financial adjustment policy and the equalisation of health levels among prefectures. J Epidemiol Community Health 2001;55:748-54. PMID:11553660 doi:10.1136/jech.55.10.748
5. Bayarsaikhan D, Mauiser J. Financing health promotion [HSS/HFS/DP.07.4]. Geneva: WHO; 2007.
6. Report of international consultation on social insurance and health promotion. Helsinki: International Social Security Association & WHO; 2004.
7. International Social Security Association. Investing in people's health [technical commission paper]. In: World Social Security Forum, Moscow, September 2007.
(Submitted: 12 February 2008 Revised version received: 30 July 2008 Accepted: 31 July 2008)
1 Correspondence to Dorjsuren Bayarsaikhan (e-mail: bayarsaikhand@wpro.who.int).
doi:10.2471/BLT.08.052126