Financial protection of older persons in health care in the Kansai region of Japan: Barriers to effective implementation of financial protection policies and programmes

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October 2021 to September 2022

Implementing partners:

Lead research institutionKyoto University Graduate School of Medicine / School of Public Health, Department of Healthcare Economics and Quality Management 
Principal investigatorProfessor Yuichi Imanaka

Location of research:


Total Budget:
US$ 60,000


Financial protection against catastrophic or impoverishing health spending is a cornerstone of universal health coverage. Japan has established several policies and programmes to ensure financial protection against impoverishment due to health care costs. This includes universal health insurance, social welfare services, coverage for medical expenses exceeding age- and income-adjusted thresholds, free or low-cost medical care and a public assistance programme. Despite these measures, there is likely to be a growing proportion of older people in Japan who do not receive or forego health services because of their increasing financial hardship, as indicated by the growth of the proportion of older people on public assistance from 1.6% in 1995 to 2.9% in 2015. Financial barriers to health care may be particularly a problem for those in the Kansai region which has some of the highest rates of households on public assistance in the nation, many of which are households with older people. 


  • To explore the current situation of older people in the Kansai region facing difficulties in paying for health care services when seeing a health professional, receiving a diagnosis, and being treated.
  • To identify possible reasons behind the gaps in policy implementation and the unmet needs of older people who could not utilise the existing financial support systems and policies.
  • To identify the policies that could be better utilised and more effectively disseminated in the Kansai region and across Japan with implications for other countries.


  1. Reviewed public documents published since 2005 that provide information on eligibility for and benefits of financial protection policies for healthcare that currently apply to older people in Kansai to identify potential challenges with implementation.
  2. Conducted a self-administered postal and web-based survey of social workers in hospitals, local government offices and community-based social service agencies across all six prefectures of the Kansai region from October 2021 to February 2022. Analysed data obtained from 553 respondents (23% response rate) to identify common reasons for older persons’ financial hardship in healthcare and to assess the financial protection programmes that are infrequently used by social workers for their clients. 
  3. Solicited volunteers from the survey respondents to participate in in-depth interviews immediately following the survey to clarify details that could not be adequately captured in the survey. Twenty of the survey respondents, mostly veterans with 17 to 25 years of experience, cooperated in these supplementary interviews.
  4. Applied the Behaviour Change Wheel1 to identify possible intervention points of the households with multiple burdens.


  1. The literature review found that financial protection policies, laws, and regulations are frequently revised in Japan. Also, financial protection for healthcare use is closely related to other relevant financial protection policies, such as for housing, but they are not well integrated. As a result, the system is complex making it difficult to navigate for the older person, their families and service providers.
  2. The survey data showed that financial problems in healthcare for older persons are often complicated by social and mental health hardships of the older person and/or their household members. Several programmes exist that could be potentially helpful, such as free or low-cost medical care for low-income and other vulnerable persons, the reduction, suspension or exemption of the national health insurance premium for those who cannot afford it, and the adult guardianship system. However, the survey data showed that these programmes are infrequently used. Statistical analysis showed that the social worker’s gender, length of work experience, and institutional setting are associated with the use of some key financial protection programmes.
  3. The follow-up interviews helped clarify some of the details of the survey results. The financial problems affecting older persons often involve the person having an income at a level eligible for public assistance but not applying for it, or delaying payment of insurance premiums and losing coverage. Common complicating factors include the older person and/or cohabiting spouse having dementia, being socially isolated, or lacking a primary caregiver. Major reasons for the infrequent use of essential financial protection programmes include fragmented services, complicated application processes, and difficulty in accessing information about the programmes. 
  4. By applying the Behaviour Change Wheel framework to the results of this study, interventions at multiple levels were identified that may increase the use of available financial protection programmes for older persons in need of healthcare, especially for households who experienced multiple burdens. Such burdens are multi fold: cognitive impairment or multiple debts at individual-level; living alone, poverty, or abusive relationship at household-level; social isolation, lack of healthcare knowledge of infection prevention, or lack of financial support for mobile phone use to connect with help desks at local community-level; and insufficiency of guarantor system for housing or a lack of support for digital divide at national-level. Each of these could be the potential policy intervention points for improvements. 

Global Implications

Older people’s financial problems with health care are often complicated by other financial, social and mental hardships of their own, or of their household members, making them difficult to be solved by financial protection policies alone. A comprehensive approach may be needed that involves multiple interventions at the levels of the individual, household, service provider, community as well as public policy. One of the key challenges identified in this study is that even the social workers are often not fully informed about existing financial protection systems and programmes. Such information should be made easily accessible, and the actual use of these programmes should be monitored regularly.

Implications for Kansai

This study identified some challenges that are commonly faced in financial protection for health care by older persons in the Kansai region. Systems to enable better coordination among the various professions involved in social work, local government, health and social care facilities, the patient and their families may be needed. Access to information and educational opportunities for social workers should be improved so that they can be better informed about relevant policies and programmes to help their clients. 


1 See for reference: Michie S, Atkins L, West R. The behaviour change wheel. A guide to designing interventions. 1st ed. Great Britain: Silverback Publishing. 2014: 1003-10.


WKC Forum 2022 Report: Systems of financial support in healthcare for families with complex problems and marginalized populations: overcoming the challenges of ‘leaving no one behind [In Japanese]

Sasaki N, Rosenberg M, Shin J, Kunisawa S, Imanaka Y. Policy-implementation gaps in the financial protection in health care for older persons: Insights from a cross-sectional survey of local governments, health and social care organizations. [In progress]


Sasaki N, Imanaka Y. Challenges to identifying barriers and policy intervention points in relation to the financial protection of older households: applying the Behaviour Change Wheel Framework to the complicated cases experienced by local social workers. 16th Guidelines International Network Conference, Toronto, Canada. 21-24 September 2022. [Poster presentation]

Sasaki N, Imanaka Y. Key challenges to policy and practice related to financial protection in health for older persons: results of a survey of social workers.60th Academic Congress of the Japan Society for Healthcare Administration, Okayama, Japan. 16-18 September 2022. [Online presentation in Japanese]

WKC Forum

 “Systems of financial support in healthcare for families with complex problems and marginalized populations: overcoming the challenges of ‘leaving no one behind’” 28 July 2022. [Online event in Japanese]

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