Philosophy and Mechanisms of Health, Medical, and Welfare Administration and Finance Based on Realistic Conditions (1): The Role of Public Health Nurses in Local Governments

Introduction

I will now begin the lecture on Health, Medical, and Welfare Administration: 'Philosophy and Mechanisms of Health, Medical, and Welfare Administration and Finance Based on Realistic Conditions'.

This is the least interesting lecture in the entire Health, Medical, and Welfare Administration course.
Just looking at the title is enough to make you shudder.

I imagine many students are already thinking, 'I've had enough.' Honestly, even when looking at actual textbooks for the national public health nurse examination, it is hard to understand what is written.

Today's slides are designed to make it understandable. If you still don't understand after this, it is your fault, not mine (laughs).

As a result of trying to make sense of such confusing textbooks, the explanations have been broken down quite significantly.

I should note that since I used to work in administration, the content of this lecture will be based on the realistic conditions of such administration.

Textbooks often contain what you might call 'armchair theories' or 'moralistic and idealistic arguments'—things that are absolutely impossible to implement.

Administration is about exercising wisdom on how to navigate effectively in the place where you actually are.

People cannot act like saints or fulfill idealistic demands, such as a child crying for the moon.

It is important to look at reality and take 'feasible actions'.

Mechanisms of Administration

First of all, administration has always started with 'tribute' or 'taxes'—in short, 'tax revenue' or 'annual revenue.' Administration without revenue cannot exist.

So, everyone, please pay your taxes (laughs).
If you don't pay taxes and there is no revenue, we cannot hire anyone.

This is a fundamental principle that applies to any organization.
For example, it is the same for universities. If the money runs out, the university cannot continue to operate.

It is the same for a household; if there is no income, the household truly cannot continue.
It is the same for companies, and for everything else.

You must obtain proper revenue and execute it properly. You must manage the budget. You must settle the accounts after execution.

It is not good to do these things only among yourselves. It is important to consult a third party—for example, in the case of a prefecture, the assembly—and obtain their approval.

Municipalities are the same; they have municipal assemblies. It is necessary to have them check and provide approval, or what is called a resolution.

Without such sound check-and-balance functions, an organization will surely perish. If you just say, 'I can spend whatever I want,' and use up the budget, you will end up saying, 'Well, the money is gone, what are we going to do now?' Therefore, proper budget management is essential.

Therefore, the philosophy and mechanisms of administration and finance are actually important. However, you cannot understand these things at all by just reading the textbook, so I would like to explain them so that you can understand.

Winslow's definition of public health is 100 years old.
The term 'organized community' is important, isn't it?

Administration is, in short, an organization. An organized community works to prevent disease, prolong life, and promote physical and mental health and efficiency.

Specifically, it involves efforts toward environmental sanitation, control of communicable diseases, health education, the organization of medical and nursing services, and the improvement of social systems.

Think about it carefully. These initiatives cannot be carried out without money. Public health activities cost money.

To do things properly, a certain amount of revenue is necessary. As I mentioned earlier, money is needed to maintain an organization.

For example, professional baseball is like that. Professional soccer teams also need money. Without money, you cannot recruit good players.

Conversely, if you have money, you can recruit good players and win games.

The Dodgers recruited Shohei Ohtani and built an invincible team. On the other hand, what has become of the Angels now that Ohtani has left?

The media doesn't report on it at all, and I don't know.
That is the cold reality.

An organization that has appropriate revenue, executes it appropriately, and can run the PDCA cycle is healthy.

Therefore, the keyword in Winslow's definition of public health is 'organization'.

Activities of Public Health Nurses

Since the enactment of the Public Health Nurse Regulations in 1941, the activities of public health nurses have consistently addressed national health issues in direct relation to social needs and changes in administrative policy.

The 1950s were the era of tuberculosis and infectious diseases, then it shifted to maternal and child health, mental health, and then health promotion. Then came community-based integrated care and collaboration with long-term care.

In the Heisei era, many disasters occurred, and health crisis management became an important issue.

Now, health is not just about lifestyle habits; social determinants are attracting attention.

Where you were born, where you grew up, what kind of education you received, who you married. In short, it is becoming the global mainstream that health is also determined by things other than medicine, such as social and environmental factors.

For example, those of you born in Japan and Miyazaki are completely different from those born in the Gaza Strip or Ukraine.

Where you are born and what kind of education you receive changes your level of health. We must respond while taking such things into account.

In that case, preventive activities are not limited to medicine or public health, but are expanding rapidly into social spheres.

Therefore, the work of a public health nurse never converges. Please be prepared for the fact that this is a profession destined to expand year after year.

If public health nurses do not continue to study, the people in society will end up in a state of poor health.

I want public health nurses to study constantly, boldly grasp the health needs of residents, and consistently tackle national issues within the administration.

This is where public health nurses work.
Where exactly do public health nurses work?

There are roughly 60,000 public health nurses.
Half of them are in municipalities.

17% are in public health centers, and while some work as nurses in hospitals with public health nurse qualifications or as industrial nurses, the main focus is administration.

Approximately 80% of public health nurses work in administration.
85% are in municipalities and 15% are in prefectures.

Some municipalities are core cities that have their own public health centers. For example, in Miyazaki Prefecture, that would be Miyazaki City. That accounts for about 10,000 people.

In addition, there are about 1,600 public health nurses in the 23 special wards of Tokyo.

Public health nurses are told to "bloom where you are planted," but in order to perform various tasks in the places they are planted, whether it be a municipality or a prefecture, they must understand municipal administration and prefectural administration.

Without knowing how the administration works, you cannot collaborate with other professional fields or engage with residents.

You must be able to refute your superiors or administrative staff when they ask, "Wait, is that really the job of the administration?"

They might say, "Don't do this as a hobby."

Once you are employed by the administration, you must first become an administrative official, and on top of that, possess the soul, passion, and skills of a public health nurse.

It is important to use your skills as a public health nurse while being grounded in the mechanisms and customs of the administration.

In other words, it is important to become a civil servant with a public health nurse mindset.
Public health nursing is a qualification with truly infinite possibilities.

It is important to learn the customs of the government office, understand the field of the prefecture or municipality well, and play an active role as a public health nurse who is not just a typical bureaucrat.

Existing textbooks lack this kind of passion.
We need the "Storm of Passion" like Hideki Saijo.

Textbooks state that public health nurses have these roles and are responsible for these tasks, but it is important to remember that before that, you are an administrative official with your own professional responsibilities, and you must utilize your public health nurse mindset based on that foundation.

The basics are important.
To become an unconventional public health nurse, you must first know the "form".

Today, I will talk about knowing the various customs and structures of administration.

Types of Local Governments

First, let's look at what types of local governments exist. Ordinary local public entities include prefectures and municipalities.

On the other hand, there are also special local public entities. The special wards of Tokyo are called special because they are written as special.

Local public entities can form associations. For example, they may create organizations called partial affairs associations or wide-area unions.

In Higashiusuki District, where Shiiba Village is located, they have formed a partial affairs association to operate a crematorium. If Shiiba Village were to build a crematorium on its own, the population would be too small.

In some cases, fire departments are combined. The fire department for Nishiusuki District is operated by a partial affairs association formed by Takachiho Town, Hinokage Town, and Gokase Town.

Partial affairs associations are often organizations where small towns and villages gather to extract one common function and manage it together.

Wide-area unions exist for things like the late-stage elderly healthcare system. Miyazaki Prefecture and each municipality have formed a wide-area union to operate it as a single entity.

This is done based on laws, with the national government instructing that it be handled this way.

Local governments consist of prefectures and municipalities. This is the foundation.

I would like you to remember that there are special entities such as the 23 special wards of Tokyo, as well as partial affairs associations and wide-area unions.

I want you to know that partial affairs associations and wide-area unions are things that exist close to you.

Administrative Structure of Miyazaki Prefecture

Where is this? Yes, this is the Miyazaki Prefectural Office.

The prefectural office actually changes into various colors. It is lit up in blue, red, pink, purple, and other colors to match various commemorative days.

What color is it for World Diabetes Day? Pink? No, that's incorrect.

It is blue. The symbol for diabetes is called the Blue Circle.

World Diabetes Day is November 14th. It is the birthday of Banting, the Canadian doctor who first extracted insulin.

To commemorate this, various buildings and monuments are lit up in blue for World Diabetes Day.

For example, in Miyazaki Prefecture, the prefectural office is lit up in blue; in Yamanashi Prefecture, the statue of Takeda Shingen is lit up in blue; and in Kumamoto Prefecture, Kumamoto Castle is lit up in blue.

Everyone, if you happen to not know about World Diabetes Day on November 14th, be careful, as people might say, 'You're a public health nurse, how do you not know that?'

If someone asks, 'Why is the prefectural office blue?',
if you answer, 'That's because it's World Diabetes Day,' you will be respected.

If you don't know and confidently say, 'Isn't it because the governor likes blue?', you will be scolded later, so please make sure to remember it.

It is interesting to take photos on the day the prefectural office is lit up.
It is lit up in various colors about once a month.

Now, regarding Miyazaki Prefecture, did you know there is a monument to Mr. Susumu Kawagoe at the prefectural office?

Our Miyazaki Prefecture was established in 1873, but it was abolished in 1876 and annexed to Kagoshima Prefecture.

Mr. Susumu Kawagoe, along with his comrades, stirred up public opinion for the movement to separate the prefecture, stood at the forefront and worked tirelessly, and after many twists and turns, on May 9, 1883, he finally realized the re-establishment of the prefecture, which had been the long-cherished desire of the citizens, and laid the foundation for today.

With the sentiment of 'dedicating deep gratitude from all the citizens for the selfless efforts and achievements made by the pioneer in the re-establishment of our prefecture, and honoring his legacy,' the monument to Mr. Susumu Kawagoe is located inside the prefectural office.

At the Miyazaki Prefectural Office, every year on May 9th, the governor, all prefectural assembly members, and all executives at the section chief level and above gather in front of the monument to Mr. Susumu Kawagoe.

They offer bouquets and everyone sings the prefectural song, 'Blue Sky, Rich in Green.'
They are truly grateful that Miyazaki Prefecture was re-established.

Descendants of Mr. Kawagoe also come here.

If the citizens are inattentive, the prefecture could be merged before they know it.
It is necessary to cherish the history of the prefecture and love the prefecture, saying, 'Miyazaki Prefecture is the prefecture of myths, and it is impossible to lose the prefecture where the heavenly grandson descended.'

This is the office of our Shiiba Village.
The interior is made of cedar. It is a very wonderful setting.

Whether it is the Miyazaki Prefectural Office or a municipality like Shiiba Village, the place where you all work as public health nurses will be this kind of administrative organization.

You must first learn about administration. You have to know more about the local government where you work and the department you are assigned to than anyone else.

Miyazaki Prefecture's administrative structure (1).
The prefecture has the governor's department, which is the executive agency, the Board of Education, and the Public Safety Commission.

The Board of Education oversees the Board of Education Secretariat, and the Public Safety Commission oversees the Police Headquarters.
These organizations are not under the governor to maintain impartiality.

Education is independent because it must be separated from power and executed from a fair standpoint.

If the police were too close to the governor, the governor could say things like, 'Go arrest someone I don't like,' so the police are independent, saying, 'No, no, Governor, that's not allowed.'

There is a legislative body for these executive agencies.
It is the prefectural assembly.

The prefectural assembly reviews, approves, or amends the budget proposals and ordinance proposals submitted by the governor.

Both the governor and the prefectural assembly (members) are directly elected by the residents.
The governor is elected once every four years, and the assembly members are also elected once every four years.

The basis of democracy is that residents choose these two functions by electing them directly.

People who don't vote are no good.
People who have the right to vote but don't vote shouldn't complain about the governor or prefectural assembly members.

Everyone, let's go vote.

It is important to understand that there are executive agencies and legislative bodies.

We refer to ourselves as the 'executive branch'.

The role of the assembly members is to properly check various things done by the executive branch.

Because such a check function is working, the administration runs smoothly.

Without a check function, it will run out of control.
For example, President Putin.

Russia essentially only has an executive agency, doesn't it?
It is easy to do things in such a dictatorship.

Things move forward exactly as one thinks, but without a check function, it will eventually collapse. Democracy is important to prevent running out of control.

This is a poster from the previous prefectural gubernatorial election. You have the right to run for election, and you are free to vote for it. That is democracy.

Becoming a city council member and then getting arrested and losing the position was the first time since the history of Miyazaki City began. You can see from this one photo that you never know what the future holds. I will stop here as saying too much might be problematic.

This is the Miyazaki Prefectural Administrative Organization (2). This is the structure of Miyazaki Prefecture. There are two vice governors under the governor, and then there are departments.

There are a total of eight departments in the governor's bureau, and independent of the governor's bureau, there are the Enterprise Bureau and the Hospital Bureau.

The Enterprise Bureau sells electricity generated by prefectural dams and uses that income for the prefecture's revenue. The prefecture is earning money by selling electricity, just like Kyushu Electric Power.

I said that revenue is necessary for administration to proceed, but the prefecture itself operates an electric power company and uses the income from it to run the administration.

Hospitals also have hospital revenue in the same way. There are three prefectural hospitals. They are in Nobeoka, Miyazaki, and Nichinan.

Basically, they should be able to make a profit, but it is difficult to do so. They are in the red, so we proposed to the prefectural assembly last fiscal year to lend 4 billion yen from the governor's bureau to the Hospital Bureau, saying, 'Please manage the hospitals, and you must pay the money back.'

The prefectural assembly did not approve it in its original form. The assembly agreed only after it was decided that a new committee, headed by the vice-governor, would be established to examine the management of the prefectural hospital. This is an example of the prefectural assembly's oversight function at work.

There is a question of whether the doctors at the prefectural hospital are aware of this. Just because it is a prefectural hospital does not mean it is acceptable for it to run a deficit.

In general, a hospital is an organization that will run a deficit and be unable to pay salaries if patients stop coming. Ideally, not only the doctors at the prefectural hospital but all hospital staff, including nurses, should know that a deficit will occur if patients do not come. This is an important point for any organizational member.

Public health nurses working in the governor's department are generally assigned to the Welfare and Health Department. There are eight public health centers and three child guidance centers.

While there are other branch offices, public health nurses primarily work at public health centers. They work at the public health centers, return to the main office, and also work at places like child guidance centers and mental health and welfare centers.

The General Affairs Department also has a division that manages the health of all prefectural employees, focusing on employee health management, especially mental health. There are people who suffer from mental health issues, and when they return to work after a long-term leave, the department provides support for their return to the workplace.

This is the same work as an industrial public health nurse, meaning that public health nurses at the prefectural office also fulfill the role of industrial public health nurses.

Personnel transfers generally occur once every three years. You cannot expect to do the same thing forever.

In return, as you transfer, your rank gradually increases. As you move up, you will have subordinates, be given more responsibilities, and eventually be entrusted with larger tasks.

In the public health nurse profession, there are currently two section chiefs at the main office. They also provide answers at standing committee meetings in the prefectural assembly. Even when asked difficult (?) questions, they respond calmly.

If you work at a prefectural office, you may also find yourself in such a situation. In municipalities as well, public health nurses sometimes become section chiefs or department directors, and in such cases, they may also have to provide answers at assembly meetings.

Similar to the prefectural organization, municipalities have similar departments. In cities, these are departments, and in villages, they are sections. There is a section similar to a Welfare and Health Department where public health nurses work.

When you are hired as a prefectural employee, you receive a written appointment order with the governor's name and seal that says, 'I hereby appoint you to [position].' You only become a prefectural employee after receiving this appointment order from the governor.

When you work for a municipality, you only become a municipal public health nurse after receiving an appointment order from the head of the municipality. Your first job is to make your business cards.

Heads of local governments

The head of a local government is called a 'kubicho' (chief).
Please remember this.

The chief is the highest authority. In a prefecture, the governor's orders are absolute. In a municipality, the orders of the head of the municipality are absolute.

If you are asked who you are working for, the answer is the governor or the head of the municipality.

Also, assembly members are people elected by the residents of the prefecture or municipality, so they are representatives of the 'people.' If you view it as the residents' representatives asking questions, you need to express gratitude by saying, 'I understand. Thank you for your kind words.'

Then, the assembly members will praise you, saying, 'You're a pretty good guy.' Rumors will spread in various places that you are 'a staff member praised by assembly members,' and your status within the administration will rise.

Conversely, if you are scolded by an assembly member, you will be told, 'You are no good.'
In short, assembly members are representatives of the people.

There is a cicada called the 'minmin-zemi' (a type of cicada).
This is unrelated, but the people (min) are the most important.

I don't care about the Meimuna opal or the brown cicada.
If I were to compare it to insects, the Higurashi cicada is the most important.

I forgot what I was talking about, but there is an appointing authority, and you receive your appointment letter from that person. The head of the local government holds personnel and budgetary authority, so in American terms, they are like the President.

Whatever the head of the local government thinks of usually comes to fruition. If they say they want to build something here, for example, if Mayor Kiyoyama of Miyazaki, which is a core city, says he wants to build a child consultation center, it will happen.

The strong will of the head of the local government makes things happen. This means that how you convey the importance of health and welfare to the head of the local government is crucial. That is the role of a public health nurse.

If you say, 'My local government head is useless,' that is not good.
If that's the case, you will never be able to achieve anything.

You must seize every opportunity to tell the head of the local government that 'welfare and health are important.'

When the head of the local government is told repeatedly, they will say, 'You make a pretty good point,' and then it gets implemented.

Always facing the head of the local government and always facing the assembly members is, in short, the same as facing the residents. The head of the local government and the assembly members are people who have been called upon through elections.

Therefore, I hope you can understand that structure of democracy.

About the Assembly

This is the flow of the assembly.
You might not understand what this means just by looking at it now, but I will explain.

First, the assembly opens.
The assembly has an opening and a closing. It is for a limited time.

The assembly is truly hard work. In corporate terms, it's like a general meeting of shareholders.
If they did it every day, it would be difficult and the company would perish, so it is limited to a specific period.

Regular sessions are held in June, September, December, and February, and any sessions held outside of those are called extraordinary sessions.

When it opens, bills are submitted.
This is done by the executive branch.

If it is a prefectural assembly, the governor explains the reasons for the proposal.
They state that they are submitting such budgets and ordinances for this session, and then questioning begins.

There are various committees, and for example, in relation to the Welfare and Health Department, there is the Health and Welfare Committee.

It is referred to that Health and Welfare Committee, where it is examined, debated, and voted on by the committee. The chairperson then reports the results to the plenary session, where there is further debate, and finally, a vote is taken to make a decision.

This is the repetition.
It is a one-month period, but the people in the executive branch are terrified of what kind of questions the assembly members will ask.

The scariest thing is assembly member questioning.
What will the assembly members ask, and can we answer them well?

Once you touch upon something that the prefecture or municipality does not want touched, it is all over.
To avoid a 'game over' scenario, it is important to provide information to assembly members on a regular basis.

If something happens, it is called 'disregard for the assembly,' and if you anger the assembly members, the budget will not pass.

If the budget bill is rejected, it cannot be executed, and the prefectural administration will come to a halt. The same applies to municipalities.

Indeed, the assembly is the most important place.
Therefore, the assembly, which meets four times a year, is a place of serious competition.

If you make a mistake here, it is truly the end.
While the assembly is in session, the assembly is truly the top priority.

We even have to pull all-nighters.
That is strictly to get bills passed and to get the budget passed.

This is a photo of the prefectural assembly. Director-General Matsuura of the General Policy Department is answering questions. In Miyazaki Prefecture, he is the top director-general. He is the director-general who designs the future and comprehensive plans of Miyazaki Prefecture.

There is the Director-General of the General Policy Department, and next to him is the Director-General of the Welfare and Health Department. He is the head of the Welfare and Health Department. Behind them are the Director of the Enterprise Bureau and the Director-General of the Prefectural Land Development Department.

To the left of Director-General Matsuura is the Vice Governor. There are two Vice Governors, and they are Vice Governors who came from the national government. They have come from the Ministry of Land, Infrastructure, Transport and Tourism.

Miyazaki Prefecture has many disasters, and roads and embankments are often destroyed by various floods. Having a Vice Governor from the Ministry of Land, Infrastructure, Transport and Tourism makes it easier to secure budgets for restoration, so they are currently here.
Before that, we had someone from the Ministry of Agriculture, Forestry and Fisheries.

About municipalities

Next is the municipality series.
The prefecture is a wide-area local government, and the role of the prefecture is to coordinate various things among municipalities and to handle wide-area matters that municipalities cannot do.

In reality, the ones closest to us are the municipalities, which are called 'basic local governments.'

In the Meiji era, there were no cities, and there was a period when there were only towns and villages. There were about 70,000 of them. This was the same as in the Edo period. In the Edo period, there were only villages.

Until about the 20th year of Meiji, we operated under the same system as the Edo period.
To be reborn as a modern state, we had to implement local autonomy, so Home Minister Aritomo Yamagata learned from German local autonomy and started it with the idea that local autonomy must be rooted.

Since villages were too small, mergers were promoted so that one village would have a financial base capable of operating one elementary school.

For example, in Shiiba Village, what used to be four villages merged to become Shiiba Village.

The 70,000 locations were reduced to 15,000.
Cities were also newly born. Miyazaki City and Nobeoka City recently celebrated their 100th anniversary of municipal organization, and they were born in that series of events.

After the war, the 'Great Showa Mergers' were carried out starting around 1953.
What was done during this period was to merge so that there would be a financial scale capable of efficiently operating junior high schools, as the new junior high school system had been established.

The total became about 3,000. The number of cities was increased.
The current cities of Miyazaki Prefecture were born in this way.

Next is the Heisei era. I thought the mergers were mostly finished with the Great Showa Mergers, but the Great Heisei Mergers were pushed forward. The reason for this was decentralization.

People were saying, "The national government shouldn't be meddling in every little detail forever."
"The national government decides even the smallest things, so there's no autonomy for cities, towns, and villages."
Because of this, a great chorus arose demanding that authority be transferred to local governments.

Authority would be transferred to local governments, but there was a flow of decentralization questioning whether the current financial base would be sufficient. To strengthen the financial base for that purpose, it was decided that mergers were necessary, and there was a particular push to increase the number of cities.

They also offered a carrot called the 'Merger Special Bond,' which allowed cities to use money for 20 years after merging. As a result, mergers progressed.

Currently, the number of cities has increased significantly. The number of towns and villages has decreased. Most have been merged into cities. There are 183 villages in the whole country. Even in Miyazaki Prefecture, there are very few villages.

I think there are only Shiiba Village, Morotsuka Village, and Nishimera Village. They are all in the northern part of the prefecture. Kitaura-cho, Kitakata-cho, and Kitagawa-cho around Nobeoka City were merged into Nobeoka City, so those towns disappeared. The areas around Miyakonojo City also merged.

Koyu District did not merge. Sometimes it is better not to merge. Municipalities with high tax revenue do not merge easily.

For example, Shintomi Town has a Self-Defense Force base. Kijo Town has income from a dam. It is difficult for Takanabe Town and Saito City to merge due to historical circumstances.

Takanabe takes pride in being a castle town where a castle once stood. Saito City is a place that became a city through repeated mergers. It was originally Tsuma Town, which then merged to become Saito City.

There are various circumstances. Not merging does not mean they have bad relationships. It is a decision made by each local government.

As for why Shiiba Village did not merge, they say there was nowhere to merge with, or perhaps there was a desire to keep the name 'Shiiba'.

Saigo Village, Nango Village, and Kitago Village all have the name 'Go' (village/district), so the three 'Go's came together to form Misato Town. When you merge, the name changes.

Suppose you work for a municipality. The people who were in the towns and villages before the old mergers have a lot of pride and feelings.

Those resident sentiments remain for a long time, so it is important to know such things when conducting resident activities.

It is useful to value old place names and remember them. Knowing the history of municipal mergers is advantageous when developing health education or policies.

In places that were merged and absorbed, the population decreased and people left one after another, and there are towns like that, so there is a lot of resentment in such places.

Even if you look at the textbook, it mentions municipalities and various things, but it doesn't write about what happens after merging.

When you learn about this kind of history, you see that they merged to build elementary schools or merged to build junior high schools; Japanese people are amazing. They are merging to build schools.

Schools are places where people learn to read, study, succeed, and then return to the village with various knowledge. They built those schools for the sake of the people in the villages and towns. That being the case, I really hope that those who have studied at university will give back to their local communities.

The Great Heisei Mergers were for the sake of decentralization. To decentralize, a proper financial base is required.

A financial base is essentially revenue. Mergers were carried out because it was believed that a certain population size is necessary to become a municipality with a strong foundation capable of collecting sufficient tax revenue.

These are the requirements for municipalities. First, regarding designated cities, they are called government-designated cities because they are designated by cabinet order from cities with a population of 500,000 or more.

This means that for administrative tasks that require the involvement of the prefectural governor, such as approval or permission, that involvement is eliminated, which in essence means becoming independent from the prefecture.

Kitakyushu City and Fukuoka City are government-designated cities, so they do not have to listen to Fukuoka Prefecture. They don't have to listen. Legally, they can act without that involvement.

It is said that government-designated cities located in prefectural capitals and the prefectural governments themselves do not get along well.
For example, Fukuoka Prefecture and Fukuoka City are in competition. Kitakyushu City is far from the Fukuoka Prefectural Government, so that is not as much the case.

As mentioned in the movie Frontline, the Kanagawa Prefectural Government and Yokohama City do not get along very well. I am not sure about the relationship between Kumamoto Prefecture and Kumamoto City, but since Kumamoto City has also become a government-designated city, the city can act independently without the prefecture's involvement.

The relationship between prefectures and government-designated cities became an issue during the outbreak of the novel coronavirus infection.

The prefecture tries to implement infectious disease control measures, but it is difficult if a government-designated city creates its own rules. Infectious disease control should be done together. I think the same applies to core cities.

Core cities are designated by cabinet order based on the request of cities with a population of 200,000 or more, and it is stated that administrative tasks, excluding those that are more efficiently handled by the prefecture, are delegated to them.

It is a roundabout way of saying it, but it basically refers to public health center operations. Core cities are allowed to operate public health centers.

You can consider a core city to be a city that has a public health center. In Kyushu, Kurume City is one. Nagasaki City, Sasebo City, as well as Oita City, Miyazaki City, Kagoshima City, and Naha City are prefectural capitals. These have become core cities.

Miyazaki City has its own municipal public health center. The city can operate it independently. When the prefecture prepares its budget, it may exclude Miyazaki City, which is a core city.

Coordination with core cities is necessary.
Knowing things like this is useful when you work for a prefecture.

Also, if you work for Miyazaki City, it is fine for the city to act alone, but I think you can also solidify the city's intentions by saying things like, 'It is easier to coordinate if we work with the prefecture, and it is better not to use unique rules for infectious diseases.'

There are things that can be changed and things that cannot be changed, so it is important to understand that while also keeping track of the prefecture's movements.

Watching what other core cities are doing is also very educational.

Other cities have a population of 50,000 or more and have no special exceptions.
Towns and villages do not even have requirements. There is no difference between a town and a village.

In Japan, there are places called 'machi' and places called 'cho'.
In Miyazaki, they are all 'cho'. Hinokage-cho and Gokase-cho are 'cho'.

In northern Japan, they are 'machi'. For example, Kamiichi-machi in Toyama Prefecture.

For villages, there are 'mura' and 'son'. When I went to Aomori and said I was from Shiiba-son, I was asked, 'Oh? Isn't it Shiiba-mura?'

When I answered, 'No, I'm Son from Miyazaki,' they were surprised and said, 'What?' Aomori was a village (mura).

Even just these topics about municipalities are quite interesting. In the future, you will all be working for prefectures, designated cities, core cities, or other municipalities.

When becoming an administrative public health nurse, as I mentioned earlier, there are partial administrative associations and wide-area unions, which are so-called special local public entities.

Partial administrative associations may involve prefectures or be handled by municipalities. It means that constituent organizations jointly process a part of their executive functions or a part of the same content.

There is no involvement from the national government in this; it is something created by discussing things like, 'Let's do fire fighting together,' 'Let's do waste disposal together,' 'Let's do crematoriums together,' 'Let's do hospitals together,' or 'Let's do public sports betting together.'

Wide-area unions are a system created to respond to diversified wide-area administrative needs by partnering with prefectures and municipalities.

It is a system where the national government asks you to do something because they are doing it, for example, the medical care system for the late-stage elderly. For other things that should be done on a wide-area basis, such as long-term care insurance or welfare for people with disabilities, they ask you to form a wide-area union to handle it.

Please remember well that there are two systems: partial administrative associations, where you work together regardless of the municipality's form and discuss things together without a legal basis, and wide-area unions, where you work based on laws and because you are told to do so by the national government or others.

Autonomous Affairs and Legally Delegated Affairs

Next, there are autonomous affairs and legally delegated affairs.

This is actually quite difficult, but previously, municipalities handled all the work of the national government. Since that was considered strange, it was reorganized during the decentralization reform, and it was decided that the affairs handled by local governments would be limited to two types: autonomous affairs and legally delegated affairs.

Legally delegated affairs are affairs related to roles that the national government should fundamentally fulfill.
Because it is necessary to ensure their proper processing at the national level, the processing of these affairs is mandatory based on laws and the like.

For example, elections. National elections are work that the national government should do, but prefectures and municipalities handle the election administration.

Issuing passports, national designated statistics, public assistance, and family registers are national tasks, but the municipalities are asked to handle the counters properly. In return, the national government provides advice, asks for data submission, and may also provide various approvals or corrections.

If it absolutely cannot be done, the national government may step in and do it instead. This is something that the national government should be doing but has delegated down to the municipalities.

On the other hand, autonomous affairs are defined as affairs handled by local public entities, excluding legally delegated affairs.

These include benefits for long-term care insurance services, benefits for national health insurance, and subsidy administration.

Regarding autonomous affairs, the involvement of the national government is strictly limited to technical advice.

Often, in notifications from the national government, after stating what to do and how to do it, they write at the end, 'Please note that this notification is technical advice based on the Local Autonomy Act.'

While saying it is strictly technical advice, they are telling you to follow it.
Even while formally calling it advice, there are times when they say to submit data or make changes.

Therefore, the administrative affairs of local governments are legally organized into two categories: autonomous affairs and statutory entrusted affairs.

It is useful to know this.
When something happens, if you say, 'Well, that is an autonomous affair, isn't it?', you will be respected as someone who knows the law.

If you say something like, 'That is not a statutory entrusted affair, is it?', you will be seen as cool. It is a useful keyword to know. If you say it too much, people will dislike you.

Regarding local taxes

I mentioned that revenue is important. Revenue refers to taxes. The question is who collects them. Local governments consist of prefectures and municipalities, and there is a battle over taxes.

It is a battle over which side gets to collect the taxes.
In the old days, this would be the 'share of the rice tax'.

Prefectures have prefectural inhabitant tax and business tax. What companies pay goes to the prefecture. Therefore, if there are large companies, the prefecture makes money.

If there is a factory of a large company like Asahi Kasei, tax revenue comes in, so the prefecture is happy. That is why they engage in various attraction activities. They offer conditions favorable to companies, such as providing prefectural land for free or making water supply cheaper.

A major Taiwanese company came to Kumamoto Prefecture, didn't it? They are spending trillions of yen. That is amazing. A considerable amount of tax revenue comes in, and since people gather, the population increases, right?

Inhabitant tax will increase. Aiming for that, shops and restaurants line up, and supermarkets are built. It keeps increasing.

Universities are the same. When a university is built, students gather, and various shops increase around the university.

The local consumption tax paid by businesses that conduct transactions goes to the prefecture. Also, when real estate is acquired, the tax goes to the prefecture, and if you own real estate, it goes to the municipality.

Tobacco tax is quite interesting; it goes to the prefecture when you buy tobacco, and it goes to the municipality when you sell tobacco.

Golf tax goes to the prefecture. In Miyazaki Prefecture, there is one prefectural golf course in Segawa. The Public Enterprise Bureau owns it.

Automobile tax goes to the prefecture. Light motor vehicles and motorcycles go to the municipality. The license plates for motorcycles have names like Miyazaki City or Shiiba Village on them, don't they?

I own a light motor vehicle, and when I wondered if I would get a tax notice from the prefecture, it came from Miyazaki City. I learned for the first time that I pay taxes to Miyazaki City.

Hot spring tax goes to the municipality. Places with hot springs, such as Yufuin or Kurokawa Onsen, are lucky because they receive that hot spring tax.

Unfortunately, there are no hot springs in Shiiba Village. Hot spring tax becomes the revenue of the municipality.

The tax system does not change easily. Even if you try to change it, people will say, 'How dare you, are you trying to collect more taxes?', which is like raising the rice tax, and they will say, 'Are you trying to make the residents suffer? You should cut taxes instead.'

People often say things like 'cut taxes' or 'reduce the consumption tax,' but as a government official, I find it difficult to agree with that.

For example, the 2% portion of the consumption tax increase from 8% to 10% is used for social security, and it has become a fund for the construction of hospitals and welfare facilities, bringing in a significant amount of money.

The construction costs for when the Miyazaki City Medical Association Hospital relocated were paid for from that fund. A considerable amount of money for the Heart and Stroke Center that was recently built in Miyakonojo City also came from there. This means that if the consumption tax were to return to 8%, that source of revenue would disappear.

As someone in the Welfare and Health Department, I am against losing the budget used for hospital construction, medical personnel training, welfare facility construction, and welfare personnel development. This is strictly my personal opinion.

Once you know how tax money is used, it becomes hard to simply say 'lower taxes.' Public health, in particular, is supported by taxes, so you must understand how taxes work.

It means you have to study. Public health nurses should also have knowledge about taxes.

There is the 'furusato nozei' (hometown tax donation) system. Although it is called a tax payment, it is a system where you donate to a municipality of your choice and can deduct that amount from your taxes.

This system was created by Prime Minister Suga. Miyakonojo City is the best in Japan at utilizing this. This is a photo of Haneda Airport Station in Tokyo. There are a lot of these big advertisements there.

There are photos of Miyakonojo's beef and shochu, and it costs a considerable amount of money just to put these up. But because they receive the most in Japan through the hometown tax donation system, they can afford such large-scale PR.

People riding the monorail at Haneda Airport see this and realize that Miyakonojo beef and Kurokirishima shochu will be sent as return gifts. That leads them to think about making a hometown tax donation.

Nowadays, local governments across the country are researching various return gifts to increase their tax revenue.

However, things have become too heated, and various incidents have occurred, such as the discovery of false labeling of origins, where products were not actually produced locally but brought in from other municipalities.

Local governments have strategists with various ideas. Some municipalities have been banned by the national government from participating in the hometown tax donation system due to issues with return gifts. Some municipalities have even filed lawsuits claiming that the disciplinary action was unjust.

The hometown tax donation system is a place where one must show wisdom to increase such revenue.

In that context, Miyakonojo City's decision to narrow down its return gifts to symbolic items like beef and shochu may have been the key to its success. The combination is exquisite. The person who thought of it first is a genius. I think it is wonderful from a marketing perspective.

Thanks to the large amount of revenue from hometown tax donations, Miyakonojo City has been able to implement various measures. They are making childcare free and are working to increase the population by giving money to people who move there.

When you have money, you can do many things. However, when you don't have money, it is difficult to do what you want. Also, even if you have money, you cannot use it if its purpose is already determined.

The Ministry of Health, Labour and Welfare appears to have a large budget, but because the use of these funds is determined by law, they cannot be used freely.

The Ministry of Economy, Trade and Industry has a smaller budget, but it has funds that can be used freely. It is completely different depending on the government office.

Financial Foundation of Local Governments

This shows the ratio of local taxes and local allocation taxes to revenue by population size. Local taxes are essentially the revenue of the local government.

Local allocation tax looks similar, but it is a budget provided by the national government. The money collected by the national government is distributed to each local government by the Ministry of Internal Affairs and Communications.

It is determined by factors such as population size. It is called the local allocation tax grant. Medium-sized cities have about 33% of their revenue from this. Revenue from local taxes can be used freely at the discretion of the local government.

As the population size gradually decreases, the blue portion will decrease, won't it?

Small towns and villages with a population of less than 10,000 are mostly living on the red portion, the local allocation tax, which is money granted by the national government.

There are also organizations that do not receive this allocation tax. These are called 'non-allocation entities,' and they are municipalities that are doing very well financially.

Non-allocation entities, to put it bluntly, are doing quite well for themselves. Conversely, municipalities that rely mostly on allocation taxes are struggling.

Therefore, they are making efforts to increase their independent revenue sources, such as by putting effort into the hometown tax donation program.

Policies and Measures

This book, 'The Mechanism of Government Offices,' is very educational. The materials I have shown on the slides so far are from this book.

The author is the mayor of Hamada City in Shimane Prefecture. He was originally a banker, then became a university professor, and after that, he was called upon by everyone to run for mayor, was elected, and is now serving as mayor.

He didn't know anything about how city government worked at first, but he is a university professor after all. He studied various things and wrote an interesting book about the mechanisms of government offices.

To be honest, today's lecture is based on what is written in this book. It is thanks to Mayor Kubota. Mayor Kubota describes the flowchart of policies and measures like this.

First, there are administrative issues for the city. These are incorporated into various policies. And another aspect is the issues of the region, for example, Hamada City if it were Hamada City.

There are the needs of the residents. Then there were proposals like this from assembly members. And my own thoughts. When you put all these things together and decide, 'Okay, I'll do it,' that is a policy.

Policies contain many thoughts. There are also aspirational things like 'I want to do this' or 'I want to do that'.

Measures are things that should actually be done. You properly flesh out the budget and proceed concretely. There are two routes to translate them into measures, and the intersection of these is the policy. It is a diagram that I found very convincing.

This is the reality of administration.

Legalism, conservatism, vertical silos, lack of excellence, formalism, and budget-centrism. It is tied up in all sorts of ways.

And it is quite difficult to create laws.

This is the National Diet. On the right of the photo is the House of Representatives, and on the left is the House of Councillors. A bill cannot become law unless it passes through these two houses. Each ministry and agency struggles to get things through the Diet.

This is the time when policies are born. For example, when the top leadership changes, during budget requests, or when various systems are being reviewed.

It happens when results are published, when an incident or disaster occurs, when a petition is filed, when a response is given in the assembly, due to external pressure or changes in the situation, when an acquaintance becomes the top leader, or when something is deemed impossible to handle—from the mayor's perspective, they are asked for many things.

When asked over and over again, they might say, 'I can't just do everything you say; I have my own thoughts too.'

To create policies, you, as public health nurses, can enter the administration, extract administrative issues, and compile them into policies; you can also get involved in those routes, and there are many things public health nurses can do to pick up on residents' needs.

And, support the thoughts of the head of the local government.
Saying, 'Mayor, wouldn't it be good if you did this?'

By being able to work from these routes, you can achieve things like collaboration between welfare, health, and medicine, disaster-resilient community development, or community development where people naturally become healthy; you can do many things.

Public health nurses are like ninjas.
You can go through both routes.

Pick up on residents' needs and develop various whispering strategies for the head of the local government.
Saying things like 'It would be better to do this' casually at a drinking party, or quietly leaving a document behind.

'Isn't this great! Who created this material?'
That is how it ends up.

Public health nurses create policies.

This is the winning formula.
Policy equals implementation. It means securing systems, ordinances, and budgets to organize them.

The possibility of success depends on the initial enthusiasm; this is important. In other words, passion.

Since it is laziness multiplied by time, if there is laziness, the initial enthusiasm will gradually decrease, so you need to reduce laziness and gather a lot of information.

This means reading books and continuously gathering information from local governments of similar size. Get information, increase your enthusiasm, and reduce your laziness.

Time is equal for everyone.

Put forward lofty ideals and a just cause that no one can oppose.
Science, scientific basis or evidence, and also emotional appeals, playing the sympathy card, charm, cuteness, prostrating yourself—there are various methods, but acting cute from the start won't work.

Suddenly starting to cry sadly, saying, 'Oh, I didn't mean to make you cry,' and things like that; it would be good to become someone the head of the local government remembers.

It really comes down to science. Saying things like, 'According to my research, this is the case,' or 'Such-and-such village in such-and-such prefecture is doing this, so I think we should copy it.'

Saying things like, 'The Ministry of Health, Labour and Welfare says this,' or 'The Constitution doesn't mention medical care, but it does mention public health,' or 'Drucker says this,'—anything is fine.

Just read books, like those about Christ, Buddha, or the famous Yozan Uesugi from Miyazaki. Takanabe is all about Yozan Uesugi. If you say that Yozan Uesugi said so, that settles everything in Takanabe.

Local areas have absolute heroes, so if you say that person said so, it gets decided. That is why it is important to know history.

A bureaucrat's job is to create explanatory papers.
A single sheet of paper.

And when explaining, your voice is also important.
A quiet voice won't do.

You cannot sound like a cicada. If you are going to do it, be like a Kumazemi cicada, buzzing loudly, keeping your posture straight like a Kumazemi, and being sharp and clear like a Kumazemi. I don't know why it has to be a Kumazemi (laughs).

Next is the picture. It is called a 'ponchi-e' (cartoon/diagram).
Before-and-after is best.

It is important to have something that shows, 'It is like this now, but if you do this, it will become like that.' Creating many materials like this is a great way to learn.

PowerPoint is the standard.

For paper, regular Word documents are fine. Some people write too much and create ten pages without a second thought, but no one reads them.

Attach one summary sheet, put the rest as attachments, and say, 'Please take a look at these later.' Explain things using 'one sheet of paper and a picture'.

Everyone is busy. To help them understand the importance and essence of things in a short time, simple is best.

Some people who create policies are smart.
Some work with brute force. This can sometimes cause unreasonable situations, create backlash, or potentially be called power harassment.

As for 'legs' (footwork), people will say, 'This person is diligent.' Footwork actually leaves a good impression.

Footwork is used in a good sense, like visiting frequently. Footwork is important. The liver is also important, but since people no longer drink while working, that approach has declined.

I was from the Showa-era liver school, so I have retired.
I don't think it will ever make a comeback.

However, there are people who like the Showa era, so for those who do, you can still compete with your liver. 'Someone who is smart, has brute force, has diligent footwork, and can compete with their liver'—such a person is the strongest.

Which school do you belong to?

People who compete with their brains create a persona by wearing glasses.

People with brute force should do about 100 push-ups to build up their arm strength like Popeye.

People who rely on footwork should wear high heels, high-end sneakers, or high-end leather shoes to show off their feet.

People who rely on their liver should be knowledgeable about things like wine, or in Miyazaki, shochu.

I am quite knowledgeable about wine. You know, there are red and white varieties, for instance.

For example, you could say that public health is all about gin, and recommend Osuzu Gin from Kuroki Honten. If you mention that public health actually started with gin, people will be impressed, so it is important to acquire such skills.

What I recommend is your feet.
If you visit frequently, you will develop an emotional connection with anyone, so I recommend it.

The Role of Public Health Nurses

I believe everyone is familiar with the definition of a public health nurse under the Public Health Nurse, Midwife, and Nurse Act. It refers to a person who has received a license from the Minister and, using the title of public health nurse, engages in public health guidance as their profession.

Ten years ago, the Health Service Bureau of the Ministry of Health, Labour and Welfare issued guidelines regarding the activities of public health nurses in local communities. A review process is currently underway.

Once the new guidelines are released, it would be a good study exercise to read them promptly, compare them with the old ones to see what has changed, and check what kind of discussions took place.

The minutes and materials from these study meetings are likely available on their website. Please take a look.

I asked the Director-General of the Health Service Bureau at the Ministry of Health, Labour and Welfare.
They said, 'We are currently working on it diligently. We are pushing the study meetings forward vigorously, so I hope to be able to present something eventually.'

I do not know what kind of guidelines will be created under the Director-General of the Health Service Bureau, but stay tuned.

However, this is ultimately just technical advice. A notification from a Director-General is merely technical advice. I would like you to view it with the flexibility of saying, 'Well, I'll use this as a reference,' and then interpret it in your own way to take on various challenges.

The status of public health nurse activities.

For prefectures, designated cities, special wards, and municipalities, direct interpersonal support accounts for about half, or 40 percent, of their work.

This means that municipal staff need to polish their interpersonal skills, such as those required for maternal and child health or home visits.

Since you are meeting residents directly, it is important to polish all interpersonal skills, including your choice of words and attitude.

Prefectures have less direct interpersonal support, but they need public health nurses who can provide advice on crisis management or when wide-area municipalities are at a loss as to what to do, suggesting, 'Why don't you try this?'

For example, asking if they should send a DHEAT team.
Reaching out by saying, 'Is there anything we can do for you?' There are tasks such as regional support, management, and human resource development.

Health crisis management is particularly important for prefectures. There is also a lot of administrative work, such as handling paperwork or getting stamps from superiors, which is necessary for any profession, so you need to polish those skills as well.

In summary, prefectures should polish skills for looking at things from a wide-area perspective, while municipalities should polish skills for direct operational tasks.

That concludes the first half. We will take a ten-minute break.

.