Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries

Document Type : Editorial


Keio University, Tokyo, Japan


When the Japanese government adopted Western medicine in the late nineteenth century, it left intact the infrastructure of primary care by giving licenses to the existing practitioners and by initially setting the hurdle for entry into medical school low. Public financing of hospitals was kept minimal so that almost all of their revenue came from patient charges. When social health insurance (SHI) was introduced in 1927, benefits were focused on primary care services delivered by physicians in clinics, and not on hospital services. This was reflected in the development and subsequent revisions of the fee schedule. The policy decisions which have helped to retain primary care services might provide lessons for achieving universal health coverage in low- and middle-income countries (LMICs).


Commentary Published on this Paper

  • Universal Health Coverage and Primary Healthcare: Lessons From Japan; Comment on “Achieving Universal Health Coverage by Focusing on Primary Care in Japan: Lessons for Low- and Middle-Income Countries"

          Abstract | PDF


Main Subjects

  1. Evans DB, Etienne C. Health systems financing: the path to universal coverage. Bull World Health Organ. 2010;88:402. doi:10.2471/BLT.10.078741
  2. World Health Organization (WHO). Making fair choices on the path to universal health coverage: Final report of the WHO Consultative Group on Equity and Universal Health Coverage. Geneva: WHO; 2014.
  3. Norheim OF. Ethical perspective: five unacceptable trade-offs on the path to universal health coverage. Int J Heath Policy Manag. 2015;4(11):711-714. doi:10.15171/ijhpm.2015.184.
  4. Starfield B, Shi L, Macinko. Contribution of primary care to health systems and health. Milbank Q. 2005,83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x
  5. Ikegami N, Campbell JC. Dealing with the medical axis-of-power: the case of Japan. Health Economics, Policy and Law. 2008;3:107-113. doi:10.1017/S1744133108004428
  6. Filmer D, Hammer JS, Pritchett LH. Weak links in the chain: a diagnosis of health policy in poor countries. World Bank Research Observer. 2000;15(2):199-224. doi:10.1093/wbro/15.2.199
  7. George A, Iyer A. Socially embedded informal health providers in northern Karnataka, India. Soc Sci Med. 2013;96:297-304. doi:10.1016/j.socscimed.2013.01.022
  8. Lewin S, Lavis JN, Oxman AD, et al. Alma-Alta: Rebirth and Revision 2: Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systemic reviews. Lancet. 2008;372(9642):928-939. doi:10.1016/s0140-6736(08)61403-8
  9. Ikegami N. Universal Health Coverage for Inclusive and Sustainable Development – Lessons from Japan.
    . Published 2014.
  10. Sakai S. History of Medical Care in Japan. Tokyo: Tokyo Shoseki; 1982:432
  11. Hashimoto H, Ikegami N, Shibuya K, et al. Universal health care at 50 years 3. Cost containment and quality of care in Japan: is there a trade-off? Lancet. 2011;378(9797):1174-1182. doi:10.1016/S0140-6736(11)60987-2
  12. Ikegami N, Yoo BK, Hashimoto H, et al. Japanese universal health coverage: evolution, achievements, and challenges. Lancet. 2011;378(9796):1106-1115. doi:10.1016/S0140-6736(11)60828-3
  13. Shah NM, Brieger WR, Peters DH. Can interventions improve health services from informal private providers in low and middle-income countries? A comprehensive review of the literature. Health Policy Plan. 2011;26:275-287.
  14. Ikegami N. Fee-for-service payment - an evil practice that must be stamped out? Int J Heath Policy Manag. 2015;4(2):57-59. doi:10.15171/ijhpm.2015.26