Shiori Miyazawa

Towards the crisis of increasing elderly population in 2025, reforming the medical care system is an urgent issue. The purpose of this paper is to clarify Japan's regional differences in medical supply and demand in 2025 by focuses mainly on secondary medical areas. The data used for this analysis is taken from the "number of necessary beds in 2025" estimated by the prefecture governments in 2017 in the "Regional Health Vision". Regional differences are examined through categorizing the hospital beds per 100,000 population by quartiles among 341 secondary medical areas. As a result, regional disparities remain in the medical supply and demand even in 2025.

In recent years, public hospitals in Japan's rural areas, which are the main providers of medical care in rural areas, have been experiencing worsening financial conditions. In response, in 2007, the Ministry of Internal Affairs and Communications issued public hospital reform guidelines to local municipalities, requesting that they improve public hospital management as quickly as possible. Because the worsening fi nancial position of public hospitals is linked to their special organizational structure of strong ties with local governments, the guidelines urged making hospitals managerially independent from municipalities. However, in rural areas that would be especially strongly affected by the guidelines, the issue of medical care is an administrative issue of high public interest, and public hospitals and municipalities are linked inseparably. Consequently, whether the independence of public hospitals from municipalities as proposed by the guidelines is suitable for rural areas persists as an important research subject. <br/>This study, which was conducted to clarify management improvement measures for public hospitals in rural areas and benefi cial governance structures necessary to enable such measures, examined Oguni-Town in Yamagata Prefecture, which improved management of public hospitals without making them independent from municipalities. Measures adopted and implemented by the Oguni public hospital during 2008.2011, including the implementation of a change in the classification of hospital beds, promotion of medical examinations, and introduction of generic drugs, raised medical practice income and contributed to the improvement of management. These measures were developed through cooperation and the exchange of ideas among medical personnel of various specialties and local government officials. Such collaboration is a method that has been emphasized by Oguni-Town throughout its town planning activities. Through the use of common methods, administrative support for public hospital reform was obtained readily. Because the protection of medical care in rural areas is an important part of community building, it can be argued that maintaining a close relation between medical care providers and the community is important.

Many people living in rural areas must travel to distant urban areas for medical care. The problems that such low accessibility to hospitals bring to patients differ depending not only on patients’ conditions but also on their family structure. This study, using a medical behavior survey of residents of a mountain area who have constantly experienced problems of hospital access, examined how family support should be conducted for medical behavior. The region surveyed was a settlement in Oguni Town, Yamagata Prefecture. Members of all households in one settlement were interviewed, with inquiries about outpatient hospital visits and hospitalization of household members, and family support for medical related activities. Results revealed that many residents went to or were admitted to distant hospitals more than about 31 km distant from their homes, but that distance did not necessarily cause problems in their daily life. The reasons were the following: 1）For hospital visits, the frequency was low and travel was less burdensome. 2）For hospitalization, patients received more support from family members living separately near the hospitals than from family members living together.

This manuscript presents analysis of damage on medical institutions by the Great Eastern Japan Earthquake and its consequent tsunami in Iwate Prefecture and Miyagi Prefecture in 2011.<br>Results reveal the following facts:clinics in the southern Sanriku region of Iwate Prefecture, Sanriku region and northern part of Sendai bay region in Miyagi Prefecture, where built-up areas are located near the shore, were inundated in numerous cases. Hospitals were flooded at a higher rate in Miyagi Prefecture where small-scale municipal hospitals and private hospitals are distributed along the coast, than in Iwate Prefecture, where large-scale prefectural hospitals were built at elevated locations. Particularly, the inundation ratios of both clinics and hospitals were high in the Sanriku region of Miyagi Prefecture, which resulted in “medical vacancies”. Victims and patients who were unable to receive medical aid in disaster-affected areas were transported to adjoining cities and towns. Case study of Minami-Sanriku Town in Miyagi Prefecture indicates that inpatient acceptance was limited because of bed shortages, although numerous trauma patients were accepted as outpatients in adjoining Tome City. This fact implies that operations of medical systems degraded from their ordinary condition can have increased vulnerability in time of the disaster.

This paper elucidates the relationships between the maintenance of village functions and the life issues of residents at settlement M of Hinohara-mura, Tokyo, which has been classified as a "marginal settlement", and considers measures adapted to actual conditions there. The facts that most village functions are maintained by out-migrants consisting of mainly the adult children of residents and that population decrease and aging are not directly connected to the marginalization of village functions and residents' lives in settlement M are revealed. However, land and housing ownership, and management are pointed out as areas where supplementation by out-migrants is not possible. This is preventing the elderly residing in areas where unfavorable conditions exist from relocating within the settlement and has become a major obstacle to continued living in the region. Regarding this point, the interrelatedness of the decline in village functions and the growing difficulty of the daily lives of residents have been suggested. Therefore, the utilization of vacant houses in settlements facing similar issues should be considered as an administrative measure for welfare purposes. "Marginal settlement" defined based on uniform numerical criteria are very diverse in terms of characteristics, and measures that match the conditions of each settlement will likely be considered to be necessary. 本稿では，「限界集落」に分類される東京都西多摩郡檜原村のM集落を対象に，集落機能の維持水準と住民の生活問題との関係を明らかにし，実態に即した課題への対応策について考察した．その結果，M集落では別居子らの転出者により集落機能の大半が維持されており，人口減少と高齢化が集落機能ならびに住民生活の限界化に直結しないことが明らかとなった．ただし，転出者による補完が不可能な領域として土地・住宅の所有と管理に関する問題が指摘された．このことは，条件の不利な居住地に在住する高齢者の地域内転居を阻み，地域での生活継続を妨げる大きな障害となっていた．この点において，集落機能の低下と住民生活の困難化との相互関連が示唆された．ゆえに，同様の問題を抱える集落では，行政の対応として福祉目的による空き家の利活用が検討されるべきである．一律の数値基準により定義される「限界集落」もその性格は多様であり，今後は集落状態に即した対応が必要とされるであろう．