Individual income, income distribution, and self rated health in Japan: cross sectional analysis of nationally representative sample

To the Editor:

Dr. Shibuya, et al., found that in Japan the level of individual
income is more strongly associated with self-rated health than is income
inequality at the prefecture level.1 The authors warned that this evidence
does not mean we should not be concerned with reducing income inequality
as it effects social conditions. They including in their caveat the
effects of local policies that are not easily observed.1 In order to
attenuate individual income disparity, we believe that public health in
Japan must focus on smaller regions than the prefecture level. Because
cities and districts are less homogeneous, income inequality can be
detected more easily. Local governments should be key stakeholders in
reducing health inequality associated with individual income disparity.

In order to bridge health disparities, one indispensable strategy we
can employ today is the dissemination of Healthy Japan 21 at the local
level. The Ministry of Health and Welfare established a structured
national health plan for the first time in 2000 ¨C Healthy Japan 21. This
plan focuses on health promotion, developing a supportive environment for
individual health, setting national health goals and concrete objectives,
and expanding evaluation and collaboration among various stakeholders.
Smaller governments, more effective because they are closer to the people,
have started to tailor their own health goals after Healthy Japan 21 as a
result of the national plan's recommendations for local governments to
account for health disparities in their communities.

However, the Japan Health Promotion and Fitness Foundation reported
in November 2001 that only 140 smaller local governments (cities, towns,
villages, and Tokyo wards) have established their own health goals related
to Healthy Japan 21. Among Japan's 3246 smaller governmental units, only
1365 plan to establish local goals within three years, while 1741 reported
they have no plans to do so. Towns do not perceive a smooth process and do
not understand well enough the importance of developing their own goals.

We know that local health strategies are more quickly implemented,
stronger, more comprehensive, involve people more fully, and more easily
build intersectional collaboration than do centralized strategies.
Involving people in the process of constructing local health goals for the
people rather than for the government is important. Robert Putnam, who
examined the performance of local governments in Italy during a 20-year
study, found that the stock of social capital in a region, as measured by
the density of citizens' participation in community organizations, turned
out to be the best predictor of local government performance.2,3

Local governments' establishment of health goals, led by Healthy
Japan 21, is the key to better population health in Japan.

References

1. Shibuya K, Hashimoto H, Yano E. Individual income, income distribution,
and self rated health in Japan: cross sectional analysis of nationally
representative sample. BMJ 2002;324:16-9.

2. Putnam RD. Making democracy work. Civic tradition in modern Italy.
Princeton University Press, 1993.

3. Kawachi I, Kennedy BP. Health and social cohesion: why care about
income inequality? BMJ 1997;314:1037-40.

Kimiko Ueda, MD, MPH

Assistant Director, Division of Community Health

Masako Takano, MD, PhD

Director

Shijonawate Public Health Center,
Osaka Prefectural Government, Japan
1-16 Esemi-chou,
Shijonawate, Osaka
575-0034, Japan

Correspondece to:
Kimiko Ueda


kueda@xb4.so-net.ne.jp