Tokyo Report | Society | East Asia

How Japan’s Universal Health Care System Led to COVID-19 Success

The biggest key to Japan’s coronavirus success? Its all-access, no-gatekeeping health care system.

By Haruka Sakamoto, Yosuke Kita, and Satoshi Ezoe for
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How Japan’s Universal Health Care System Led to COVID-19 Success
Credit: CEphoto, Uwe Aranas

As of August 22, Japan has registered 9.24 deaths per million people due to COVID-19. Though Japan is the most aged country in the world, this mortality rate is much lower than in many other developed countries (i.e., 529.92 in the United States, 609.92 in the U.K., 110.61 in Germany). The reasons for the lower mortality rate in Japan compared to Western countries are still being examined. However, the Japanese health care system is thought to be one of the main factors underlying Japan’s success so far in tackling the COVID-19 pandemic domestically.

Japan’s health care system is characterized by universal health insurance, a uniform fee schedule, and a no-gatekeeping system. In 1961, even though Japan was not a high-income country at that time, the government established a universal health insurance system. This system covers the entire population living in Japan and secures access to health care services at an affordable cost. In order to ensure cost containment, Japan also introduced a uniform fee schedule alongside the establishment of the universal health insurance system. As in many European countries, fees for health care services are determined publicly, and these publicly defined fees apply to both private and public health care facilities. The uniform fee schedule helps contain the total cost of healthcare, even though the majority of healthcare facilities in Japan (80 percent) are privately owned.

By combining the universal health insurance scheme and the uniform fee schedule, Japan has secured access to health care services for all people regardless of their socioeconomic status, while at the same time controlling total health care expenditures.  

In addition, public health centers have also played an essential role in improving population health in Japan. For example, tuberculosis (TB) was one of the leading causes of death in Japan during the post-war period. In order to facilitate containment of the disease, all payments related to TB management are covered by public financing through taxation. While public health centers have been in charge of the public health management of TB, health care facilities have also played an important role. Individuals who have any symptoms that indicate the possibility of TB infection can access health care facilities at an affordable cost thanks to the universal health insurance system. By combining tax-based public financing and the universal insurance system, as well as coordinated roles for both public health centers and health care facilities, Japan was able to rapidly decrease deaths by tuberculosis.

In the case of the COVID-19 pandemic, this effective combination of policies and health infrastructure is thought to have partially contributed to controlling the outbreak in Japan. During the initial response, even though the number of public health centers has decreased considerably due to administrative reform in recent years, public health centers played the central role in COVID-19 management. That includes contact tracing, and arranging PCR testing, while public financing has covered all the costs for tests and treatment. In addition, thanks to the Japanese health care system’s universality and no-gatekeeping system, any person who had any symptoms had access to health care facilities without worrying about the cost, which resulted in early detection, and isolation of COVID-19 patients.

We also need to note the negative aspects of the no-gatekeeping system, however. Because individuals can easily and affordably go to healthcare facilities, there was a concern that people would rush en masse to health care facilities seeking COVID-19 tests out of fear. Accordingly, the government set screening criteria to prevent the spread of infections within public health centers. These criteria, which encouraged the general public — excepting older people and those who have any underlying conditions — to stay home for at least four days from the onset of symptoms, in line with the recommendations from the World Health Organization, seem to have contributed to preventing massive nosocomial infections, but at the same time caused some confusion due to lack of understanding of the aim of the policy.

The COVID-19 pandemic reminds us of the importance of resilience in health systems. It is not enough to strengthen the crisis response to epidemic outbreaks alone: a crisis response will not be effective without also strengthening the underlying health system itself. In 2016, when the global community was still struggling from the aftermath of the 2014 Ebola outbreak, Japan set health security and universal health coverage (UHC) as mutually reinforcing central health agendas of the G-7 Ise-Shima Summit in Japan. Since then, Japan has advocated for UHC on several occasions, including during the G-20 Osaka Summit, which culminated in the landmark UN General Assembly high-level meeting on UHC in 2019. As Prime Minister Shinzo Abe of Japan, together with Director General Tedros Adhanom Ghebreyesus of the WHO, reiterated even before the COVID-19 pandemic, in order to better prepare for future pandemics, we once again need to recognize the importance of attaining UHC with strong health systems and better preparedness for public health emergencies.

Haruka Sakamoto, MD MPH, is a primary care physician and assistant professor at the Department of Health Policy and Management, Keio University. She’s also currently working at the Department of Global Health Policy, Graduate School of Medicine, the University of Tokyo as a project researcher.

Yosuke Kita and Satoshi Ezoe are project researchers at the Department of Global Health Policy, the University of Tokyo.