Japan's health system toward 2040: structural challenges and a renewed social contract.

Japan's universal health coverage system has supported healthy longevity, but now confronts institutional stagnation: widely recognised structural pressures persist without reform of its core architecture. A multidisciplinary working group of 25 experts from Japan and the Western Pacific identified three interdependent structural challenges perpetuating policy inertia. These comprise a volume-driven, hospital-centric delivery model sustained by fee-for-service incentives, rigid budget allocation, and underdeveloped health technology assessment; fragmented data infrastructure and eroded public trust undermining evidence-informed governance; and institutional insularity limiting global interdependence. We propose a Vision 2040 framework with three goals: transitioning to an open, community-based ecosystem prioritising daily functioning and wellbeing; establishing trust and scientific independence as foundations of governance; and ensuring equity through circular innovation, in which Japan contributes to and learns from regional health networks by integrating global learning with domestic value assessment. Nine recommendations provide a roadmap for governance reform, data integration, reimbursement realignment with societal value, and reciprocal workforce partnerships. Reconstructing the social contract underpinning universal health coverage is central to sustainability across ageing Western Pacific societies.