Running head: AGING POPULATION IN JAPAN 1

Health Impact Framework/Research Paper

Aging Population In Japan

Delaware Technical Community College

NUR 310 Global Health

Christine E. Davis

April 20, 2018

AGING POPULATION IN JAPAN 2

Abstract

The aging population in Japan has placed an immense burden on the government, to cover the

increase in medical expenses. Due to the population living longer there is a higher risk of

dementia and Alzheimer’s. The burden of disease is also due to living longer which is lower

back pain which can lead to stroke and pneumonia from not being mobile and ischemic heart

disease. Alzheimer’s disease and dementia is also on the rise in Japan. Japans aging population

and social security are at the core of the countries deficit. The country has a loss of working

adults from age twenty to sixty-four. Strong cultural traditions limit fertility and immigration.

Women in Japan are focusing on their careers and/or having babies at a later age, if at all. Slow

economic growth discourages families from having a single child let alone multiple. Families

can’t afford to take care of loved ones at home; they are choosing to work and/or cannot afford to

have them live with them to care for them. The government is having trouble trying to figure out

a way to cover medical expenses and fix the shortage of health care persons to care for the aged.

Throughout the years Japan’s government has been working on how to live in a country where

the aged population is higher than any other age group.

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Socioeconomic Factors

As Japans aging population grows it is estimated that in 2025, 1 in 5 people will be aged

over 75, and 1 in 5 seniors aged over 65 will have dementia (Aoki, 2016). Females in Japan are

living to age 86.9 and men to age 80.8 (IHME, 2016). However, IHME also states that the

healthy life expectancy for women is 71.7 years of age and for men it’s 68.8 years (2016).

According to The Lancet article Japan has entered the era of super-ageing and advanced health

transition, which is increasingly putting pressure on the sustainability of its health system (2017).

With Japan’s ageing population the disability rates are going to keep rising (IHME, 2016).

According to International Longevity Center-Japan (ILC -Japan) older people are more

prone to chronic health conditions or disabilities that interfere with their daily lives, often

requiring some kind of assistance for an extended period (long-term care) (2013). If they have an

acute illness the chances of them having some type of disability is higher in older adults. The

three highest cases of burden of disease in Japan are stroke, low back pain, and ischemic heart

disease. The disabilities in Japan are lower back pain and sense organ disabilities which are

contributors of old ageing (IHME, 2016). Women’s chance of having “weakness due to frailty”

is higher than men due to cerebrovascular disease (stroke), dementia and bone fractures (ILC,

2013). The leading behavioral risk factors that have contributed to DALY’s have been unhealthy

diet and smoking according to the Global Burden of Disease Study in 2015. Japan has been

successful in reducing mortality and disability from most major diseases (Nomura, et al, 2015).

Alzheimer’s has risen almost 200% from 1990 to 2010 (IHME, 2016). In 2015 over 12,00

Japanese with dementia were missing, most were found wandering within the first week, 479

were found dead and 150 were never located (Yeung, 2016). The rise of dementia and

Alzheimer’s has and will have families unable to take care of their loved ones, and be able to
AGING POPULATION IN JAPAN 4

have a job and family of their own. Providing care for the elderly in Japan is linked to

inheritance of the household, meaning the co-residing son had the ethical obligation to care for

his parents while his wife is doing the actual caregiving (ILC, 2013). According to ILC 64%

reside with family members, most caregivers are old themselves, at 69.4% over 60 years of age

(2013). There is a heavy burden on the youth to take care of the ageing parents and/or

grandparents (Ghosh, 2014). According to a survey done in 2016, 40% of families looking after

relatives said they were unable to care for them at home, 70% said their caring responsibilities

had become a burden (Yeung, 2016).

An ageing population means higher cost for the government, a shortage of pension and

social security funds, a shortage of people to care for the aged, slow economic growth, and a

shortage of young workers (Weller, 2017). An aging population causes many difficulties, most

notably for Japan's government finances, already hard pressed by two decades of economic

stagnation. More retirees inevitably means more spending on social security when Japan's public

debt, at twice GDP, is already one of the industrialized world's worst (Hiroshi & France-Presse,

2011). Japan has a shortage of the working age of twenty to sixty four year olds and it has placed

a large deficit to contribute monies to social security, to cover the older population. The ministry

said the main factor behind the figure is a decline in the population of women in their 20s and

30s, and the trend will continue unless the age composition of Japan’s graying population

changes (Kyodo, 2016). The risk of the middle-aged people will become poorer due to increased

social security burdens (Aoki, 2016). According to Gross & Minot in 2008 there were three

workers for every retiree and by 2018 they estimate there will only be two Japanese workers to

support each retiree (2008).

AGING POPULATION IN JAPAN 5

The ageing population has placed an immense burden on the government to cover the

increase in medical expenses. According to Yoshikawa the medical cost of ageing is five times

higher than those working (2012). Physician-patient ratio is not even, physicians are

overwhelmed with their case-load, and are rushing through patients (Marlow, 2017). Marlow

states that Japan is facing a shortage of physicians as well, particularly in outlying areas, and

many can be pressed for time. They go to the doctor, but the doctor doesn't take time to explain

this stuff to them (2017). Older people were being admitted to hospital for long periods – not for

any medical reason, but simply because they could not be looked after anywhere else (Holder,

2014).Decreased birth rates and growing ageing population will lead to more spending on

nursing care; the nursing care is experiencing a severe labor shortage while the number of the

elderly needing care is rapidly increasing (Aoki, 2016).

Women today are choosing their careers’ over a family, due to this Japans’ population is

overwhelmingly decreasing. Japan’s population has shrunk by almost 1 million people in 5

years, and one-third of the population is over the age of 65 (Taylor, 2016). Cultural negativity

won’t allow women to work and have a baby (women are delaying marriage to have a full time

job). Women are better educated, pursue careers, can support themselves financially and don’t

see the traditional family as the only way to lead a fulfilling life (Smyth, 2017). A drop in

arranged marriages (omiai), except for marriage to a doctor or a man in a more elite job, and that

has also contributed to a drop in women having children. Japanese women find it hard to juggle

marriage and a full-time job, and couples are expected to have children shortly after getting

married. Husbands will want the women to give up the job; also domestic chores are unevenly

shared in Japanese marriages (Smyth, 2017). The birth fertility rate is at 1.39 per female in Japan

(ILC, 2013). Society in Japan does not accept cohabitation in lieu of marriage for childbearing
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and children tend to live with their parents until marriage (Farnsworth Riche, 2004). In Japan

only 2% of babies are born out of wedlock, compared to 41% in the United States (Ghosh, 2014).

Almost all women join the workforce after finishing school in Japan, but about 70% quit

when they get married or when they have children. Many also occupy career tracks with few

prospects of promotion (Gross, & Minot, 2008). The rate of employment among Japanese

women remains considerably lower than that among men with the same level of education

(Tobitate, 2014).

Japan has restricted immigration laws for decades and now has a desperate need for

skilled foreign workers, nurses and construction workers as well as to replenish population itself.

The easiest solution would be to allow immigration, but this solution will not work, Japan is a

civilization unto itself. It cannot integrate wide cultural diversity, unlike the United States

(Ghosh, 2014).

Changing The Context To Making Individuals Default Decisions Healthy

As the nation’s population rapidly grays, ensuring that there are enough nursing care

workers to meet the growing demand has become a pressing issue. The government is looking to

hiring non-Japanese nursing care workers by creating a new resident status category for those

who graduated from schools in Japan and passed the national care worker license exam (Aoki,

2016).

According to ILC the older Japanese are capable of contributing to the society and many

desire to do so, 30% of older adults are willing to work over life-time (2013).
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Japanese government is taking desperate measures to reverse the nations’ plunging birth

rate by funding matchmaking and dating services to get more young people married and

producing babies (Ghosh, 2014).

Japanese continue to prize their country's ethnic and linguistic homogeneity. To make up

for population decline, Japan would need to Import 300,000 to 400,000 foreigners a year until

2050. Japanese are not likely to be open to such a high level of immigration. There is a need to

increase importation of foreign workers. However, Japan continues to allow very few of these,

nearly two-thirds of respondents said they supported allowing unskilled workers into Japan.

Currently, only skilled workers are allowed (Gross & Minot, 2008). Simultaneously accepting

moderate levels of immigration into the country will allow the population to sustain or grow

(Farnsworth Riche, 2004).

Japanese often see their work as a source of pride and like to be able to be kept busy after

retirement. Japanese law prohibits age discrimination, seniority is respected in Japanese culture,

and some hiring sees this negatively as they view older job applicants. This is a mistake; some

have valuable skills to offer (Gross & Minot, 2008).

Long Lasting Protective Interventions

The government is planning to create new nursing care facilities to accommodate

500,000 more users in 2020 (Aoki, 2016). Aoki also states that in April of 2015, the government

lowered its overall benefit rate payments by 2.27 percent while raising the basic salary for care

workers by 1.65 percent (2016). In 2015 around 800 of 1,741 municipalities in Japan have signed

agreements to serve people with dementia and to respond in times of emergency (Yeung, 2016).
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Japanese older population are health-conscious and try to stay healthy, according to ILC

they get enough hours of relaxation, maintain a schedule, walk and eat healthy (2013). Japanese

have a higher percentage of older population seeing a physician once a month at 60% (ILC,

2013). Japan’s older adults pay a lower health premium than the rest of the country, they do pay

monthly payments, copay’s for in-patient and out-patient services and for prescription’s (ILC,

2013). Japanese government has encouraged preventative health care services like free medical

check-ups and consultations for older adults (ILC, 2013).

Employers are implementing child care leave and other accommodations to make the

work-place more female friendly. With experienced workers retiring in greater numbers it is

crucial to give women opportunities for career development (Gross & Minot, 2008). If

companies gave more protection to new, young hires and reduced the privileges of other

employees, young couples would have a more stable basis on which to marry and raise families

(T.B., 2014).

Many Japanese companies are turning to elderly workers to make up for the decline in

the size of the younger-generation workforce. Some major firms are extending the retirement age

from 60 to 65 if they wish to continue to work (The Japan Times, 2017). Government offers

financial incentives for employing older workers (Gross & Minot, 2008).

In 2017 the government required elderly people with certain levels of income to pay for

more of their own medical and nursing care cost (The Japan Times, 2017). The Japanese are

justly proud of their health-care system. People get good basic care and are never bankrupted by

medical bills. Japan is known for the longevity of a people who eat less and stay trimmer than

the citizens of any other rich country (Tokyo, 2011).

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Pension premiums are scheduled to grow steadily to make up for demographic changes of

two Japanese worker supporting one retiree, the government plans for Employee Pension

Insurance to be at 18.3% of salary by 2018 (Gross & Minot, 2008).

In Japan the federal government has just loosened the requirements for new, highly-

skilled immigrants to become permanent residents. Under the new law, applicants with multiple

degrees who earn a high salary will only need one year to become residents. The change reflects

Japan's desire for more workers with advanced skill sets (Weller, 2017). If you've immigrated

with a work visa, the Japanese government determines how long you must stay to achieve

permanent residency based on your qualifications. In 2012, Japan launched a point system to

shorten the wait for highly skilled applicants. If your academic and professional background net

you 70 points, for example, you only have to wait three years. If it earns you 80 points, it's one

year. All residents gain permanent status after 10 years by default (Weller, 2017).

Counseling and Education

Given the urgency to the lack of care workers in Japan the Prime Minister Shinzo Abe’s

administration released an action plan outlining measures to secure enough nursing care workers.

Under the EPA (Economic Partnership Agreement) program, people who pass the nursing care

worker exam can continue to work in Japan; in 2015 they accepted 2,069 examiners, only 317

passed the exam (Aoki, 2016). In 2016 Japans government trained specialists, improved

structures for early diagnosis, and expanded community-based care to relieve the pressure of

family workers who have to care for their loved ones with dementia (Yeung, 2016).

Prime Minister Abe has had his government host speed-dating events and held fatherhood

classes to help single guys see themselves in a parenting role (Weller, 2017). There have also
AGING POPULATION IN JAPAN 10

been schemes to encourage childbearing, including a “women’s handbook” to educate young

females on the high and low points of their fertility (T.B., 2014).

Equality in the sexes needs to come from the government, not private industry. Fewer

than 10% of managers in Japan are female, a disparity stemming from a systemic bias against

hiring women. Firms view female hires as a bad investment as pregnancy leave and maternity

leave drain company investments (Weller, 2017). The government has a responsibility to

implement policies that favor women while also appealing to corporate interest, gender equality

is not a goal for Prime Minister Abe (Weller, 2017). Natsuko Fujimaki holds seminars for

working mothers, 15 working mothers get together to swap stories, and share tips for navigating

motherhood and careerism. She also teaches Japanese children English while running a daycare

(Weller, 2017).

Citizenship in Japan requires knowing Japanese at a 7-year-old reading level (while

permanent residence comes with no such requirement). Past that, immigrants will have a much

easier time getting enmeshed in the culture if they accept how different it's likely to be from their

home countries. Japan tends to operate by a traditional set of values, which focus on deference to

elders and exercising discretion in public. The legal and logistical barriers are only the beginning

to a new life in Japan (Weller, 2017).

Future Interventions

The Japanese government introduced long-term care insurance, offering social care to

those aged 65+ on the basis of needs alone. The system is part-funded by compulsory premiums

for all those over the age of 40, and part-funded by national and local taxation. Users are also

expected to contribute a 10% co-payment towards the cost of the service. The costs are seen as
AGING POPULATION IN JAPAN 11

affordable and the scheme is extremely popular. The result is that older people in Japan can

access a wide range of institutional and community-based services and requires levels of public

spending on social care taking into account disability-related cash payments such as Attendance

Allowance (Holden, 2014).

Leaders at the hospital surveyed a community to figure out their problems with the

existing system, they organized a private transit network of subsidized taxis and buses that bring

elderly patients for appointments, and implemented electronic health records long before other

jurisdictions in the West. The hospital even issued digital ID cards tagged with the person's

medical history, allergies and illnesses to hundreds of elderly people in the district, which can be

quickly scanned by emergency personnel or doctors (Marlow, 2017).

A variety of companies, ranging from health care firms to car makers, are developing robots they

say can provide physical or emotional help to the elderly or those caring for them (Hiroshi &

France-Presse, 2011). Japanese researchers are now looking at whether robots can help as the

country ages, from robot suits that help rehabilitation to fully functional humanoid robots. One of

the best examples is a robotic seal called Paro, invented by Takanori Shibata, the chief senior

research scientist at Tsukuba's National Institute of Advanced Industrial Science and

Technology. The fuzzy seal has been proven in various settings to reduce anxiety, stress,

depression and even patients' perception of pain during chemotherapy treatments. Distributors in

various countries have sold about 3,500 seals in 30 countries (Marlow, 2017).

Ueda Kaichi, a 32-year-old who founded a non-profit that helps disabled people find

jobs, thinks like many young people in Japan, who are increasingly skipping pension payments

(Marlow, 2017).
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Makiyo Iwatsuki opened up a café for family caregivers, who are often under emotional

and physical stress. There's no place for caregivers to express their feelings in Japan. The café is

also a place to exchange information about caregiving techniques, and is visited every other

week by Yoko Hori, a nurse and volunteer who checks people's blood pressure and makes gentle

suggestions about what to ask their doctor. Ms. Hori says.

Mr. Abe's so-called Abenomics revival program – which also includes getting more

women in the workplace – is an emphasis on new medical technologies, including experimental

regenerative medicine and cell therapy. The hope is that with two new acts governing

regenerative medicine to help commercialize technologies more quickly, the Japanese

government can save money on future health care costs while spurring the creation of a valuable

new industry – particularly in bio-medical hubs such as the one in Kobe, which features a

gleaming new mini-city of medical buildings, research centers and hospitals on a man-made

island near the port city's airport (Marlow, 2017).

New citizens must be at least 20 years old, and have lived in the country for at least five

years, and be willing to renounce their former citizenship. Officials will perform a background

check, mental-health exam, and will request a long list of documents related to your life and your

family. They may even inspect your home and workplace if those details are hard to verify

online. The whole review process takes roughly six months to a year (Weller, 2017).

Japan’s private health insurance market has been actively developed, driven by the robust

growth of third-sector insurance products over the past 10 year, the third-sector insurance

market, which includes coverages for medical, cancer, nursing care, personal accident and

income compensation. A recent series of reforms in the national health care insurance schemes
AGING POPULATION IN JAPAN 13

have been made by the government in order to control the medical expenses. Foreign and domestic

life insurers penetrated the third-sector insurance market to provide supplemental health insurance

products to cover the extra costs resulting from hospitalization, which the national health insurance

scheme does not cover (A.M. Best, 2016).

Professional Opportunities in Global Health

The use of tobacco and poor diet choices in Japan are high and causing a burden in non-

communicable diseases. Due to the high risks of cerebrovascular disease, cardiovascular disease,

and ischemic heart disease, I would implement teachings on quitting smoking and better diet

choices. All of these areas can be great teaching opportunities. Stress on working adults is high

and learning new ways to deal with stress would be helpful. Cardiovascular disease is the largest

cause of death, and non-communicable diseases make up the largest burden (Skolnik, 2016).

The National Center for Productive Aging and Work (NCPAW) advances lifelong well-

being for workers of all ages and supports a productive aging across the working life (CDC,

2017). As of 2017 the NCPAW is not in Japan. I would build and work with a committee to

bring awareness of older ageing and the benefits of them working. I would also like to start some

type of traveling nursing-mobile; I feel that would benefit everyone in a community. It would

alleviate over-loading on doctors, in hospitals, and the families wouldn’t need to worry about

transportation.
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