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Japan's elderly population is continuing to grow. This means that the need or demand for health care services is increasing. Ensuring a high quality of care becomes a central task for health service providers in local and regional governments. A comprehensive understanding of the issues faced by the elderly in rural Japan is essential before strategies and reforms for the better delivery of care can be developed and implemented. This review emphasizes challenges such as strained resources, inequity of distribution of resources, lack of support and dissatisfaction with care. Together these challenges highlight the need for effective strategies to tackle the issues confronting the elderly in rural Japan.