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 the reasons behind the unmet needs of these 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. Use the Behaviour Change Wheel as the theoretical framework to guide the data collection and analysis.

  2. Conduct a literature review of current financial protection policies that apply to older people in Kansai to identify possible gaps in coverage.

  3. Implement a self-administered mail survey of social workers in hospitals, local governments and community-based social welfare and relevant agencies in all six prefectures of Kansai to identify common situations in which older people experience financial hardship in relation to health care use and the challenges that the older patients and health service providers face in utilising financial protection services.

  4. Conduct in-depth interviews with a subset of the survey respondents to explore additional issues that cannot be adequately captured in the survey.

Expected outputs

  1. Peer-reviewed journal articles that describe the financial hardships and unmet health care needs experienced by older people and the obstacles faced by the older patients and health service providers in utilising financial protection services in health in Kansai.

  2. Evidence summary intended for local audiences with implications for policy and practice to strengthen financial protection of older people in relation to health care utilization in Kansai.

  3. Contribution to future Global Monitoring Reports on Financial Protection in Health published jointly by WHO and the World Bank.

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