Introduction

In our previous column, we introduced the Framework for Promoting Dementia Care presented by the Japanese government in June 2019 and the Basic Law for Dementia which was submitted to the House of Representatives as a lawmaker-initiated bill that same month. In this month’s column, we will continue our discussion on the Framework and look at the direction of society after the Basic Law for Dementia is enacted and consider efforts we should engage in.

At the time this column – our fifth installment – will be published, the Basic Law for Dementia will have yet to be enacted. The discussion of the Basic Law for Dementia contained in this column is based on the current content of that law and the views expressed within are my own.

 

The Plan for the Promotion of Dementia Measures in local governments holds the key
It is not mandatory for local governments to formulate plans to promote measures for dementia

The aforementioned Basic Law for Dementia includes the Basic Plan for the Promotion of Policies for Dementia which is to be carried out by the national government as well as the Plan for the Promotion of Dementia Measures that will be followed by local governments and municipalities (including special wards, which this article will include in “municipalities”). Article 11 of the law obligates the national government to formulate plans with the words “must formulate a plan.” We can expect that in practice, this will be done according to the Framework for Promoting Dementia Care which was presented recently. On the other hand, Articles 12 and 13 of the law address the Plan for the Promotion of Dementia Measures and specify that local governments and municipalities “must work to formulate plans.” In other words, they have been obligated to make an effort.

Over the course of several opinion exchange sessions on dementia policy with groups representing people with dementia, healthcare providers, long-term care providers, and people involved in social welfare, I have heard many people ask, “Why doesn’t the Plan for the Promotion of Dementia Measures obligate local governments to formulate plans?” The Cancer Control Act enacted in 2007 and the Basic Law for Persons with Disabilities enacted in 1970 (which is said to have been used as a reference when the Plan for the Promotion of Dementia Measures was drafted) made it mandatory for local governments and municipalities to formulate basic plans (the Cancer Control Act only applied to local governments). Based on this key difference, we can assume that the current state of the plan reflects the recent trend of decentralization.

 

Policy formulation at local governments and municipalities and decentralization

In 1993, resolutions about the promotion of decentralization were passed in the Diet, and the Ministry of Internal Affairs and Communications (MIC) (formerly the Ministry of Public Management, Home Affairs, Posts, and Telecommunications) kicked off decentralization reforms. Historically, Japan has had a centralized system in which the national government was the main actor in administrative management. This system has been in place since the Meiji Restoration. Over time, however, efforts to decentralize have advanced to allow local governments to proactively administer their own regions.

One significant hurdle appeared in the process of decentralization. After the First Stage of Decentralization Reform which eliminated delegated administrative systems and other such systems, what was known as the Trinity Reforms famously reformed state subsidies, transferred tax sources to local governments, and reformed local allocation taxes. One step in this series of events was a recommendation to review requirements placed on local governments and regional frameworks by national decree with the goal of eliminating MIC laws relating to requirements and quotas. That particular recommendation was made in the third set of recommendations presented in 2009 by the Decentralization Reform Committee (which was formed in 2007).

Even after that, problems related to requirements placed on local governments have cropped up from time to time. One such event in recent memory was the inclusion of a long-term vision for local governments and municipalities in the Act on Overcoming Population Decline and Revitalizing the Local Economy that was enacted in November 2014. This particular law was written in a way that required local governments to “make efforts,” but because a later statement from the national government made such efforts a prerequisite for receiving subsidies, most local governments were practically required to formulate plans. However, many of those local governments already included measures for revitalization in their comprehensive plans and other strategies that were already underway. This caused many local governments to struggle to maintain consistency between the national government’s long-term vision and their own plans and regulations. To overcome such issues, the national government created a manual detailing formulation procedures, guidelines for plan content, and other such information. In response, local governments outsourced the formulation of plans to outside parties or revised their plan to strictly adhere to the manual, creating a situation in which Japan was flooded by uniform plans.

In other words, from the perspective of local governments, the act of creating plans became the goal. By no means did this help local residents. It also undermined the efforts of local government employees who were doing their best to exercise their ingenuity for their communities.

 

Is it a requirement or an obligation to make an effort?

Like the laws mentioned above, the Basic Law for Dementia also obligates local governments (at the province and municipality level) to make efforts to formulate plans. From a political science perspective, placing excessive requirements on local governments to formulate plans would be going against the current trend of decentralization. Therefore, it is more appropriate to obligate them to make efforts. In addition, from the perspective of policy effectiveness, requiring local governments to formulate plans in the manner described above would result in the act of creating plans to promote dementia measures to become the goal. This would result in the creation of uniform, ineffective plans.

The Basic Law for Dementia also states that plans for dementia created at the level of the provincial government have to harmonize with plans like the prefectural regional welfare support program, the Medical Care Plan, the Act on Social Welfare for the Elderly, and the prefectural plan for long-term care services. Plans created at the level of municipal government have to harmonize with acts like the Municipal Community Welfare Plan, the Municipal Welfare Plan for the Elderly, and the Municipal Insured Long-Term Care Service Plan. Striking a balance between so many varying types of plans is by no means an easy feat. Of course, reflecting the needs and issues of each region within these constrictions will also take time.

As you are already aware, each region and municipality face wildly different circumstances. There are various elements required for building dementia-friendly communities and there are various resources that can be used to do so. One region might be facing a manpower shortage in healthcare and long-term care while another region might not even have an adequate understanding of the basic facts of dementia. Also, as the population continues to age, there may be regions that desire to include healthy elderly people in local activities, while other regions might have their hands full with the urgent issues arising from depopulation.

As we work to build a dementia-friendly and inclusive society, I believe we can expect effective government policy if our efforts to identify and prioritize the necessary elements in each region are based on the stories and opinions of people with dementia and their families.

I repeat myself, but the goal is not the mere formulation of plans to promote dementia measures. Even if regions are “obligated to make efforts,” the stories and opinions of people with dementia and their families must be respected. If plans are created according to the issues and potential of each region, we can expect the ensuing policies to be far more effective than if uniform plans are hastily created nationwide.

 

Summary – Actions to take moving forward

To create dementia-friendly and inclusive communities in every region, we must not only focus on whether or not each local government has formulated a plan for promoting dementia measures. We must monitor the processes used to formulate plans and sometimes get involved in the creation process to ensure that each plan is as good as possible.

Accurately reflecting the perspectives and opinions of people with dementia and their family members is particularly important. The law states, “When drafting a prefectural plan, each prefecture must endeavor to hear the opinions of persons with dementia and their families, etc. in advance” (Paragraph 3, Article 12 and Paragraph 3, Article 13 address similar obligations for municipalities). However, merely “hearing” their opinions is not enough. Methods used to consider those opinions and actions taken as a result must not be overlooked.

Because the plans will be formulated in this manner, they will result in health policy that represents the people most affected and the public. As written in our previous column, our duty is to cooperate and act to help those plans function effectively.

Looking forward to the next fiscal year, HGPI and the Designing for Dementia Hub intend to continue monitoring efforts for the effective formulation of plans for the promotion of dementia measures at local governments and municipalities. We will make proposals in the future as we watch those developments.

 

About the author
Shunichiro Kurita (HGPI Senior Associate; Steering Committee Member, Designing for Dementia Hub)

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