In the midst of population aging and population shrinking, Japan experiences a hitherto unknown degree of de-familiarization of eldercare. The already shortage prone health-care labor market subsequently has been opened up to international health-caregivers, even if only half-heartedly

Gender and Ethnicity
in Japan’s Eldercare

di Gabriele Vogt

Japan is among the fastest aging nations in the world. The population segment of those aged 65 and above continues to experience numerical growth (+2.64% in 2015), while the working age population (14 to 64 years) and the child population (13 years and below) have long faced a numerical decline (-1.27% respectively -1.49% in 2015). In 2013, one in four Japanese was elderly, and by 2035 it will be one in three.[1]

This demographic development poses a challenge to Japan’s welfare provisions. Ever since the introduction of Japan’s Long-term Care Insurance (LTCI, kaigo hoken) in 2000, the number of beneficiaries has been on the rise. Policy-makers in Japan need to face the question of who will be providing health-care to the growing number of the nation’s elderly.

De-familiarization of eldercare in Japan

This question is all the more pressing as the numerical growth of the elderly population is accompanied by a shift in attitude regarding the acceptance of health-care services provided outside the realm of the family. This shift in attitude is taking place in the caregiving and the care-receiving generation alike, as large-n surveys conducted by the Cabinet Office of Japan over the course of some decades has shown.[2]

Another survey conducted by Unicharm, one of the world’s leading manufacturers of sanitary products, reveals a gender gap within this overall trend. When asked, “who would you prefer to help you with your intimate care should you no longer be able to perform it yourself”, 46.9% of female respondents in Japan stated that they plan on relying on professional health-caregivers. So did 25.8% of the male respondents. It should not go unnoticed that in fact 66.7% of the male respondents chose their spouse as their preferred caregiver.[3]

Despite this prevailing discrepancy in preference that separates the sexes today, the acceptance of professionalized health-care by now has reached even Japan’s most old-fashioned rural areas as Nanako Tamiya, a scholar of social medicine, claims.[4] Japanese feminists made sure that the design of LTCI would support this development by lobbying against a cash-for-care system. Keiko Higuchi, a spokesperson of the feminist activists, stressed the necessity to implement a service-only insurance scheme, in order to make sure that the exploitation of daughters-in-law and daughters in what has often been deemed a “caring hell”[5] would finally come to an end.

Opening Japan’s doors to migrant health-caregivers

As a result, the already shortage prone health-care labor market faces rising personnel needs. The Japan Institute for Labour Policy and Training speaks of a necessary net increase of roughly 70,000 care workers per year through 2025.[6] How to fill these job vacancies is subject to a lively political debate, and only very reluctantly did Japanese policy-makers start to recruit migrant health-caregivers.

Under the roof of bilateral trade treaties, so-called Economic Partnership Agreements (EPA), Japan opened its domestic labor market to health-caregivers from Indonesia (as of 2008), the Philippines (as of 2009), and Vietnam (as of 2014). The quota is set at a maximum of 1,000 health-caregiver migrants per nation per year. In the light of the needs of the labor market, this quota is extremely low to begin with, yet it has not once been met. In fact, as of 2014, as the Japan International Corporation of Welfare Services reports, a total of only 1,562 health-caregivers, i.e. nurses and careworkers, have come to Japan under this system.[7]

Reasons for the low attractiveness of the EPA migration system

The reasons for the low attractiveness of the EPA migration system are manifold, yet the two most often mentioned ones in my interviews with migrant health-caregivers in Japan are a high level of Japanese language proficiency, and a non-compatibility of professional degrees. In fact, both reasons are intertwined. International health-caregiver migrants are required to pass Japan's national nursing respectively careworker exam within the first five years of their employment in Japan. These are written exams, and they are to be taken in Japanese language. This has proven to be an extremely high hurdle. In fact, the migrants’ average passing rate stands at 15.26% in the nursing exam, and at 17.58% in the careworker exam.[8] Failing to pass the exam means that the migrants lose their work permit in Japan.

On the employers’ side, too, the EPA system is not welcomed overly warmly, as employers face extra costs when hiring migrant health-caregivers starting with the language classes that should be provided, and continuing all the way to housing assistance. Add to that a prevailing uncertainty regarding the migrants’ skill level, their life-course, and, as one head of a nursing home in Miyagi Prefecture pointed out in an interview, a fear over how patients and their families react to foreign personnel. He stressed that employing male foreign caregivers was next to impossible, since it would add gender as yet another dividing variable next to ethnicity in the staff’s composition. In fact, among the first batch of Indonesian caregivers who applied to come to Japan in 2008, 86 candidates could not be matched with Japanese employers, and 66 of them were male caregivers.[9]

On the future of caregiving in Japan

While the EPA administered migration system is unattractive to the migrants and their employers alike, it is likely to be continued. Too valuable is their existence to Japan’s partner countries within the EPA treaties, many of which cannot offer other “export goods” but human resources.

Beyond the EPA system, an increasing number of foreign long-term residents of Japan has become engaged in the caregiving profession, overwhelmingly so in the home-helper sector. Sociologist Maria Ballescas, however, criticizes this career choice by pointing out that many of these foreign women came to work in Japan’s red-light districts in the 1980s, and oftentimes stayed on as spouses to Japanese husbands. When they now turn to caregiving as a profession, they do nothing but go back to the essence of their former professions in terms of caring for the bodily needs of their Japanese clients.[10]

While this point may be put overly bluntly, it is fair enough to critically assess the role of foreign health-caregivers in Japan. While in the long haul they may play a part in the liberation of Japanese women from reproductive work, their potentially rising numbers also free Japanese men from finally stepping up as equal partners to their spouses when it comes to sharing the burdens of reproductive work. In times, when Japanese Prime Minister Shinzō Abe keeps advertising “womenomics” (i.e. women-economics) as a strategy to increase female workforce participation, also in leading positions, it is high time to call upon the nation’s men to live up to their duties as well. This, however, would deem necessary a substantial reform of Japan’s gendered labor market along with deeply rooted gender norms.


[1] National Institute of Population and Social Security Research (2012): Population Statistics of Japan 2012

[2] Cabinet Office of Japan (2004): Kōreisha kaigo ni kansuru yoron chōsa. Tokyo: CAO.

[3] Vogt, Gabriele (2018): Population Aging and and International Health-Caregiver Migration to Japan. Cham: Springer.

[4] Tamiya, Nanako et al. (2011): Population Aging and Wellbeing: Lessons from Japan’s Long-term Care Insurance Policy. In: The Lancet 378: 1183–1192.

[5] Peng, Ito (2001): Women in the Middle: Welfare State Expansion and Devolution in Japan. In: Social Politics 2: 191–196.

[6] Japan Institute for Labour Policy and Training (2015): Labour Situation in Japan and its Analysis: Detailed Exposition 2014/2015. Tokyo: JILPT.

[7] Japan International Corporation of Welfare Services (2014): EPA ni motozuku gaikokujin kangoshi, kaigofukushishi ukeire panfuretto

[8] ibid.

[9] Vogt, Gabriele and Holdgrün, Phoebe (2012): Gender and Ethnicity in Japan’s Health-Care Labor Market. In: ASIEN. The German Journal on Contemporary Asia. 124: 69–94. 

[10] Ballescas, Maria (2009): Filipino Caregivers in Japan: The State, Agents, and Emerging Issues. In: Kyūshū Daigaku Ajia Sōgō Seisaku Sentā Kiyō 3:127–138.

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