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The primary care system (PCS) is an essential national health infrastructure defined by the delivery of comprehensive, integrated, and accessible services that serve as the patient’s first and sustained point of contact with the healthcare system. A comparative review was performed through searches of PubMed, KoreaMed, and J-STAGE databases using terms including “primary care,” “general practitioner,” “family physician,” “gatekeeping,” “Korea,” and “Japan.” Gray literature from the Japan Medical Association, Korea Medical Association, and OECD (Organisation for Economic Co-operation and Development) was also reviewed. Clinical case examples from one author’s practice were included to illustrate real-world general practitioner (GP) challenges. Both Japan and South Korea feature universal health insurance but differ substantially in physician training pathways, gatekeeping enforcement, and community care integration. Japan is transitioning toward a kakaritsuke-i (registered home doctor) model with a nascent GP specialty board, whereas South Korea relies primarily on specialist-led private clinics for primary care delivery. International evidence suggests that structured, continuous family physician (FP) training is associated with improved chronic disease management, preventive care utilization, and patient satisfaction. Strengthening South Korea’s PCS requires a clearly defined mandatory FP residency framework, reinforced gatekeeping mechanisms, and greater investment in community-based integrated care. Japan’s ongoing reforms offer a useful regional comparator, while international FP models provide a proven evidence base for structural improvement.
Accessible and sustainable medical care is a fundamental responsibility of governments and a critical social safety net for citizens worldwide. While centralized systems sometimes face structural collapse, and purely free-market models can produce excessively high costs that threaten equity, the primary care system (PCS) represents a well-validated middle path toward universal health coverage. A robust PCS is defined by the delivery of comprehensive, integrated, and accessible services that serve as the patient’s first and sustained point of contact [1]. Investment in primary care is globally recognized as the most efficient mechanism for achieving and sustaining universal health coverage, with strong evidence linking it to superior population health metrics, including enhanced life expectancy and reduced disease prevalence [2].
The South Korean healthcare system currently faces significant strain, particularly in the maldistribution of medical residents across essential clinical departments, including internal medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and family medicine. This internal crisis is compounded by a rapidly aging population, threatening the long-term sustainability of the national reimbursement system and the postgraduate medical education structure. Kim and Yoon [3] have emphasized that “reinforcement of primary care must be prioritized in Korea’s healthcare reforms.”
Japan serves as a compelling regional comparator. It has achieved remarkable cost-efficiency through its national health insurance system, boasting one of the world’s highest life expectancies, despite maintaining medical expenditures close to the Organisation for Economic Co-operation and Development (OECD) average [1]. This success is attributed to a combination of effective hospital-clinic cooperation and broad insurance coverage, operating within a free-access framework in which patients may consult virtually any facility they choose.
Although South Korea and Japan share many cultural and demographic similarities, including rapidly aging populations, low birth rates, and historically hospital-centric care, crucial differences exist in their primary care structures, physician training pathways, patient access mechanisms, and policy directions. By systematically analyzing these structural differences and situating them within the international evidence on family physician (FP)-based models, this review aims to identify policy-relevant recommendations for strengthening primary care in South Korea.
Methods
This is a comparative narrative review. A narrative approach was selected given the heterogeneity of the relevant literature and the policy-oriented, system-level focus of the research question. Narrative reviews are appropriate for synthesizing diverse evidence sources and contextualizing findings within specific healthcare system settings.
Search strategy
Literature searches were conducted in PubMed, KoreaMed, and J-STAGE using the following MeSH terms and keywords: “primary health care,” “family medicine,” “general practitioners,” “gatekeeping,” “family physician,” “Korea,” “Japan,” “primary care training,” and “community-based integrated care.” The reference lists of retrieved articles were manually searched for additional relevant sources. Gray literature from the Japan Medical Association, Korean Medical Association, World Health Organization, and OECD health statistics databases was also reviewed.
Inclusion and exclusion criteria
Studies and documents were included if they described primary care organization, physician training, health system structure, or policy reform in South Korea or Japan or if they provided international comparative data relevant to FP- or general practitioner (GP)-based primary care models. Opinion pieces and narrative reviews were included if they provided policy-relevant context. Articles not available in English, Korean, or Japanese were excluded.
Analytical framework
A structured comparison framework was applied across the following domains: (1) definition and role of primary care physician; (2) training and certification pathways; (3) healthcare system access and gatekeeping; (4) primary care characteristics and scope of practice; and (5) systemic challenges and ongoing reform efforts. International evidence regarding FP training outcomes was incorporated to contextualize the South Korea-Japan comparison.
Results: comparative analysis of the primary care systems
Differences in medical service organization (Table 1)
Neither South Korea nor Japan has a fully established, legally mandated GP system with a defined scope of practice. In Japan, physicians traditionally accept a wide range of patients regardless of their specialty training. By contrast, private South Korean clinics tend to focus on specific specialties, meaning that primary care is often delivered by board-certified specialists rather than by generalist physicians.
South Korean patients can visit tertiary hospitals freely, even with minor complaints. Japan has recently introduced regulations encouraging referrals before visiting large hospitals, and the government is promoting a registered kakaritsuke-i (home doctor) system, modeled in part on the UK’s GP registration model. This structural difference creates a more tiered coordinated care pathway in Japan, in which private clinics typically serve as the first points of contact.
South Korea’s healthcare system became highly digitalized at an early stage, offering potential infrastructure advantages for integrated care coordination that have not yet been fully leveraged for gatekeeping purposes.
Comparison of the GP role in Japan and South Korea
Patients experiencing physical or psychological distress often have varied needs that do not align closely with specialty boundaries. The role of the GP is to comprehensively address these problems, including undifferentiated presentations outside of a single specialty. In both countries, primary care physicians must balance patient expectations with evidence-based clinical judgments.
In Japan, the concept of a GP is aligned with the kakaritsuke-i, the patient’s continuous community-based point of contact. This physician is expected to provide longitudinal, relationship-based care. In South Korea, by contrast, the term “GP” commonly refers to any non-specialist physician who has completed the mandatory internship but not obtained board certification. This means that South Korean GPs are legally permitted to open general practice clinics, while board-certified specialists (in family medicine, internal medicine, or pediatrics) fill the primary care role. This terminological divergence reflects a fundamental structural distinction: Japan conceptualizes primary care as a relationship-based, continuous service, whereas South Korea allows primary care to be driven by specialty competition and market demands.
In Japan, there is no mandatory GP residency requirement for general practice. Many doctors enter primary care after hospital-based specialty training in internal medicine or pediatrics. The Japan Primary Care Association offers voluntary board certification. The Japanese Medical Specialty Board introduced a new GP specialty in 2018, although it remains nascent and incompletely integrated into the broader medical workforce structure. This historical fragmentation contributes to variability in clinical competencies among Japanese primary care providers.
In South Korea, completion of the internship year is legally sufficient to open a general practice clinic. In practice, the most active primary care is delivered by board-certified specialists, predominantly in family medicine, internal medicine, or pediatrics, who operate high-volume private outpatient clinics. Family medicine as a specialty was established in South Korea in 1989. However, its distinct role within the PCS remains underutilized and insufficiently promoted as a career pathway for medical graduates.
Both nations offer highly accessible healthcare under universal insurance coverage; however, their mechanisms for accessing secondary and tertiary care differ. In Japan, patients enjoy free access to virtually any clinic or hospital without referral, promoting choice but contributing to specialist overuse for routine complaints. South Korea also permits direct access to private clinics, but applies a partial gatekeeping mechanism for tertiary hospitals through higher copayments for patients without referrals. The effectiveness of this financial disincentive in redirecting care toward appropriate settings remains unclear in the literature [2]. Japan is now moving toward formalizing referral requirements with financial surcharges for large hospital visits, bringing its policy direction closer to South Korea’s existing partial gatekeeping structure.
Japanese primary care places a strong emphasis on continuity of care and is increasingly oriented toward the complex needs of its rapidly aging society, including home visits, geriatric care, and integration with long-term social services. The South Korean system is characterized by high-volume outpatient clinics with a competitive market-driven structure. Private clinics often prioritize efficiency and rapid patient turnover, sometimes resulting in fragmented care, in which patients visit multiple specialists across a single episode of illness, a pattern that is particularly problematic for patients with multiple chronic conditions.
The primary challenges in Japan include the lack of structured mandatory GP training, overspecialization of the workforce, and difficulty in establishing a cohesive, standardized primary care identity. South Korea’s primary weakness is its underdeveloped gatekeeping mechanism and the resulting overuse of specialist and tertiary care resources. Despite the existence of family medicine as a recognized specialty since 1989, its role in shaping a distinct and comprehensive primary care workforce has remained limited. Both countries face the shared challenge of an increasingly elderly population with rising multimorbidity and the demand for coordinated, community-based care.
Japanese GP-based primary care in practice
Japanese GPs function as comprehensive consultants, managing a wide spectrum of conditions across the disease continuum. In terms of chronic diseases, this includes hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, heart failure, chronic kidney disease, fatty liver disease, chronic gastritis, thyroid disorders, and post-stroke follow-up care. In terms of acute conditions, GPs manage respiratory infections and febrile illness, and they serve as the first point of contact for potential acute abdomen, acute coronary syndrome, and stroke by arranging timely referrals where appropriate. Many GPs also perform minor surgical procedures and handle nursing care coordination and home visit consultations.
The following de-identified clinical cases from one author’s (N.H.) practice illustrate the breadth of competency required of Japanese GPs and the real-world challenges they encounter. The requirement to obtain informed consent was waived.
Case 1: polymyalgia rheumatica in a 70-year-old woman
A 70-year-old woman with known diabetes mellitus and pulmonary fibrosis presented with a 1-month history of low-grade fever (37.3 °C) and pain in her shoulders and thighs. Test results for coronavirus disease 2019 and influenza were negative, and no signs of acute bacterial infection were identified. The clinical diagnosis of polymyalgia rheumatica was based on the characteristic symptom distribution, elevated inflammatory markers, and exclusion of infectious and malignant causes. Corticosteroid treatment produced a prompt clinical response, confirming the diagnosis. This case illustrates the diagnostic complexity inherent in undifferentiated musculoskeletal presentations and the importance of a broad differential diagnosis in generalist practice, particularly in older patients with multiple comorbidities and atypical features.
Case 2: vertebral compression fracture in a 90-year-old woman
A home visit was requested for a 90-year-old woman who was unable to mobilize because of severe back pain. The GP clinically suspected a vertebral compression fracture and arranged for a hospital referral. Initial computed tomography (CT) imaging and laboratory studies were inconclusive. Magnetic resonance imaging (MRI) performed 2 weeks later identified a fracture at the Th11 level, which was visible only on MRI during the early postinjury period. This case underscores the diagnostic limitations of CT for early spinal fracture detection and highlights a relevant policy difference between Japan and South Korea. MRI for vertebral fracture evaluation is covered under Japan’s national insurance system but is not routinely approved in South Korea (Table 2), a difference with direct implications for primary care diagnostic capacity.
Case 3: end-of-life decision-making for a 101-year-old woman
A 101-year-old woman with dementia and history of stroke developed aspiration pneumonia. Her daughter had previously requested a do-not-resuscitate order, but during acute deterioration consented to emergency intubation in a moment of distress. After 1 month of mechanical ventilation, the patient’s condition continued to deteriorate, and the daughter consulted the home GP regarding palliative care and discontinuation of life-sustaining treatment. Following extubation, the patient was transferred home, where the GP and visiting nurses provided comfort-focused end-of-life care until death. This case illustrates the GP’s critical coordinating and mediating role in complex end-of-life situations and the significant cultural differences between South Korea and Japan in the preferred place of death (Table 3): South Korean patients more frequently choose to die in hospital settings, whereas a larger proportion of Japanese patients and families prefer home-based death [3].
Community-based integrated care and the GP’s coordinating role (Table 4)
Almost all high-income countries face the dual challenge of declining birth rates and expanding elderly populations. This demographic transition has increased the demand for both medical and long-term nursing care, placing upward pressure on healthcare expenditure and straining hospital capacity. International evidence consistently supports community-based integrated care systems as the most effective and cost-efficient response to this challenge, systems in which GPs or FPs serve as coordinators, linking preventive care, chronic disease management, social support, and end-of-life services [2].
Japan’s Ministry of Health, Labour and Welfare is developing a roadmap for community-based integrated care, and the Japan Medical Association is preparing a formal GP curriculum to support this transition [1]. These reforms reflect the broader global trend, observed in the United Kingdom, Australia, Canada, and the Netherlands, in which structured FP training and defined gatekeeper roles have been associated with lower hospitalization rates, more appropriate specialist referral, and improved patient satisfaction [2]. South Korea, despite currently having a younger elderly population relative to Japan, is aging rapidly and must urgently build infrastructure for coordinated community care before demographic pressures intensify.
Discussion
The preceding comparative analysis highlights a central finding: both South Korea and Japan face primary care challenges rooted in insufficiently structured generalist training and fragmented care delivery. The international evidence strongly supports a dedicated FP training model as the most effective structural response to these challenges [2].
A mandatory, multi-year FP residency program, typically 3 years following medical school, as implemented in the United States, Canada, the United Kingdom, Australia, and the Netherlands, explicitly defines the specialty’s competencies across the full lifespan (pediatrics to geriatrics) and across clinical settings (outpatient, inpatient, community, and procedural). This structured exposure produces physicians with a broad, integrated clinical skill set, a preventive and psychosocial orientation, and the longitudinal patient relationships that are essential for effective chronic disease management and care coordination [2].
In contrast, Japan’s historical reliance on hospital-based subspecialists as primary care providers has produced an episodic, organ system-focused approach that is well suited to acute care but less effective for the continuous, whole-person care demanded by an aging population. While the Japanese Medical Specialty Board introduced a new GP specialty in 2018, a positive reform, it remains nascent, incompletely integrated, and insufficiently standardized compared with established international FP programs [1].
Importantly, the evidence that structured FP training translates into measurable practice quality improvements is not merely theoretical. Countries with established FP systems report lower hospitalization rates, higher preventive care utilization, better chronic disease control, reduced emergency department attendance, and greater patient satisfaction than those with specialistfirst systems [4]. Similarly, a 2019 review by Kato et al. [1] identified the absence of structured generalist training as a key barrier to effective primary care in Japan. These international data support the inference that a comparably structured FP program in South Korea and a strengthened GP curriculum in Japan would yield measurable quality improvements, while acknowledging that direct outcome comparisons between the South Korean FP model and the current Japanese GP system are limited by available data and warrant further empirical study.
It is important to acknowledge that the clinical cases presented in this review demonstrate a high level of clinical competence among Japanese GPs. The ability to diagnose polymyalgia rheumatica in a complex older patient, suspect an early vertebral fracture on MRI, and coordinate a dignified home death for a centenarian reflects the holistic, continuous, and patient-centered practice that an ideal primary care physician should embody. The argument in favor of structured FP training is not that Japanese GPs lack clinical capability, but rather that their current training pathway lacks the standardization, mandatory scope, and family-oriented focus that would ensure that all primary care physicians, not only those with exceptional training backgrounds, achieve a consistently high baseline of generalist competence.
Translating the South Korea-Japan comparison into actionable policy requires specificity. Based on this review, the following recommendations are proposed for the South Korean healthcare system:
First, South Korea should invest in elevating family medicine as a clearly defined, valued, and well-resourced specialty, attracting a greater proportion of medical graduates through competitive residency positions, mentorship, and aligned financial incentives. The current underinvestment in family medicine as a career pathway is a structural vulnerability.
Second, the partial gatekeeping mechanism should be strengthened. The current copayment differential for tertiary hospital self-referral is insufficient to redirect the care flow. Evidence from countries with stronger gatekeeping (the Netherlands, Denmark, and the United Kingdom) demonstrates that defined primary care registration, combined with a referral requirement, substantially reduces inappropriate use of specialists and the emergency department [2].
Third, South Korea should build upon its existing digital health infrastructure to make coordinated, longitudinal care records accessible to primary care physicians, thus facilitating the continuity of care that FP-based systems depend on.
Finally, a community-based integrated care policy must be developed proactively. Japan’s community-based care roadmap provides a regional model; South Korea must develop an analogous policy infrastructure before demographic pressures peak [5].
This study had several limitations. As a narrative comparative review, it is subject to selection bias in the literature inclusion and does not provide a quantitative synthesis of outcomes data. Direct head-to-head empirical comparisons between South Korean FP and Japanese GP outcomes are not available in the literature, which limits the strength of the causal inference. The personal case examples, while clinically illustrative, are from a single practice context and cannot be generalized. Future research should prioritize prospective, outcomes-oriented studies comparing primary care quality metrics, such as preventable hospitalization rates, chronic disease control, and patient-reported outcomes, across both systems.
Conclusion
Free and equitable access to medical care is a cornerstone of public health protection. To sustain this access amid an aging population, rising multimorbidity, and constrained health budgets, highly skilled, continuously trained, and clearly defined primary care physicians are essential [6,7]. The comparative analysis of South Korean and Japanese PCSs presented in this review reveals that both nations face structural challenges rooted in insufficiently defined and under-incentivized generalist training pathways.
An ideal primary care physician, whether termed a GP or FP, is a holistic professional who listens to patients’ needs expertly, maintains broad and current clinical knowledge, acts as a responsible referral gatekeeper, proactively supports preventive and lifestyle care, and coordinates nursing and community services. International evidence supports the FP-based residency model as the most effective structural mechanism for producing and sustaining such physicians at scale.
Specifically, for South Korea, this review recommends as follows: (1) formal elevation and resourcing of family medicine as a distinct and valued specialty; (2) strengthening of gatekeeping through primary care registration and referral policy; (3) leveraging the existing digital infrastructure for longitudinal care coordination; and (4) proactive development of community-based integrated care systems. Japan’s ongoing GP curriculum reforms offer a valuable regional reference, while international FP systems provide a proven evidence-based template. Together, these directions offer a pathway toward PCSs in both countries that are equitable, efficient, and fit the demographic challenges of the coming decades.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
None.
Data availability
Data of this research are available from the corresponding author upon reasonable request.
Author contribution
Conceptualization: DHK. Data curation: NH. Formal analysis: DHK. Investigation: NH. Methodology: DHK. Resources: DHK. Software: DHK. Validation: NH. Visualization: NH. Project administration: DHK. Supervision: DHK. Writing–original draft: NH. Writing–review & editing: all authors. Final approval of the manuscript: all authors.
Table 1.
Key differences between South Korea and Japan
Aspect
South Korea
Japan
Access to hospitals
Patients freely visit large hospitals even for minor issues
Referral letter often required to visit large hospitals; extra fees without it
Primary care system
No formal GP registration system
Japan promotes a “family doctor” model but lacks mandatory GP registration
Ownership of hospitals
Over 90% are privately owned, including for-profit institutions
Mostly private but operated by non-profit medical corporations
Clinic specialization
Many clinics are specialized (e.g., dermatology, ENT)
Clinics often serve as generalists, especially internal medicine
Patient flow
Weak gatekeeping; patients tend to bypass clinics
Referral-based flow from clinic to hospital is encouraged
Digital systems
Online reservations and digital health services are widespread
Progress varies; some institutions still rely on phone reservations
GP, general practitioner; ENT, ear, nose, and throat.
Table 2.
Key differences in health insurance systems
Aspect
Japan
South Korea
Structure
Decentralized (many insurers)
Centralized (single-payer)
Flexibility
High (e.g., separate system for elderly)
Unified and standardized
Elderly care
Well-developed long-term care insurance
Less extensive than Japan
Non-covered treatments
Fewer (many procedures are covered)
More frequent (e.g., cosmetic surgery often uncovered)
Challenges
Rapid aging, rising medical costs
Aging population, equity of contribution and benefits
Table 3.
Comparison: place of death in Japan and South Korea
Country (year)
Hospital (%)
Home (%)
Nursing/care facility (%)
Others (%)
Japan (2022)
59.9
13.8
20.9
5.4
South Korea (2020)
74.1
16.7
1.3
7.9
Table 4.
Community-based integrated care: key components and general practitioner role
Aspect
Japan
South Korea
Policy launch
2012 (Community-Based Integrated Care System)
2018 (Community-Based Integrated Care pilot)
Home-based medical care
Developed
Limited
Long-term care insurance
Since 2000
Introduced in 2008 (nursing homes), home care underutilized
Cultural acceptance
Gradually growing
Still hospital-oriented
References
1. Kato D, Ryu H, Matsumoto T, Abe K, Kaneko M, Ko M, et al. Building primary care in Japan: literature review. J Gen Fam Med 2019;20:170-9.
4. Organisation for Economic Co-operation and Development (OECD). Health at a glance 2023. OECD Publishing; 2023
5. Ock M, Kim JE, Jo MW, Lee HJ, Kim HJ, Lee JY. Perceptions of primary care in Korea: a comparison of patient and physician focus group discussions. BMC Fam Pract 2014;15:178.
