Health inequality across prefectures in Japan

www.thelancet.com Published online July 19, 2017 http://dx.doi.org/10.1016/S0140-6736(17)31792-0 1 Japan has exemplary records in human development as measured by a human development index of 0·903 in 2016 (ranked 17th in the world). Universal access to health services with no financial barrier for every citizen in Japan launched in 1961 and has contributed to nearly equitable access and relatively small gaps in health status across regions and socioeconomic groups in the country. Ageing is homogeneously distributed across all communities, which has led to high demand for health care in all prefectures (provinces). Despite these achievements in the past, health inequity is increasing and has become a challenge for Japan. In The Lancet, Shuhei Nomura and colleagues use trend data for burden of disease between 1990 and 2015 to document comprehensive health measures on mortality, morbidity, and injuries and variations across prefectures in Japan. Between 1990 and 2015, average life expectancy has increased by 4·2 years. Although similar rises have occurred between men and women, the gap between the lowest and highest prefectures widened from 2·5 years in 1990 to 3·1 years in 2015. The average health-adjusted life expectancy (HALE) overall increased by 3·5 years over this period, but the disparity between HALEs in the highest and lowest performing prefectures has slightly widened across the period, from 2·3 years in 1990 to 2·7 years in 2015. In Nomura and colleagues’ study, Japan performs well in reducing years of life lost (YLL) over time, probably driven by the reduction in mortality from cardiovascular diseases and neoplasms rather than by reducing the numbers of years living with disability (YLD) between 1990 and 2015. Age-standardised disabilityadjusted life years (DALYs) were reduced by 19·8%: age-standardised YLDs contributed a 3·5% reduction and YLLs contributed a 33·4% reduction. Although mortality from other diseases is declining, both the numbers of deaths and age-standardised mortality from Alzheimer’s disease and other dementias have increased; possibly leading to a slow down of progress in population health since 2005. There has also been a slow pace of reduction in age-standardised mortality rates from cardiovascular diseases since 2005 in Japan. Clearly health status progress overall has been hampered by a leveling off of mortalities from cardiovascular diseases, Alzheimer’s disease, and other dementias after 2005. Primary prevention of Alzheimer’s disease and dementias is therefore a major policy priority taken by the prefecture governments. Notably, Alzheimer’s disease, breast cancer, and other neoplasms are the only three diseases that have little variation across prefectures. This study also shows prefecture variations in burden of diseases; for example, Shiga prefecture located in the western region of Honshu island has the highest number of diseases with mortality rates that are significantly lower than the national mean, hence Shiga has the highest life expectancy at birth in 2015. By contrast, Aomori prefecture in the most northern part of Honshu island has the highest number of diseases with mortality rates that are significantly higher than the national mean. For example, in Shiga the age-standardised mortality rate in 2015 for ischaemic heart disease was 39·8 deaths per 100 000 individuals, whereas in Aomori the mortality rate was 50·1 deaths per 100 000 individuals; the national average was 44·7 deaths per 100 000 individuals. Such large variations in age-standardised mortality rates across prefectures should prompt further investigation of the causes and policy interventions to minimise the prefecture gaps. Although this study offers a comprehensive assessment of the health status trends and prefecture variations of mortality and DALYs in Japan, it provides little by way of what explains these variations. Exposure to risks, variations in lifestyle, and other socioeconomic Health inequality across prefectures in Japan