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Rural health program can learn much from Japanese experience
Leotes Marie T. Lugo
Business World, Manila

SAKU, Nagano Prefecture (Japan) -- Fifty-six years ago, a young doctor from Tokyo who by his own admission was a communist sympathizer then, left a promising career in the capital to head the one-man surgery department of a rural hospital owned by farmers.

Saku Central Hospital was located in the then rural and agricultural Usuda town in Saku district in eastern Nagano Prefecture.

But after years of hard work, patience and innovation, Dr. Toshikazu Wakatsuki transformed the Saku General Hospital to a world leader in rural health.

In fact, Filipino doctors and rural health workers have visited Saku Central Hospital in a bid to replicate its success in the Philippines, where close to half of the population live in rural areas.

A group of rural administrative health officers from Mindanao are also set to visit the Hospital's training center for a one-day observation tour on June 13. The Benguet General Hospital has also entered into a sister agreement with Saku Hospital for possible technology transfer.

But Mr. Wakatsuki, who granted an interview with BusinessWorld at the hospital here, said it takes years and patience to push for advancements in rural medicine. At 91 years old, he has won several awards and recognition for his work in rural health care, including the prestigious Asia-wide Ramon Magsaysay Award in 1976, the 1972 Social Services Award given by Asahi Shimbun and the 1990 Supreme JMA Award of the Japan Medical Association.

Mr. Wakatsuki recalled that when he first came to Saku district in 1946, the place was "very poor with many farm animals and no toilets." He described the health situation in the area then as "very bad."" There were just three doctors in the hospital, including himself. The other headed the one-man internal medicine department, while the other one, a female, headed pediatrics.

Saku hospital, which is owned by farmer-cooperatives in Nagano Prefecture, turned only a year old then, having been established in January 1944 by Junichi Kinoshita, who is now chairman of the board. At the hospital's opening, there were no medical services available in 13 of the county's 23 towns and villages.

Mr. Wakatsuki recalled back then the hospital had only 20 beds, but it was never filled to capacity.

Now, the hospital has 983 beds and over a hundred doctors comprising the 1,396 medical staff. The Saku Central Hospital Nursing College, Japan Institute of Rural Medicine, National Training Center for Rural Health and the Saku Institute of Oriental Medicine, among others, were also established as annexes of the hospital. Hospital director Dr. Shigefumi Shimizu also said plans are under way for the hospital's renovation and expansion.

Mr. Wakatsuki noted that when he first came to Saku hospital, it had only one patient. So the doctor tried to find out why residents did not patronize the hospital. It was not difficult to see. Local residents, mostly farmers were busy tilling their farms and wary about doctors and hospitals in general, relying instead on herbs and traditional medicine.

"They had so much work to do. Farmers had no time, no money and no patience to visit the clinic," Mr. Wakatsuki said. He, thus, exerted extra effort to apply the concept of community medicine. "But it takes a long time and you need patience. You need a sincere effort."

His rural health approach is a unique initiative and partly the secret to his success. "Simply teaching people about health is not a good idea. They (the medical people) have to experience it themselves."

He and the other doctors and medical staff went out of their way to visit houses and win the trust and respect of the local residents. He devised such hospital mottos as "Together with farmers," "Residents first," and "Prevention is better than cure."

In December 1945, the hospital's caravan team delivered medical care in the villages. The caravan mass health screenings were also launched in 1959 in Yachiho village, 12 kilometers south of the hospital. At present, more than 100,000 residents in Saku undergo health screenings every year. Nagano Prefecture, site of the 1998 Winter Olympics, also has the highest life expectancy rate for men in Japan. Saku hospital, up to the present, continues to send mobile clinics to rural areas to check on farmers and other local residents who might not have direct access to medical facilities.


Mr. Wakatsuki, who became the hospital's director in 1946, also devised a training program where doctors, nurses and other medical staff had to experience the life of a farmer.

Hence, at the now famous Japan Rural Health Care Training Center, the medical staff also get to till the fields and plant rice -- the better for them to relate to the farmers' aches and pains.

"My idea is to understand better the lifestyle of the farmers at the same time I have to convince the people that the hospital's service is good," Mr. Wakatsuki said. "At that time, people did not know the concept of community medicine. But now we understand the lifestyle of the people."

Another innovative practice pioneered by Saku Hospital is the holding of an annual open-house byoin, or hospital festival, where residents troop to the hospital not to get cured but to have fun.

Started in May 1947, the event provides a good opportunity for the medical staff to educate residents on health issues and to bring Saku Hospital closer to the people. This year's byoin was held last May 20 with the theme "barrier-free world." An estimated 2,000 people attended the festival to either get a free medical checkup or simply join the fun.

The hospital's parking area was transformed to a food court and the open-parking area to a stage for bands and dancers. Traditional Japanese dances were presented at the multipurpose hall where the open-forum with the hospital's director and doctors was held.

There were also displays, charts and other exhibits on health issues, including on old age and disability. The hospital staff, who prepared the materials, were also on hand to explain the exhibit.

Due to its success in rural medicine, many doctors and medical practitioners from various parts of the world want to train at Saku Hospital. Now, the Hospital has a visiting program for foreigners and even local medical practitioners from other parts of Japan.


But what attracts them to practice in Saku Hospital, Mr. Wakatsuki said, is certainly not the pay but the concept of social justice. "It's the idea of helping people."

He said the hospital staff are also trained to follow the "human-based service," a people-centered approach where the needs of the patients come first. Hence, the hospital boasts of courteous and friendly medical staff that is often not found in many countries, including in Tokyo hospitals.

But Mr. Wakatsuki could not say whether the success of Saku Hospital can be replicated in other countries like the Philippines, owing to the differences in the situation. Although he has been to the Philippines three times in the past, he said he is not too familiar with the situation of rural health in the country to judge whether the Saku model can be replicated in Philippine rural areas.

For one, medical treatment in Japan is not as expensive due to its comprehensive health insurance system. The income gap between urban and rural areas is also not as high compared to the mostly low-income rural areas in the Philippines.

Still, Mr. Wakatsuki said he would have wanted to work in the Philippines. "If I were younger and healthier, I would like to work in the Philippines."


Efforts to learn from the Saku Hospital model and apply it in Philippine rural areas are under way through the help of the Japan International Cooperation Agency (JICA).

Dr. Kijo Deura, head of the Saku Hospital Department of International Health, is now coordinating with JICA for the Benguet General Hospital (BGH) project. BGH entered into a sisterhood agreement with Saku Hospital last November. Last March, two BGH doctors visited the hospital to meet with counterparts. As a result, a memorandum of understanding (MoU) for the cooperation and interchange between BGH and Saku Hospital was signed last March 14.

Part of the agreement provided for taking steps for technology transfer including exchange and training of personnel in endoscopic/ultrasound examinations, CCU/ICU management and operating skills, neonatology, community health, public health, hospital management, maintenance and operation of equipment and other specialties to be needed.

The MoU also states regular exchanges of personnel from both the BGH and the Saku Hospital on a voluntary basis.

A pilot program on comprehensive health care will also be started in Benguet province with the help of the JICA agricultural project. The BGH division of training/research/community services will also conduct training courses for community care. A drug revolving fund program will also be introduced as a pilot program for providing essential drugs and medicines to communities in Benguet.

"We hope to make Benguet hospital the next mini-Saku hospital in the Philippines," Mr. Deura added. He said Saku hospital is more than eager to help BGH and other Philippine hospitals due to the "special relationship we have with the Philippines because of Mr. Wakatsuki's) Magsaysay Award."

He noted, however, one problem of rural health care in the Philippines is the government's limited resources. Many hospitals in the rural areas have problems with budgets and are often understaffed. But he noted the barangay health worker system and the local health centers is a good system to promote rural health.

Mr. Deura also said JICA is sponsoring the visit to Saku hospital of 13 administrative health officers from Mindanao. The health officers will be in the hospital for a one-day training, particularly in community care. The visit is part of a six-week training under JICA's "Country focused training course on participatory integrated health administration promotion in the Mindanao SZOPAD for the Republic of the Philippines." SZOPAD, which stands for Special Zones of Peace and Development, is composed of 14 provinces and 10 cities in Mindanao.

JICA noted SZOPAD has been socially and economically underdeveloped due to decades-old political and military conflict. It believes that getting the cooperation of local government units is the key to achieving participation in the area.

Thus, the program was set up in 1998 "to provide and equip local government health officials the necessary knowledge, skills and attitudes critical to the improvement of health indices in the SZOPAD."

The program is also conducted in cooperation with the Chubu International Center and the Asian Health Institute in Nagoya, all of which have cooperation agreements with the Saku hospital.


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