The Risk of Collapse in Regional Healthcare as Seen Through the "1.29 Million Yen Gift Certificate Issue"

— The gift certificate issue is a mirror reflecting the "structural fatigue of regional healthcare" —

The Itoda Town-run Midorigaoka Hospital in Fukuoka Prefecture provided gift certificates worth a total of 1.29 million yen to a university hospital's medical department.
The town explained that this was within the "bounds of courtesy" and posed no legal issues, but anxiety and criticism have erupted from the public, with questions such as "Does this constitute bribery?" and "Is there a risk that medical staff dispatches will be stopped?" In particular, because there is a legal precedent where a professor was found guilty of bribery for receiving money and goods in the past, it is natural for the university side to be sensitive.

However, the essence of this issue is not a simple matter of whether gift certificates are "good or bad."
Rather, it can be said to be a "symbolic event" where the structural fatigue inherent in regional healthcare has surfaced.

Regional municipal hospitals suffer from chronic doctor shortages and cannot maintain their medical care systems without dispatches from university medical departments. On the other hand, if they use private doctor dispatch agencies, success fees of 30% of the annual salary and monthly fixed costs impose a heavy financial burden on the town.
Caught in between, there is also the aspect that the municipality had no choice but to rely on the custom of handing over gift certificates as a "courteous greeting."

This debate highlights an unavoidable dilemma:
"Should formal integrity be prioritized?"
"Should the survival of regional healthcare be prioritized?"

In this article, using this issue as an entry point, we will carefully unravel how the relationships between regional healthcare, university medical departments, and municipalities are formed, and where their limits lie.

The "Gift Certificate Issue" is the tip of the iceberg — The "desperate doctor recruitment" faced by regional hospitals

◆ Regional healthcare cannot exist without doctor dispatches

In regional municipal hospitals and small to medium-sized hospitals, doctor shortages are chronic, and it is not uncommon for the medical care system itself to be unable to function without doctor dispatches from university medical departments. In particular, it is extremely difficult to secure doctors for emergency care, surgery, obstetrics, and anesthesiology, and some hospitals fall into immediate medical service reduction or suspension if medical department support is cut off. The Itoda Town-run Midorigaoka Hospital, which became the subject of this issue, is no exception.

From the perspective of the medical department, dispatches to depopulated areas or small-scale hospitals tend to be disliked by young doctors because educational opportunities are limited, the workload is high, and there is little benefit to their careers. Against this backdrop, municipalities have tried to show "polite greetings" or "expressions of gratitude" as much as possible, and gift certificates have been used as a means to that end.
Of course, the exchange of money and goods should be handled with caution, but it is necessary to understand that there are pressing circumstances behind this custom, namely that "hospitals cannot function without securing doctors."

◆ Is 1.29 million yen in gift certificates really an "abnormal value"?

What drew attention in this report was the fact that a total of 1.29 million yen worth of gift certificates were given to the university medical department over the five years from fiscal 2020 to 2024. However, breaking down the amount, it is "about 20,000 yen per time x 64 times," and there are many opinions in the medical field that this is perceived as being within the "bounds of courtesy." Among the reactions, there are many voices saying, "It is actually negligible compared to the amount paid to private recruitment agencies."

Of course, as long as public funds are being used, transparency is required. However, in the medical field, municipalities, hospitals, and universities are constantly searching for "how to maintain regional healthcare," and customs have been formed to fill the gaps in rigid systems.
Therefore, there is a danger that if we only isolate and condemn the existence of gift certificates, the structural problems facing regional healthcare will become even harder to see.

◆ Using recruitment agencies is a "last resort" — Costs are several times higher than medical departments

When doctors cannot be secured, the use of private doctor dispatch agencies is something municipalities are forced to consider. However, as seen in the reactions, using a dispatch agency incurs a success fee of 30% of the annual salary and monthly fixed fees, which generally amounts to a burden of several million yen. For municipalities with tight finances, this option is not realistic.

Also, unlike through university medical departments, doctors from dispatch agencies do not have smooth "transfers" or "rotations," and it is difficult to build a relationship of trust with the community. Since the "educational functions" and "backup systems" that medical department dispatches have cannot be expected, the burden on the hospital is also greater in terms of quality.

Thus, the reason why the town-run hospital had to rely on "courteous greetings" in the form of gift certificates is that there are almost no realistic alternatives for securing personnel. Even if there is room for criticism from a systemic perspective, discussing it without understanding the structural circumstances behind it carries the risk of further strangling regional healthcare.

Legal risks and the university's position — The "worst-case scenario" of dispatch suspension

◆ The precedent of a professor's bribery case casts a shadow

One of the reasons this issue makes the university side nervous is that there is an actual precedent where a professor received money and goods in exchange for medical department dispatches and was found guilty of bribery. In this case, even if there were excuses such as "it did not go into personal pockets" or "it was a custom," the judicial judgment was strict, and it remains a major trauma for the university side.

This legal precedent has led to a strong awareness of the framework that "exchange of money or goods = potential bribery," causing universities to adopt an extremely cautious stance.
Therefore, even if the town explains that it is "ceremonial and poses no legal problems," the university's honest preference is to avoid any situation that is "outwardly suspicious." Above all, universities are organizations highly vulnerable to scandals, and once "suspicions of money or gift exchanges" are reported, damage to their social credibility is inevitable.

Given this background,the exchange of gift certificates like this is highly likely to be perceived by university medical departments as a "no-go zone.".

◆ Qualification Risks for Specified Function Hospitals—"Doctor Dispatch" is also a Duty for Universities

What makes the issue even more complex is that Specified Function Hospitals like Kyushu University Hospital are now required to meet certain criteria, one of which is "dispatching a certain number of doctors to the region."
In other words, there is a structure where the university cannot meet the requirements as a Specified Function Hospital without conducting dispatches, which could even lead to the risk of losing their qualification.

If this gift certificate issue is interpreted as "dispatch adjustment through the provision of money or goods," the university could be seen as having "suspicions of misconduct," which could cause serious damage to the entire hospital, let alone compliance with dispatch standards.
The reason the university appears to be overreacting is due to the intense pressure to minimize this "organizational risk."

Therefore, even if the town intends it as a polite gesture, actions that could be seen by the university as a "quid pro quo for dispatch" can become a threat that affects the survival of the entire organization.

◆ If Dispatches Stop, Regional Healthcare Will Collapse—There Have Been "Tragedies" in the Past

The most serious concern is the "worst-case scenario" where the university medical department chooses to reduce or stop dispatches.
In fact, there have been multiple cases in the past where universities withdrew doctors and it became difficult for hospitals to continue medical services because issues of money exchange surfaced. Among these, there have been painful reports of cases where the mental burden on those involved reached its limit, leading to the suicide of administrative staff.

For a university, it is rational to stop dispatches to avoid its own risks. However, for a municipal hospital, it is equivalent to a "death sentence," leading to a chain reaction of consequences such as:
・Suspension of emergency services
・Closure of surgery or obstetrics departments
・Downsizing of the hospital, and eventually closure
・Collapse of the local residents' living infrastructure

Healthcare is a regional infrastructure, and once it collapses, it takes an enormous amount of time and cost to rebuild.
Nevertheless, the stance taken by some assembly members to "condemn excessively" regarding this issue can be said to result in an act of suicide for regional healthcare.

What is the Essence of the Problem—The Dilemma Between "Formal Integrity" and "Maintaining Regional Healthcare"

◆ Is Ceremonial Culture Truly "Evil"?

This issue focuses on the formal argument of "whether gift certificates are appropriate." However, the essence lies much deeper. In every organization, not just in the medical field, but also in companies, local governments, and universities, ceremonial gift-giving culture exists to a certain extent, and many argue that it is unrealistic to make medicine the only exception and aim for zero risk.

Of course, transparency must be ensured in the exchange of money and goods, and it is not healthy to continue practices based solely on custom while rules remain ambiguous. However, the reality that regional healthcare is in an extremely fragile state due to a shortage of doctors lies in the background of the problem.

The reason why "actions that look gray in form" occur, as in this case, is that the field is being forced to "patch up" areas that the system does not account for.
In other words, what should be criticized is not the gift certificates themselves, but the structure itself that forces reliance on ceremony.

◆ Ensuring Transparency and Alternative Methods like "Donations"

When money moves between a university and a municipal hospital, the most sound method in terms of form is to use the donation systems that universities accept (departmental donations, entrusted accounting funds, etc.). These systems are operated within a public framework, and because the amounts and purposes are recorded, they are more transparent than ambiguous forms like gift certificates.

Therefore, shifting to a mechanism where it is processed as a formal donation rather than the "ceremonial form" of gift certificates is considered the method with the least risk in the future.

However, there is difficulty here as well. The premise is that the form of "donation" is treated as support for education and research, not as payment for doctor dispatch, so the municipal side must operate it carefully to avoid being misunderstood as "expenditure to get doctors dispatched."

In other words, to increase transparency, it is essential not only to organize the form but also to have governance that can clearly draw a line regarding "what the expenditure is for".

◆ The Biggest Issue is "Doctor Shortage," and Gift Certificates are Merely a Symptom

The most important point in this discussion is not the appropriateness of the gift certificates.
It is the fact that if doctor dispatch stops, the hospital will malfunction, and as a result, the residents will suffer the greatest damage. Among the reactions, there are even voices saying, "Thanks to the commotion, I can see a future where doctor dispatch stops and the hospital shrinks or closes." This is by no means an exaggeration, as in regions where the doctor shortage is serious, the suspension of even one or two dispatches leads directly to the collapse of regional healthcare is a reality.

This gift certificate issue is merely a 'symptom' caused by the 'disease' of structural physician shortages.
If we only try to correct the formalities, we can easily foresee a counterproductive outcome where the cooperation of medical departments is lost, and patients and residents become the ultimate victims.

Beyond the Gift Certificate Issue: Three Perspectives Necessary to Protect Regional Healthcare

This 'gift certificate provision issue' is often simplified as an inappropriate practice by municipal hospitals, but what lies in the background is the structural problem itself where regional healthcare continues to be exhausted by the gap between the system and reality. Focusing only on the superficial debate of whether gift certificates are good or bad will obscure the essence.

In rural areas, medical services cannot function without dispatch from university medical departments, and if that dispatch stops, hospitals are forced to downsize or close. Furthermore, the option of using staffing agencies is too expensive to be realistic, and the background to why municipalities had to rely on the form of 'courtesy' is the fact that the front lines have been driven into a corner as a result of the worsening physician shortage.

On the other hand, universities must also avoid any suspicion of bribery due to past precedents and their responsibilities as specialized function hospitals. In other words, while both sides are 'correct' in their positions, there exists a structure where both forms of justice collide from the perspective of protecting regional healthcare.

What is needed now is not to condemn the 'pros and cons of gift certificates,' but to simultaneously advance these three things:
• Transitioning to a transparent donation system • Establishing governance through collaboration between municipalities and universities • Policy approaches that fundamentally improve the physician shortage

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The collapse of regional healthcare due to the pursuit of formal integrity is the greatest disadvantage for residents. This issue can be said to be a question posed to Japanese society as a whole regarding how to maintain regional healthcare.