Japan’s Contribution to Global Health:
Pioneering Elderly Care for an Aging Asia

- Profile -

Dr. Hajime Inoue began his professional journey as a pediatric resident in Tokyo before dedicating himself to fieldwork as part of the Maternal and Child Health program in rural Philippines. Following post-graduate studies in public health, Dr. Inoue joined the Japanese Ministry of Health, Labour, and Welfare, where he amassed a wealth of technical expertise across various critical areas of global health, including UHC, Community Health, Health Emergency Response, Health Promotion, Population Ageing, Pharmaceutical Regulation, and Anti-Microbial Resistance(AMR). He has served as a Senior Advisor to the Director-General of the WHO and as Special Representative for AMR, bringing his extensive political acumen to bear as the G20 and G7 Sherpa of WHO. Among his recent achievements are the development of a new financing mechanism, the Contingency Fund for Emergency at WHO, the management of Japan's largest national hospital as its Director-General, and his pivotal role in crafting the national response plan for COVID-19 as the chief technical officer of the cabinet secretariat. Dr. Inoue's recent appointments include serving as an advisor at the World Bank’s Health, Nutrition, and Population program, and currently serving as Assistant Minister for Global Health at the Japanese Ministry of Health, Labor and Welfare. He holds a Medical Degree from Tottori University (Japan), a Master of International Health from the University of Tokyo (Japan), a Master’s of Public Health from Harvard School of Public Health (USA), and a Doctor of Public Health from Teikyo University (Japan).

(1) Introduction to the lecture

Norie KAWAHARA, lecture series moderator, noted that on the one hand more and more people in the Asian region hope to live long and healthy lives, but at the same time, challenges within the region are becoming more complex. In today's uncertain world, people are once again being obliged to ask the question, what does true prosperity mean? 

Humanity is entering a time when we must rethink the value of wellbeing, not just from the view of progress or of development, but from a deeper, more human perspective. 

This University of Tokyo lecture series is structured as an intellectual journey to critically explore the evolving concept of wellbeing in Asia, especially through the lens of cancer and aging. In step one, we asked a fundamental question, what does wellbeing mean in Asia? 

In the first two lectures, we explored ideas from philosophy, sociology and culture. We looked at how different society defined wellbeing, especially during times of suffering. Today we begin step two of our five step learning process.

We now turn our attention to real life issues, whereby we use cancer as one important entry point, not to study it medically, but to understand deeper social structures and inequalities. Cancer reveals issues like the urban-rural divide and the challenges of population aging under the limits of our current health systems.

This lecture series is not only about cancer. Cancer is a lens to see how our society is built and to ask how we can redesign it for a more inclusive and sustainable future. We aim to produce a policy brief for the NCDs Conference on Sustainability and Inclusion in Malaysia in September 2025. Together we are connecting theory with action.

Dr. Kawahara introduced the speaker for the third lecture, noting that Hajime INOUE not only gave this course its name – Cross-Boundary Cancer Studies – but since 2007, he has supported the work of the lecture series with powerful insights into global health. He currently serves as assistant minister for global health and welfare at Japan’s Ministry of Health, Labour and Welfare (MHLW). 

(2) Japan’s Contribution to Global Health: Pioneering Elderly Care for an Aging Asia

Dr. Inoue noted that he is a pediatrician by training, but has been working in the public health arena in the past 30 years, much of that time spent in Japan’s MHLW. 

The theme for the lecture is “Japan's contribution to global health: pioneering elderly care for an aging Asia.” Japan is the most aged society and the aging process is heading towards its peak in the middle of this century. What Japan will experience in the coming decades will have substantial lessons for the rest of the world, including cancer care.

The lecture will cover two major areas: firstly, cancer care in Japan, which has comprised a dual transition, namely demographic and epidemiological transition, and the loss of social capital, which has an impact on cancer care. Secondly, the lecture will discuss the implications of such transitions for the rest of Asia.

In Japan the under-five mortality rate (the number of babies who could not reach five years of age out of 1,000 newborn babies) has plummeted over the course of the last century. In the 1920s it was the case that about one in seven children could not live to five years old for various reasons, but mainly due infectious diseases such as diarrhea, pneumonia, etc. This under five mortality is actually generally considered as the indicator for overall health status of a nation. Each of my grandmothers had seven children and each lost two children when they were very young. Over the course of the past century this under five mortality rate has rapidly improved, or decreased, reaching the current figure of 3 out of 1,000 babies in the early 2000s. This is an incredibly rapid improvement compared to previous thousands of years of human history. Japan and other developed countries are therefore heading towards a world without premature death. Today the majority of people live to 65 years of age, and approximately 80% of all people reach 80 years of age. The current Japanese status is that we are reaching a point where we can perhaps not expect any further improvement. 

Japan also reports excellent figures with regard to the control of illicit drugs and other indices, with the amount of health lost due to drug use being the lowest among the G7 nations (Fig. 1). It is outcomes such as these, including low infant mortality and low incidence of illicit drug use, and low rates of obesity, that is making Japan such a long-lived and healthy country.

Fig. 1 Amount of health lost due to drug use

Thanks to excellent healthcare services, universal health coverage, and concerted efforts in every aspect of society, including drug control, obesity control, nutrition, and medication, etc., Japan is now reaching a stage where 80 to 90% of the people will live to 80 years of age or beyond. 

While this is of course a good thing, the population as a whole is aging and in combination with the declining fertility rate. Japan’s population pyramid has two humps, the first has people who were born a few years after the end of the Second World War, and the second hump is the generation who are the children of the postwar baby boomers. These two humps on the population face specific challenges. The first hump, namely people in their 70s-80s today, generally have many siblings and have two children on average. However, the people in the second hump (people in their 40s and 50s) have on average only one child and few, if any, siblings. The people in the second hump are therefore likely to experience more severe challenges than their parents’ generation. 

Japan’ s high aging society is ahead of the rest of the world, but it is the case that other countries, including the U.S. and China will be facing similar challenges in another generation. Ultimately, the broader global population will also face the challenges of aging, before the global population will stabilize at an aging ratio around 30%. 

The key challenge is how to respond to the aging ratio spike, the first country to experience it being Japan. In this rapid aging process, one of the most important diseases is cancer for obvious reasons, as shown in the attached figure. (Fig. 2) 

Fig. 2 Increasing incidence of cancer

As can be seen from the above figure, the death rate from other conditions such as tuberculosis or cerebrovascular disease is on a downward trend, but cancer continues to inexorably increase. This means that cancer is a disease that requires a concerted response in the years ahead. 

In terms of cancer care in Japan, let us take a look at how the loss of social capital is impacting cancer care. In the next 10 years, our challenge will be to take care of the people reaching their 70s and 80s, many of whom will contract cancer and require care and treatment. The epicenter for aging in Japan is the greater Tokyo metropolitan region, where the population is concentrated, and particularly the commuting belt that surrounds central Tokyo. This region could be termed the most rapidly aging region in human history. Many of the people who live in these suburban regions around central Tokyo moved there in the 1960s and 1970s, where they raised their families. Now their families are grown, leaving the aging parents on their own in aging apartment complexes. It is these people who will require cancer care and other support in the coming years. However, the care paradigm in these areas is not ideal, because the elderly people are living in isolation in large and impersonal apartment complexes, rather than smaller communities in rural Japan, where there is more of a chance that people will look after each other, and share a generational connection. In the suburban areas around Tokyo there are many places where this is little sense of community, resulting in a loss of social capital. When people living in such environments contract cancer it can present challenges in terms of care and support, because of isolation and lack of social cohesion. 

The issue of loss of lack of social capital is not unique to Tokyo, as other cities around the world are also experiencing aging, including the mega-cities in the emerging economies of Asia and Latin America, including New Delhi, Mumbai, Mexico City and Sao Paolo, etc. In these cities around the world, similar to Tokyo in the 1960s and 1970s people are moving to an urban setting, resulting in a loss of social capital. Around the world the progress of urbanization is continuing in both middle and low-income countries.

  Over the course of the years there have been substantial advancements in the clinical treatment of cancer, resulting in improvements in the five-year survival rate. As the society ages, however, this has major implications for cancer prevalence. In general, the aging of a population is a good thing, because everyone aspires to live a fulfilling life without premature death, but the extension of healthy longevity raises the challenge of non-communicable diseases such as cancer.

  Japan is just one generation ahead of the rest of the world in terms of aging, so in the course of the next 30 years, the world will face the same issues and challenges that Japan is currently dealing with. East Asia in particular is a region that will experience high degrees of aging. Japan’s experiences therefore have huge implications and lessons for the rest of the world.

(3) Questions posed to students

Dr. Inoue posed the following questions for students to consider as their assignment: 

1) Japan is still in the process of process of population aging, which will peak in the mid-21st century. While it is not possible to intervene in the demographic and epidemiological transition,  there are ways in which society can work to on social capital.  What would be the optimal approach to maintain the social capital?

2) What are lessons and implications for Asian countries from Japan’s experiences? 

With regard to the first question there is no clear answer and no consensus among Japanese policy makers, but it would be useful for students to think about aging and cancer as an issue that will inevitably affect all countries.

With regard to the second question, Japan’s efforts and initiatives are still ongoing, and has achieved successes, but also experienced challenges.

(4) Discussion

Dr. Kawahara noted that in the past, global health has seemed to focus mainly on supporting the most vulnerable people in developing countries and has often felt disconnected from Japan’s own healthcare system. However, the issues that Japan are facing are not unique, including rapid aging and increasing prevalence of cancer. Many Asian countries will follow a similar path in the coming decades. It seems that global health is indeed going through a major transformation, especially in how it is connected to domestic realities. Dr. Kawahara asked if this shift is becoming more significant in the global health context.

Dr. Inoue responded that global health has different dimensions and different aspects. One dimension is to focus on the “bottom 1 billion “ of the global population, who are living in poverty and require assistance. A further element that requires attention is to focus efforts on the global population as a whole. This is because of demographic and economic transitions, more people from various countries are requiring assistance for non-communicable diseases (NCDs), such as cancer, hypertension, diabetes, etc., as well as mental disorders. 

  As the focus turns to from communicable diseases to NCDs in high and middle income countries, it is increasingly important to focus on a common agenda. Global health is not only for infectious diseases, but for the entire global population, the great majority of which face diseases such as cancer, diabetes and obesity. 

Dr. Kawahara introduced a special guest to the lecture, Dr. SUGIMURA Haruhiko, Director of Kyoundo Hospital in Chiyoda-ku, Tokyo, who has been engaged in research across Asia for many years. 

Dr. Sugimura noted that in the hospital where he works the patients are increasingly aged. He asked Dr. Inoue about his views on how far it is ideal to treat aged patients with cancer, noting that in modern medicine there are a wide range of therapies available, including chemotherapy, radiotherapy and operations. He asked about the degree to which it is advisable to aggressively treat cancer patients in an aging society. 

A second question related to the suburban communities that are increasingly aging, and what the government could do to provide infrastructure and support to offset the lack of social capital in such communities. 

With regard to the first question, Dr. Inoue stated that the traditional approach to medicine has been to prolong biological life as long as possible, as much as possible, at any cost. However, as society moves from one where premature death has been virtually eliminated, and people are living into their eighties and nineties, the prolongation of life may no longer be the first priority for a patient. Rather, the patient may wish to realize a “good death.” It is increasingly important to adapt to people’s wishes and desires. 

With regard to the second question, Dr. Inoue noted that there is a gradual shift in elderly nursing care away from the hospital setting to the home and community setting, as part of efforts to lessen the burden on healthcare institutions. This home-based focus is generally based on the wishes of elderly people to reside in their own homes rather than being institutionalized. In order to facilitate care at home it is essential to have substantial social capital, particularly for elderly people who need high levels of care in order to live in their own homes with a degree of independence. To do this effectively it is important to recover the power of social capital in suburban communities, which is challenging, both in terms of staffing and financial burden. 

Dr. Sugimura noted that the move to support home-based care for elderly people will necessitate the reorganization of the hospital system. He asked Dr. Inoue for his view.

Dr. Inoue noted that inevitably the system will have to change in the coming years as the number of super-aged people increase, while on the other hand there is projected to be a severe shortage of medical and healthcare workers. Notwithstanding shortages, it will also be important to respect people’s wishes for home-based support and make medicine and health more community-oriented.

Dr. Sugimura referred to the slide on the “epi-center of aging” presented by Dr. Inoue (Fig. 3). He noted that in these suburban areas the number of supermarkets, clinics, shops and services are all gradually decreasing as demand drops due to the aging of the population. People living in such areas will face increasing difficulties in accessing medical care and other services as they age, due to diminishing transportation services, etc. He asked what local governments could do to offset such reductions in services. 

Fig. 3 Rates of aging in municipalities in the greater Tokyo metropolitan area

Dr. Inoue responded that it is a major challenge to maintain the social infrastructure in such regions, and it is likely that local governments alone will not be able to respond to growing needs. That is not to say that governments are not unaware of the challenges, but the rapid speed of aging is unprecedented in human history. The solutions will not be easy, but communities are also mobilizing themselves to maintain community connectivity. A mixture of bottom-up and top-down efforts are likely to be necessary for services and social capital to be maintained. 

A student noted that Japan's healthcare system must now shift from saving lives to ensuring a “meaningful death” but in countries like Malaysia where discussing death is often taboo, a big question is how to shape policies around end-of-life care. 

Dr. Inoue noted that like in Malaysia, there is a hesitation to talk openly about death in Japan too. However, the situation is gradually changing because people are becoming increasingly aged, which is slowing changing attitudes to death, leading people to be more open about death and dying. It is possible that Malaysia will also experience a gradual change in social and cultural attitudes to death. 

A student noted that Japan's economic development has also played an important role in achieving what could be referred to as “successful population aging.” This means that most older people in Japan can access the care they need, through long-term care insurance and health insurance systems. However, in many low and middle income countries in Asia, population aging is happening before their economies have fully matured or really developed. So such countries are likely to face a growing body of unmet needs in aged care. In light of Japan's experience, what can we suggest or share with such countries to help them to prepare for or respond to aging challenges? 

Dr. Inoue noted that Japan achieved universal health coverage (UHC) in the 1960s, 70s and 80s. Japan subsequently introduced the long-term care insurance scheme in 2000, when the aging rate of Japan was still around 12%, much lower than the expected peak of 30% in the coming years. The challenge for other Asian countries, like China, Malaysia, Thailand, Vietnam, Philippines, Indonesia, etc., is that their aging rates are already at around 12%, which is at the point where Japan introduced long-term care insurance. So unless, unless efforts are introduced in the near term, it may be difficult for these countries to respond to an advanced aging society in the future. Dr. Inoue noted that his suggestion to other East Asian countries would be to not only introduce UHC schemes, but also consider the introduction of a long-term care insurance scheme like that of Japan, in view of the fact that many countries are already reaching the position where Japan was back in 2000. 

In view of the fact that Dr. Inoue has played such an important key role in shaping health policy, both in Japan and globally, Dr. Kawahara asked what points students should consider when drafting their own policy proposals? 

Dr. Inoue responded that he had been working in policy making in the Japanese government and from his experience the policy-making process is not straightforward. There are many stakeholders, and each and every stakeholder is different, with different views, vested interests and varying degrees of influence. It would not be appropriate to establish a policy without mapping each and every stakeholder. It is not possible to compile a policy totally independently from the interest of each stakeholders. Therefore, it is necessary to talk to each stakeholder and map their positions, as a means of finding realistic middle ground, on which each and every stakeholder could agree. Working based on theory alone will not lead to success. It is imperative to consider how to actually manage the different stakeholders.