[EAI Working Paper] Post-COVID World Political Economy Series ⑧_ Legacies of State-Society Relations and Crisis Response: COVID-19 and Japan

I. Introduction

The effectiveness of crisis response to the COVID-19 pandemic cannot be explained solely by the healthcare capacity of each nation. The governance capacity of each country to effectively mobilize healthcare capabilities for pandemic response has varied, and the effective operation of each country's crisis response system has been considered as important as its healthcare capacity in evaluating their COVID-19 responses (Kumar 2021). Fundamentally, the healthcare capacity within a country will be the most crucial variable in responding to COVID-19, but questions about the country's crisis response system are inevitable when the response results are inadequate despite possessing sufficient healthcare capacity. Japan from the spring of 2020 to the summer of 2021 is a representative case fitting this description.

The comparison of hospital beds per capita has been observed to symbolize Japan's superior healthcare capacity. However, during the COVID-19 pandemic, Japan experienced a shortage of hospital beds for COVID-19 patients. The COVID-19 pandemic served as an opportunity to reveal the problems in Japan's crisis response system, as it failed to effectively mobilize the nation's excellent resources during a national crisis. However, the problems in Japan's crisis response system do not necessarily mean a failure in Japan's COVID-19 response. In terms of basic figures such as confirmed cases and deaths from COVID-19, Japan's performance is not bad when compared globally. However, an assessment of the extent of COVID-19 damage itself is not the focus of this paper. Whether one overestimates or underestimates Japan's COVID-19 damage by comparing it with other East Asian countries or on a global scale only obscures the visibility of the core aspects that must be examined to analyze the political, social, and political-economic impacts of COVID-19 on Japan.

This paper attempts to analyze the problems in Japan's crisis response system observed in its COVID-19 response and to identify their causes. When discussing the problems in Japan's COVID-19 response, aspects of policy governance such as the political leadership issues of former Prime Ministers Shinzo Abe and Yoshihide Suga, the slow response of the Ministry of Health, Labour and Welfare, and the legal authority issues between the central and local governments are commonly discussed (Kim Young-geun 2020; Choi Eun-mi 2020; Choi Eun-mi 2021; Hosaka Yuji 2020; Takenaka Harukata 2020; Kami Masahiro 2020; Kanai Toshiyuki 2021). Most of these discussions are highly persuasive. However, this paper seeks to find the problems in Japan's crisis response system not only in the governance of the policy-making process but also in the structural characteristics of Japan's post-war system.

The crisis response system of a nation, which forms the basis of its governance capacity, includes not only the capabilities that the state can utilize but also the effectiveness of the cooperation mechanism between the state and society. The COVID-19 pandemic has globally heightened the emphasis on the political and economic role of the state. The trend of strengthening the state's role in politics and economics, which intensified after the global financial crisis amidst the US-China strategic competition, has been further accelerated by COVID-19. Within Japan, there is a strong perspective that the strengthening of the state's role, which has weakened, is necessary to address the problems in its COVID-19 response. However, the perspective emphasizing the weakened role of the state is divided into two main directions: one emphasizing the lack of legal authority for state intervention in society, and the other emphasizing the reduced fiscal support from the state to society.

The perspective emphasizing the lack of legal authority for state intervention in society views the post-war tradition of the state refraining from intervening in society as having led to the limitations in crisis response. From this viewpoint, the biggest problem in Japan's COVID-19 response lies in the central government's lack of clear legal authority to issue directives to the private sector. Meanwhile, the perspective emphasizing the issue of reduced fiscal support from the state to society prior to COVID-19 argues that healthcare reforms focused on fiscal soundness, rather than the post-war system itself, have weakened Japan's crisis response capabilities. This perspective implies that the nature of healthcare services, altered by healthcare reforms, is not conducive to responding to infectious disease outbreaks, and that the state must actively increase fiscal support to overcome the crisis. Although differing in nature, both perspectives that emphasize the lack of state capacity in Japan's COVID-19 response appear to be reflected in the current trend of the Japanese government attempting to expand fiscal spending and strengthen administrative capabilities.

This paper does not dispute the arguments pointing to the limitations or restraint of state capacity as problems in Japan's COVID-19 response. However, it argues that the reduction or restraint of state capacity cannot fully explain the problems in Japan's COVID-19 response. Even by the summer of 2021, a year into the pandemic, despite the establishment of active support measures for the medical community by the state, the Japanese medical sector did not easily transition to establishing a rapid and flexible response system for COVID-19 patients. This demonstrates that increased fiscal input from the state and increased legal authority for state intervention in the private sector do not immediately lead to effective crisis response. This paper further argues that the nature of state-society relations, developed within Japan's post-war system, has led to delays in crisis response. Specifically, it emphasizes the patron-client nature of the relationship between the Japanese government and the medical community, which underlies the medical sector's reluctance to actively engage in COVID-19 response. This argument implies that reorganizing the societal sector is as necessary as strengthening state capacity for enhancing Japan's crisis response system. However, such reorganization of the societal sector carries the dilemma of shaking the patron-client state-society relations that formed the foundation of Japan's post-war social stability. Furthermore, while crises present opportunities for societal reorganization, they also provide opportunities for vested interests to protect and expand their self-interest. The relationship between Japan's medical community and the government can serve as a case study for observing how Japan's state-society relations may shift in times of crisis.

The structure of this paper is as follows. Section II will analyze the process of COVID-19 spread in Japan and the current status of the Japanese government's response, as well as the problems in Japan's crisis response revealed during that process. Section III, an analysis of the causes of Japan's COVID-19 response problems, will cover discussions on the limitations of state capacity and the influence of the patron-client nature of Japan's post-war state-society relations. Section IV will discuss the political, social, and political-economic implications of COVID-19 for Japan.

II. Japan's COVID-19 Response

1. Spread and Response to COVID-19 in Japan

Chronologically, the spread of COVID-19 in Japan until the end of 2021 can be summarized into five major waves. In the approximately two years since the first confirmed case of COVID-19 in Japan on January 16, 2020, Japan experienced five waves of increasing confirmed cases.

The border control measures, symbolized by the entry ban from China, South Korea, and Italy, which expanded by March after starting with an entry ban from China's Hubei province on January 20, 2020, could not prevent the spread of COVID-19 within Japan. The Japanese government's initial response in early 2020, focused on preventing imported infections rather than domestic spread, was clearly demonstrated in its policy of keeping passengers on board the Diamond Princess cruise ship docked in Yokohama in February of that year. However, given the nature of COVID-19, which is fundamentally difficult to contain without a complete lockdown like that in New Zealand, the spread of infection within Japan was inevitable. The cumulative number of confirmed cases exceeded 100 on February 21 and reached 1,000 a month later, on March 21. The cumulative number of confirmed cases reached 10,000 on April 18, a tenfold increase in just one month. During the first wave of the pandemic from March to May 2020, the Japanese government enacted the Act on Special Measures for Novel Influenza and Other Emerging Infectious Diseases on March 26, and based on this, issued a state of emergency declaration on April 7 in seven prefectures including Tokyo, and expanded it nationwide on April 16. As the spread of COVID-19 subsided in May, the Japanese government lifted the state of emergency.

A second wave began in July as infections started to rise again. However, unlike during the first wave, the Japanese government strongly maintained a policy of balancing the economy and epidemic prevention. The continuation of the Go To Travel campaign, established as an economic stimulus measure, exacerbated the spread of infections during the second wave. The cumulative number of confirmed cases, which was 40,000 on August 3, increased to 50,000 on August 11 and 60,000 on August 20. The Japanese government's reluctance to declare a state of emergency again during the second wave, under its policy of balancing the economy and epidemic prevention, persisted even after Prime Minister Abe stepped down for health reasons and the Suga administration took office in September.

With the second wave not subsiding and seasonal factors overlapping, infections spread even more rapidly from November 2020, leading to a third wave. The cumulative number of confirmed cases surged from 100,000 on October 30 to 150,000 on December 1 and 200,000 on December 21. The Japanese government eventually decided to suspend the Go To Travel campaign on December 28 and issued a state of emergency declaration on January 7, 2021, in Tokyo, Chiba, Saitama, and Kanagawa. The state of emergency declaration during the third wave was adjusted with regional expansion and extensions, and was finally lifted on March 21.

The fourth wave between April and June 2021 and the fifth wave between July and September 2021 overlapped with the Japanese government's third and fourth state of emergency declarations. During the fourth wave, the cumulative number of confirmed cases exceeded 500,000 on April 10, 600,000 on May 2, and 700,000 on May 19. The cumulative number of confirmed cases on July 1 was 800,000 and surged rapidly during the fifth wave. It reached 900,000 on July 29 and 1,000,000 on August 6, surpassing 1,500,000 by September 1. The daily number of confirmed cases reached a peak of 25,992 on August 20. However, the fifth wave, despite the large number of cases, had a relatively lower number of deaths compared to previous waves. Meanwhile, on September 30, when all four state of emergency declarations had ended, the number of daily confirmed cases decreased to 1,575, and after October 6, with 1,125 cases, the daily number of confirmed cases fell below one thousand (see Figures 1 and 2).

[Figure 1] Trend of COVID-19 Confirmed Cases in Japan (January 2020 - December 2021)

Source: NHK. “国内の感染者数・死者数.” (https://www3.nhk.or.jp/news/special/coronavirus/data-all/).

[Figure 2] Trend of COVID-19 Deaths in Japan (January 2020 - December 2021)

Source: NHK. “国内の感染者数・死者数.” (https://www3.nhk.or.jp/news/special/coronavirus/data-all/).

Within South Korea, there was a significant overestimation of the extent of damage from the spread of COVID-19 in Japan. Of course, except for the cluster infections in Daegu in February 2020 and the period after October 2021, Japan had a higher number of confirmed cases than South Korea for most of the time, and the spread of infection was also stronger in Japan on a per capita basis. This perception was particularly strong towards the end of 2020 when Japan entered its third wave, while South Korea managed to contain the spread, and during the subsequent third, fourth, and fifth waves in Japan in 2021 when South Korea's spread was under control. With both South Korea and Japan showing similar vaccination trends in 2021, the perception of failure in the Japanese government's epidemic prevention measures was strong, focusing on Japan's relatively lower PCR testing volume compared to South Korea (see Figures 3 and 4).

[Figure 3] Comparison of PCR Test Numbers in South Korea and Japan (Trend of Tests per Thousand People, January 2020 - October 2021)

Source: Our World in Data. “Coronavirus Pandemic.” (https://ourworldindata.org/coronavirus).

[Figure 4] Comparison of Vaccination Trends (Fully Vaccinated Rate)

Source: Our World in Data. “Coronavirus Pandemic.” (https://ourworldindata.org/coronavirus).

However, when viewed globally, the damage from COVID-19 in Japan is relatively small. Compared to G7 countries, Japan ranks among those with less severe damage in terms of both cumulative confirmed cases and cumulative deaths per capita. However, when comparing six countries in Northeast Asia (South Korea, Japan, Taiwan, China) along with Australia and New Zealand, Japan can be considered a case with a similar level of damage to South Korea and Australia (see Figure 5).

[Figure 5] Comparison of COVID-19 Cases and Deaths per Million Population (Cumulative as of December 23, 2021)

Source: Worldometer. “COVID-19 CORONAVIRUS PANDEMIC.” (https://www.worldometers.info/coronavirus/). Data processed by the author.

2. Dysfunction in Japan's COVID-19 Response

It is difficult to definitively conclude that Japan's COVID-19 response was problematic based solely on the level of damage. However, positive assessments of Japan's COVID-19 response are rare within Japan. Numerous books criticizing the problems of Japan's COVID-19 response were published in Japan in 2020 and 2021. While many of these critiques were not objective, even from an objective standpoint, significant criticisms were raised.[1]The general consensus is that the relatively managed level of COVID-19 damage was not the result of effective response by the Japanese government and medical community, but rather occurred despite ineffective responses (Shimada Shinji & Aragami Hiroyuki 2020; Makida Hiroshi. 2021; Morita Hiroyuki. 2020).

The limitations in medical response, symbolized by deaths among those awaiting hospitalization, are raised as the most significant problem in Japan's COVID-19 response process. However, it is difficult to label the limitations in medical response as a problem unique to Japan. When COVID-19 cases exploded, the inability of medical systems to respond promptly was a common phenomenon worldwide. However, considering that efforts were made to strengthen the medical response system to the spread of COVID-19 over more than a year in 2020, while fearing so-called 'medical collapse,' the lack of improvement in medical response rigidity in 2021 is noteworthy. In other words, the issue is not simply the inadequacy of medical response to exploding patient numbers, but rather the question of why the medical response system did not effectively improve despite the emphasis and multifaceted promotion of medical response enhancement policies by policymakers over more than a year in 2020.

The most symbolic and discussed issue when discussing the limitations of medical response to COVID-19 in Japan is death while recuperating at home. According to an investigation by the Tokyo Metropolitan Police Department, 817 COVID-19 patients died at home or in care facilities, not in medical institutions, from March 2020 to August 2021. Of these, 250 deaths occurred in August 2021, accounting for the largest proportion.[2]While it may be impossible to completely prevent deaths among those awaiting hospitalization, the increasing number of such deaths implies a 'medical collapse' that Japan feared, and the situation approached this point during Japan's fifth wave.[3]

The Japanese government and medical community pursued a policy focused on managing the increase in COVID-19 patients rather than actively increasing the number of hospital beds for COVID-19 patients. However, as patients increased during the three waves of outbreaks in 2021, there was a need to secure hospital beds for COVID-19 response. Although Japan's number of confirmed cases in 2021 significantly increased compared to 2020, it remained relatively low compared to other developed countries, meaning the number of hospital beds required for COVID-19 response was not excessively large. Of course, maintaining the principle of hospitalization for all COVID-19 patients places a considerable burden. However, it is difficult to argue that even the number of beds required to manage severe cases was adequately increased.

The most significant problem raised is the insufficient increase in hospital beds for COVID-19 patients during the three waves of outbreaks in 2021. Although there was an increase from less than 20,000 beds before the summer of 2020 to over 40,000 by the end of 2021 (see Figure 6), the securing of beds to manage severe cases did not occur flexibly amidst the spread of COVID-19 in 2021. This is particularly noteworthy given that Japan ranks first among OECD member countries in terms of hospital beds per capita and acute care beds (see Figure 7). In other words, while Japan has a large number of potential hospital beds that could be converted for COVID-19 response, these were not converted. As of 2019, out of 1.62 million beds, excluding those for mental illness, tuberculosis, long-term care for the elderly, and convalescence, 900,000 beds are considered potential candidates for conversion to COVID-19 response (Suzuki Wataru 2021, kindle location 239).

[Figure 6] Trend of COVID-19 Bed Numbers in Japan (May 2020 - December 2021)

Source: Ministry of Health, Labour and Welfare. “療養状況等及び入院患者受入病床数等に関する調査について.” (https://www.mhlw.go.jp/stf/seisakunitsuite/newpage_00023.html). Data processed by the author.

[Figure 7] Number of Hospital Beds per 1,000 Population in OECD Member Countries (2019)

Source: OECD. “Health at a Glance.” (https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance_19991312).

The deaths of COVID-19 patients recuperating at home experienced by Japan during the third, fourth, and fifth waves of the pandemic in 2021 can be attributed not simply to the surge in COVID-19 cases, but to the functional failure of the response, which did not ensure a smooth and flexible increase in hospital beds for COVID-19 patients.

III. The Limited Role of the State and Japan's Public-Private Cooperation

1. The Paradox of Care-Centered Healthcare Reform

The immediate reason why many hospital beds in Japan were not converted into COVID-19 response beds is the shortage of doctors and nurses required to utilize these beds. Patients with COVID-19, designated as a Type 2 Specified Infectious Disease, were, in principle, supposed to be hospitalized in the 'infectious disease beds' of specialized hospitals designated as 'infectious disease designated medical institutions.' Although the government's policy changed to expand the criteria for beds in use, infectious disease or respiratory specialists and specialized nurses were required (Suzuki Wataru 2021, kindle location 294). Furthermore, to prevent the spread of infection, COVID-19 beds require the deployment of specialized medical personnel completely separate from other duties.

The issue of healthcare workforce shortage is linked to the small scale of Japan's healthcare workforce. Unlike its world-leading number of hospital beds, Japan falls below the OECD average in the number of doctors per capita. As of 2018, Japan's 2.49 doctors per thousand population ranked 27th among 31 OECD member countries, just above South Korea's 2.48. The number of nurses per thousand population (2.49 as of 2018) ranks 8th among OECD countries, but it is true that this is insufficient relative to the scale of hospital beds.[4] However, it is difficult to conclude that the overall scale of doctors and nurses is directly linked to the delay in converting beds for COVID-19 response. Given the structural conditions of the Japanese medical system, which is centered on small clinics, the core challenge lies in the active role transition of medium-sized private hospitals and large public hospitals to COVID-19 hospital response. Therefore, it is difficult to consider the small total number of healthcare personnel as the core factor in the shortage of healthcare personnel for COVID-19 response.

However, over the past 20 years, Japanese healthcare reforms have focused on resolving the disparities between healthcare facilities and personnel and establishing an efficient healthcare service system. From the perspective of the government, particularly the Ministry of Finance, the fundamental goal of healthcare reform is to curb rising medical costs due to aging and thereby alleviate the financial burden. From the perspective of alleviating the financial burden, expanding the healthcare workforce is difficult to pursue. The direction that the Japanese government has consistently pursued through healthcare reform is the efficient utilization of healthcare facilities.

During the early 2000s, under the administration of Prime Minister Junichiro Koizumi, when healthcare reform was first pursued with the aim of alleviating the financial burden, there was an interest in introducing market principles for the efficient utilization of healthcare facilities, along with curbing medical expenses. The Koizumi administration attempted deregulation of individual contracts between insurers and medical institutions, which had been prohibited, allowing stock companies to establish medical institutions in special economic zones for healthcare, and partial deregulation of mixed medical treatment (insurance-based and out-of-pocket) (Niki Tatsu 2015, 91-92). However, the concrete implementation of market-oriented healthcare reform policies during the Koizumi administration was very limited. Although the market-oriented direction of healthcare facilities was limited even during the Koizumi administration, market-oriented healthcare reforms have been difficult to find in subsequent administrations of the Liberal Democratic Party and the Democratic Party. While the policy orientation towards healthcare as a growth industry during the Democratic Party administration and the second Abe administration aligns with the market-oriented direction of healthcare reform, the overarching goal of strengthening healthcare services centered on national health insurance has been consistently maintained (Niki Tatsu 2015, 93-95).

Over the past 20 years, the core pillars of Japanese healthcare reform have been the curbing of government healthcare expenditures, the increase in individual co-payment rates, and the integration of medical care and long-term care. The curbing of government healthcare expenditures is symbolized by the suppression of increases in insurance reimbursement rates, and the individual co-payment rate for medical care has been increased to 8%. Instead of efficiency through the marketization of healthcare facilities, the central focus of Japanese healthcare reform has been the direction from 'cure to care.' For example, the 'Report of the National Council on Social Security System Reform' in 2013 explicitly stated the 'transition from 'healing medicine' to 'medicine that heals and supports' ('治す医療' から '治し，支える医療'への転換'). While healing medicine refers to actions taken for acute care, supportive medicine refers to chronic care and end-of-life care (Niki Tatsu 2020, 9-10). The direction of Japanese healthcare reform, which aims to shift healthcare services towards focusing on life management, is not neoliberal in connection with marketization. However, it emphasizes public-private cooperation systems at the regional level to alleviate the government's financial burden while placing care linked to aging at the center of healthcare. If neoliberalism is broadly interpreted as a reduction in the role of the state, then Japan's care-centered healthcare reform can also be considered neoliberal.

It is inaccurate to unilaterally claim that the Japanese government's efforts to reduce financial involvement in the healthcare sector through healthcare reform have led to a weakening of Japan's healthcare capacity. This is because Japanese healthcare reform is also part of Japan's efforts to build a sustainable livelihood security system, symbolized by regional comprehensive care (Niki Tatsu 2017, 15-54). However, the care-centered nature of Japanese healthcare reform is not well-suited for responding to COVID-19. Because Japanese healthcare reform focuses on optimizing healthcare services for chronic elderly care, it can be said to be one of the obstacles in establishing a response system for acute infectious diseases like COVID-19.

2. The Limitations of Legal Systems Based on 'Requests' and 'Recommendations'

The most crucial issue in mobilizing Japan's healthcare capacity for COVID-19 response was the active utilization of medium-sized private hospitals for COVID-19 response. Private institutions overwhelmingly constitute the majority of hospitals in Japan. As of 2018, the proportion of public medical institutions was 18.3%, the fourth lowest among 31 OECD member countries, following the Netherlands, South Korea, and Colombia. In terms of hospital beds, the proportion of public beds was 28.7%, which is larger than the proportion of hospitals, but this means that private hospitals account for over 70% of hospital beds (Suzuki Wataru 2021, kindle location 248). While the government's focus was on having medium-sized and larger private hospitals operate more COVID-19 beds, Japan's COVID-19 response differs most significantly from other countries in how it mobilized private hospitals.

In most countries with a large proportion of private hospitals, when COVID-19 spread rapidly, the government issued administrative orders to private hospitals to secure COVID-19 beds. In European countries like France and Germany, as well as in New York State in the US and South Korea, emergency orders from the government to private hospitals are common. However, Japan has never issued an 'order' to private hospitals to secure COVID-19 beds. The reason is the absence of a legal framework for 'orders.' Under the Medical Care Act, the authority to admit patients rests with the independent judgment of each hospital. Prefectural governments, which have supervisory authority over hospitals, do not have the power to issue directives or orders to hospitals regarding bed utilization. Even under the Act on Special Measures for Novel Influenza and Other Emerging Infectious Diseases, the administrative authorities' power is designed to 'request cooperation' from private hospitals. During the revision of the Infectious Diseases Control Law in 2021, the inclusion of the wording for administrative orders was discussed but was not successful. Ultimately, the outcome was the addition of 'recommendations' in addition to 'requests,' and the inclusion of penalties such as public disclosure of hospital names for non-compliance with 'recommendations' (Suzuki Wataru 2021, kindle location 450).

While some intervention by state power into societal sectors is unavoidable during crises, 'requests' and 'recommendations' were widely used in Japan's COVID-19 response as forms of state intervention. In the early stages of the COVID-19 spread in February 2021, the most noticeable actions by the Japanese government were 'requests' for self-restraint from large-scale events and 'requests' for temporary school closures nationwide. During the declaration of a state of emergency, 'requests' were also made for shortened business hours. The pattern of voluntary acceptance and self-restraint by society based on the state's actual intentions, despite the lack of formal enforcement power, is a distinctly Japanese phenomenon observed during the COVID-19 experience (Park Seung-hyun 2020; Kōkami Naoshi, Satō Tadashi 2020).

The invisibility of state power's intervention in society in Japan is a phenomenon that has consistently continued since the post-war period. In terms of the state exerting strong influence over society, pre-war and post-war Japan share continuity. However, post-war Japan has been reluctant to issue direct orders to society (Yuasa Kentō, Hayashi Kōichirō 2011). This can be considered a compromise between the post-war pacifist society and the conservative political establishment. Alternatively, it could be argued that the characteristics of pre-war Japan, which Masao Maruyama criticized for lacking modernity regarding the responsibilities and authorities of individuals within the state power system without clear boundaries between state power and society, have persisted into the post-war era. Whether it is a post-war characteristic or a characteristic that has continued from the pre-war period, the state power's less explicit intervention in society based on 'requests' and 'recommendations' observed during COVID-19 is not a new phenomenon in Japan.

However, the Japanese medical community did not actively respond to the state power's intended expansion of COVID-19 beds. The 'Japan as a special case' theory, espoused by some Japanese revivalists who claim that voluntary self-sacrifice for public good without coercion is uniquely Japanese, was not observed in the response of many private hospitals to COVID-19. When the explicitness of state power's intervention in society is low, societal responses vary depending on the power each part of society holds relative to state power.

3. The Persistence of a Patronizing State-Society Relationship

In Japan, the government's request for securing COVID-19 beds from private hospitals, made through 'requests' and 'recommendations' rather than 'orders,' lacked enforceability, and the voluntary response from private hospitals was not particularly impressive. Instead of orders, the Japanese government provided high economic incentives to private hospitals. Insurance reimbursement rates for COVID-19 patients have continued to rise over the past two years. In April 2020, the Japanese government doubled the insurance reimbursement rates for severe COVID-19 cases, increased them threefold in May, and fivefold in September. In April 2021, a general increase in insurance reimbursement rates for the healthcare sector, not directly linked to COVID-19 response, was additionally implemented. Furthermore, the 'Emergency Comprehensive Support Grant' allocated through supplementary budgets by the government also tended to flow mostly to private hospitals (Suzuki Wataru 2021, kindle location 493).

However, the increase in COVID-19-related insurance reimbursement rates did not translate into proactive engagement by private hospitals in COVID-19 response. The lukewarm attitude of Japanese private hospitals towards COVID-19 is closely linked to their small scale. The small size of private hospitals means that each hospital lacks sufficient specialized medical personnel for a professional response to COVID-19. The nature of 'low-density healthcare' in small Japanese private hospitals made it difficult to provide a specialized response to infectious diseases like COVID-19. The fact that COVID-19 severe case responses in countries like the United States were primarily centered in large hospitals demonstrates the need for economies of scale in healthcare institutions for COVID-19 response (Suzuki Wataru 2021, kindle location 667).

Given the conditions where small private hospitals find it difficult to actively engage in COVID-19 response, role-sharing among hospitals within a region becomes even more crucial. An ideal system would involve large regional hospitals handling severe COVID-19 cases, medium-sized private hospitals treating mild cases, and active patient transfers based on their treatment status. However, role-sharing among hospitals did not function effectively in Japan's COVID-19 response. While the reduction of hospital beds is undoubtedly a core objective of the regional healthcare vision promoted by the Japanese government in the 2010s, the regional healthcare vision also implies role-sharing among hospitals within a region (Niki Tatsu 2015, 41-50). In other words, if the reform of the regional healthcare vision had progressed well, it might have been possible to overcome the limitations of low-density healthcare in private hospitals through close inter-hospital linkages in COVID-19 response. However, role-sharing among hospitals in Japan did not function effectively during the COVID-19 situation.

The discussion on regional healthcare vision reform conducted before COVID-19 did not successfully establish role-sharing between medium-sized private hospitals and large public hospitals. The regional healthcare vision for role-sharing among hospitals is inevitably linked to the adjustment of hospital bed numbers, and the government's underlying intention appears to have been the reduction of hospital beds rather than the establishment of role-sharing. Given that hospital bed numbers are directly linked to hospital revenue, resistance from private hospitals to adjusting their bed numbers was strong. The Japanese government's reform efforts in this regard were not very proactive, and the adjustment of bed numbers in public hospitals came first. The adjustment of bed numbers in large public hospitals prior to COVID-19 became a negative factor in Japan's COVID-19 response (Suzuki Wataru 2021, kindle location 1224).

The excessive number of hospital beds in Japan, which is a problem in the regional healthcare vision, is closely related to the design of the insurance reimbursement system for private hospitals. In the 2006 revision of medical insurance reimbursement rates, a high rate of 15,660 yen per day was set for 'acute care beds,' leading to an explosive increase in the number of beds. While this was ostensibly for the expansion of advanced acute care, 'acute care beds' in private hospitals, which are not involved in actual advanced medical treatment and are often used for elderly chronic diseases, increased significantly, despite the category including high-level acute care beds like ICUs (Suzuki Wataru 2021, kindle location 1082).

Both the amplification of 'acute care beds' since the 2000s and the stagnation of regional healthcare vision progress under the second Abe administration conflict with the goal of improving the effectiveness of Japanese healthcare services. However, the Japanese government has not strongly pursued a reform path that conflicts with the interests of the Japanese medical community, centered on private hospitals, for the sake of improving healthcare service effectiveness.

The patronizing state-society relationship, where social forces have provided political support to conservative political circles and secured industry interests in post-war Japanese society, has persisted for a long time, particularly in low-productivity industrial sectors. The healthcare sector in Japan, along with agriculture, rural areas, and civil engineering, is a representative field where this patronizing state-society relationship has been strongly evident. The background to the ongoing discussions about reducing state financial investment in the healthcare sector and promoting it as a growth industry within the structural reform agenda aimed at changing Japan's post-war system is the criticism that the inefficiency of overall healthcare services has not been improved, while the interests of the medical community, centered on private hospitals, are guaranteed through political networks. The slow response of Japanese private hospitals and the difficulties in establishing cooperation systems during the COVID-19 crisis serve as a reminder that the rigidity of Japanese healthcare services within a patronizing state-society relationship continues.

IV. Japan After COVID-19

Experiencing COVID-19, the Japanese government is clearly choosing a direction of strengthening the role of the state. While Abenomics under the second Abe administration was largely inconsistent with the policy goal of fiscal soundness, securing fiscal soundness itself was not a priority in the government's policy objectives during the COVID-19 response.[5] In the fiscal year 2020, an unprecedentedly large expenditure of 150 trillion yen was recorded, with three supplementary budgets. In fiscal year 2021, the Kishida Fumio administration also continued expenditures exceeding 140 trillion yen, similar to fiscal year 2020, with the addition of a supplementary budget of 35 trillion yen. In October 2021, Vice Minister of Finance Koji Yano published an opinion piece in 'Bungei Shunju' expressing concerns about fiscal expansion (Yano Koji 2021). Despite this causing a significant shift in discourse within Japan, it has not posed a practical constraint on the pursuit of active fiscal policies. The criticism from fiscal authorities regarding the populist nature of fiscal policies has not overcome the political discourse that social protection is necessary in the context of the COVID-19 crisis and that an active role of the state is required for this purpose.

The argument for an active state role in Japan, symbolized by fiscal expenditure, suggests a change in the direction of healthcare reform. The financial considerations underlying care-centered healthcare reform are unlikely to be a primary concern in post-COVID-19 healthcare administration in the short term. Professor Tatsu Niki, who has raised critical perspectives on Japanese healthcare reform, predicts that state support for healthcare will be strengthened due to COVID-19 (Niki Tatsu 2020, 3-5).

Meanwhile, criticism of the administrative system, which lacks explicitness in the state's intervention in society, appears to be very strong among Japanese policymakers. COVID-19 is likely to be a catalyst for significant changes in Japanese administrative reform. The streamlining of administration, centered on digitalization, is the first area being addressed and advanced (Iida 2020). However, it is unlikely that legal and institutional reforms that clarify intervention in society beyond administrative efficiency will be achieved in the short term. Under Japan's current constitution, the extent of the central government's authority to compel local governments and society during crises is unclear. Liberal forces in Japanese society express concern that the explicitness of state power's intervention in society could lead to an increase in nationalism (Imai Teru 2020). On the other hand, given that effective control and management of society are possible without explicit legal authority for state power's intervention, it is unlikely that Japanese conservative elites will actively pursue the establishment of legal authority for state power's intervention in society, which could cause considerable conflict. However, there is growing domestic public consensus on the policy direction of strengthening state intervention in societal sectors, symbolized by recent economic security initiatives. This suggests that the degree of actual intervention in society is likely to continue to increase, regardless of the explicitness of legal authority for state power's intervention in society.

The reduction of state capacity or restraint of intervention, considered a cause of the dysfunction in COVID-19 response, is likely to move in the opposite direction after COVID-19. However, it is difficult to predict how the patronizing state-society relationship in the healthcare sector will change in the future. Criticism of the rigidity of private hospitals may drive demands for reforms to improve the effectiveness of healthcare reform. In fact, the political influence of patronizing state-society relationships in other low-productivity sectors in Japan has significantly weakened compared to the past. Interest-driven politics in agriculture, rural areas, and civil engineering are no longer as vigorous. However, the political power of the medical community differs from that of other sectors where patronizing relationships operate. Furthermore, COVID-19 may provide an opportunity for the medical community, which exclusively holds specialized capabilities for crisis response, to regain political influence. As the patronizing political mechanism weakens overall, the direction of change in the state-society relationship within the healthcare sector is an area that requires careful observation in the future.

It is natural for the medical community to actively participate in social security and healthcare policy. In future policy processes, it is important to overcome the problem where the pursuit of self-interest by small private hospitals in the past was not accompanied by the pursuit of public interest and flexibility in healthcare. In this regard, the examples of effective cooperative networks among medical institutions that operated in some regions of Japan during COVID-19 are noteworthy (Kim Sung-jo 2020; Suzuki Wataru 2021, kindle location 1501). The core issue that made the patronizing nature of the medical sector problematic in COVID-19 response was the excessive self-centeredness of hospitals. To overcome this while flexibly ensuring the stability of public services, more active public-private cooperation is needed. However, the patronizing state-society relationship was also a form of public-private cooperation. What is important is not public-private cooperation itself, but the consideration of what kind of public-private cooperation is effective for public interest and social protection. It is time to seek new state-society relationships that can replace patronizing relationships, moving beyond criticism of patronizing practices (Levy 2015; Miyamoto Taro, Yamaguchi Jirō 2016).

V. Conclusion

Japan's COVID-19 spread and the resulting damage cannot be considered severe compared to other developed countries on a global scale. However, it is also difficult to consider Japan's COVID-19 response as an outstanding case. In the early stages of the COVID-19 spread in 2020, remarks by Prime Minister Abe and others about disseminating the Japanese model of COVID-19 response as an excellent case study abroad became difficult to find as various challenges in the COVID-19 response emerged. The argument that the state should more actively utilize resources and systems to respond to crises has some validity. However, the Japanese case demonstrates that an increase in the state's role is not a sufficient condition for effective crisis response. A significant portion of the causes of the dysfunction in Japan's COVID-19 response stems from the patronizing state-society relationship within the healthcare sector. In Japan, the patronizing political mechanism has rendered discussions about public interest invisible in the political process and has hindered flexible policy responses. This article aims to emphasize that the ineffectiveness observed in the Japanese medical community and public health administration during the COVID-19 response is closely linked not only to the level of state involvement but also to the nature of the state-society relationship.

Criticism of the patronizing state-society relationship within Japan is widespread and broadly accepted. Against this backdrop, patronizing practices are tending to become a thing of the past in sectors where patronizing political mechanisms previously operated. However, COVID-19 has served as a catalyst, highlighting the strong persistence of Japan's patronizing state-society relationship in the healthcare sector. It is cautious to predict the direction in which the patronizing state-society relationship in the healthcare sector will change. However, the widespread criticism of patronizing state-society relationships must be considered alongside the positive functions that patronizing practices provided for social protection in post-war Japan. Can a new state-society relationship be established that is superior to patronizing practices in terms of public interest and social protection? These are the questions that remain in envisioning Japan's future, looking at Japan's experience with COVID-19.■

■ Author: Lee Jeong-hwan_ Professor, Department of Political Science and International Relations, Seoul National University. He holds a bachelor's and master's degree from the Department of International Relations, Seoul National University, and a Ph.D. in Political Science from the University of California, Berkeley. He previously served as a full-time researcher at the Institute for Japanese Studies, Kookmin University, and as a professor in the Department of International Studies at the same university. His main research areas are the Japanese political economy and Japanese foreign policy. His major publications include 'Decentralization Reform and Public-Private Cooperation in Contemporary Japan' (2016), 'The De-localizing Nature of Japan's Regional Revitalization Policy' (2017), and 'The Transformation of the Abe Administration's Historical Policy: Abe's Statement and Internationalism' (2019).

■ Editor: Yoon Ha-eun_EAI Research Fellow

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