One of Japan’s foremost policy challenges is to create an economicallyactive ageing society. Excellent health care will be central to achieving this. Thus far, Japanese health care has performed well – life expectancy is famously long, at 83.2 years compared to an OECD average of 80.2 years, whilst health spending is at USD 3 649 PPP per capita per year, slightly higher than USD 3 484 on average. A striking feature of the Japanese health system is its openness and flexibility. In general, clinics and hospitals can provide whatever services they consider appropriate, clinicians can credential themselves in any speciality and patients can access any clinician without referral. These arrangements have the advantage of accessibility and responsiveness. Such light-touch governance and abundant flexibility, however, may not best meet the health care needs of a super-ageing society. Instead, elderly individuals with one or more complex, chronic diseases will need continuous, proactive and tailored services to maintain their health and maximise their ability to participate in society. Japan needs to shift to a more structured health system, promoting differentiation of functions (primary care, acute care and long-term care, for example) while assuring mutual collaboration to ensure that peoples’ needs can be met by the most appropriate service, in a co-ordinated manner if needed. As this differentiation occurs, the infrastructure to monitor and improve the quality of care must simultaneously deepen and become embedded at every level of governance –institutionally, regionally and nationally.