Abstract
The rapid expansion of psychiatric hospitalization in post-war Japan during 1950s and 1960s was financed by three types of public expenditure programs, each of which was based on different institutional characteristics. The first type of program was compulsory hospitalization under the Mental Hygiene Act, which was "public custody" implemented by local governments. The second type was hospitalization with medical public assistance, which was primarily viewed as a means-tested "public assistance" program for the poor. The third and final type was healthcare benefits from the public health insurance programs that had been formulated as part of the nation-wide "social insurance" system.
In this paper, we address the following question: why and how did these three types of public expenditures come to play crucial fiscal roles in the formation of post-war large-scale psychiatric institutionalization? This question is important because previous studies have tended to focus on the extreme expansion of compulsory hospitalization by "public custody" in the 1960s and have often failed to investigate the significant contributions of public expenditures via "public assistance" and "social insurance" to the post-war increase in psychiatric inpatients. In fact, these latter two public spending schemes have persistently and significantly contributed to the increase in psychiatric inpatients from the early 1950s to the present, whereas compulsory hospitalization by "public custody" was responsible for the largest number of psychiatric hospitalizations for only a few years int he 1960s.
The above question can be divided into two research topics. First, we investigate the hypothesis that public expenditures on psychiatric hospitalization through the three different schemes, that is "public custody", "public assistance" and "social insurance", have their institutional origins in the pre-war era (hypothesis I). Second, we analyze the hypothesis that several important post-war reforms of the three types of public expenditure resulted in the rapid post-war expansion of psychiatric hospitalization (hypothesis II).
Regarding hypothesis I, our investigation based on historical documents and statistics reveals that the post-war systems of the three public expenditure schemes outlined above have identifiable origins in pre-war hospitalization schemes for people with mental illnesses. When it comes to hypothesis II, patterns of increases in psychiatric hospitalization between the 1930s and the 1970s provide some evidence that this hypothesis is plausible. In addition, we find that "public assistance" and "social insurance" had more significant roles than "public custody", at least in terms of providing fiscal resources for psychiatric hospitalization.
Overall, our study makes it clear that the post-war patterns of public expenditure for psychiatric hospitalization were not the consequence of strong political or policy initiatives and that the above three types of public expenditure schemes have their origins in pre-war institutions. In addition, while several. post-war reforms of these three types of programs resulted in the rapid expansion of psychiatric hospitalization, in some cases this was not necessarily their intended result.
