the country was still relatively
poor (with a gross domestic product
[GDP] half the size of Britain’s),
Japan reached full health
insurance coverage of its population.
In the next half-century, it
continued to develop
its health system and
improve equity, even
applying this principle
of universal health coverage in
its global health diplomacy.1
Now, however, Japan faces serious
fiscal pressure due to a sluggish
economy and the rapid aging and
low birth rate of its population
— but it is striving to sustain its
health system in the face of these
challenges.
Japan followed a nonlinear path
to universal coverage. Previous
Japanese policymakers were sometimes
motivated to develop the
health system for reasons of political
economy that were unrelated
to health. For example, Japan’s
first national policy for health insurance
was introduced in 1923,
motivated in part by imperial visions
and the desire for a strong
and healthy workforce for war.
During World War II, Japan
achieved nearly 70% health insurance
coverage. Then, in the postwar
period, political competition
among the major parties promoted
government efforts to expand
coverage, as the conservative Liberal
Democratic Party sought to
provide benefits to its rural constituents
and to weaken the agendas
of the Socialist and Communist
parties by redistributing social
resources to industrial workers.
Japan was not unique in this regard:
in countries such as Britain
and Germany, the process of attaining
universal health coverage
also stretched over long periods
and was advanced by various political
motivations.2 Though such
mixed origins don’t diminish the
value of Japan’s health policy accomplishments,
they do highlight
the importance of viewing the
process from historical and political
perspectives.
Japan’s achievements in health
status are well known (see table).
Since 1986, Japan has ranked first
in the world in women’s life expectancy
at birth, which reached
87 years in 2014. Life expectancy