Qualitative Research on access to health and medical services ofpeople with vulnerability under COVID-19 pandemic in Japan
Masaki Inaba1, Chie Matsumoto2, Naoko Tsuyama3, Kaori Hirouchi4
Africa Japan Forum

Abstract(1) Introduction
Globally, Japan has been recognized as a champion of Universal Health Coverage (UHC). However,with the impact of COVID-19, it faces a variety of difficulties in providing its people with universal
access to health and medical services, especially people in vulnerable situations.
Japan’s social model has shifted from a middle-income majority with lifetime employment for men
since the 1990s to one that exacerbates income disparity due to widespread casualization of theworkforce. Japan enjoyed rapid economic growth from the 1960s until the 1980s. This is when thegovernment developed a social security system using households as the main units as Japan was astrongly patriarchal society. Companies shared the costs of public medical insurance and public
pensions mainly for male employees as part of assumed lifetime employment, which guaranteed thestability of the system. The changes in social structure in the following decades have destabilized thissystem, but no drastic improvements were made. The transformation of the nation’s social model has,
therefore, disproportionately affected women and other marginalized communities.
The current health insurance scheme gives a false impression that it equally covers anyone wholives in Japan; however, it has encountered some systemic challenges. Our objective is to review thesituation of health and medical access of people with vulnerability and identify key obstacles of UHC.
(2) Methods
We conducted a series of interviews with the leaders of key vulnerable communities in the social
context of COVID-19 and HIV/AIDS, including migrants, elderly people, youth, urban poor, people withdisabilities, women and girls, sex workers, people using drugs, and men who have sex with men about
access to health and medical services. We also asked about their access to public medical insurance,social welfare programs and public assistance schemes based on Public Assistance Act (mainly
medical assistance), all of which ensure the people's access to health and medical services, as well as
public health and the Independence Support System for the Impoverished. We also interviewed social
workers and staff members at public health centers. After the interviews we had two consultation
meetings with the interviewees to analyze the key obstacles to universal health coverage in Japan. We
use pseudonyms in our report to protect the privacy of our interviewees.
Following the COVID-19 prevention measures, each interview, as well as two consultation meetings,
was conducted remotely using an online application. The interviews, which lasted between 60 and 90
minutes, were digitally recorded and transcribed into both Japanese and English.
(3) Results
1. From the interviews and discussions at the consultation meetings, we found that the greater
the vulnerability of an individual, the greater the time, cost, labor, and psychological burden
required for that person to expend to access health and medical care. This was mostly due tothe complicated and bureaucratic architecture of social welfare and public assistance programs.
The majority of those in the middle- to higher income bracket with stable employment can access1

Corresponding Author, Director, Global Health Program, Africa Japan Forum, ajf.globalhealth@gmail.com
Corresponding Author, Journalist, Editor, Media Cooperative Unfiltered, labor union organizer, chie.m.matsumoto@gmail.com
3
Co-Chair, Africa Japan Forum
4
Executive Director, Africa Japan Forum2

1

health services provided by public health insurance almost automatically. The insurance premiums
are also divided equally between the employers (company, etc.) and the workers. On the other
hand, the minority and the more vulnerable populations who are often low-income and on unstable
employment often experience impediments caused by heavier insurance premiums and complex
procedures of application, assessment and implementation to receive social welfare subsidies andother public assistance programs The community leaders also reported often encountering
authoritarian and paternalistic responses and causing the patients psychological burden whenaccessing medical services.
2. Many people in Japan don't have correct information on public health and medical insurance, social
welfare and public assistance programs because they have only limited opportunities to learn about
these systems both through public educational institutions and everyday life experiences.
3. Japan is no stranger to the “Shadow Pandemic,” reported in the April 2020 issue of UN Women on
gender-based violence. Experiences of discrimination and abuse often plague vulnerable
communities including women and sexual minorities with mental illness. However, low quality ofmental health care and prioritization of mental health in Japan lead to discrimination and prejudice,which hamper people's willingness to access health services. Furthermore, Japanese psychiatrictreatment still continues to isolate patients from society through long-term hospitalization. This
leaves Japan behind the international trend of treating patients while allowing them to participate insociety.
(4) Conclusion
Japan's ageing and low birthrate will continue to contribute to population decline. With about 30 percent
of its population aged 65 and older and the low birthrate recorded for five consecutive years at 1.34, thevulnerable population would inevitably increase.
Whereas public mechanisms to ensure health and medical access for the people have been
generally working, especially for the majority, the vulnerable communities have been struggling for easy
access to health services due to various obstacles, including the complicated nature of the systems andthe lack of correct information. COVID-19 has degraded the system by imposing a heavier burden.
The interviews with leaders of vulnerable communities revealed that the Japanese system suffersfrom economic, systemic, social and cultural challenges. In a way, this research and analysis is timely
because it helps address flaws in the systems, which were exposed during this pandemic. Although
Japan’s systems have long been believed to be universal in terms of coverage, they have left many
vulnerable communities behind.
Strained by an ageing population and a low birthrate, Japan’s social insurance systems have faceddifficulties with sustainability and have been facing the threat of privatization. As access to medical
services and social security should be considered basic human rights, these schemes should remain in
the public domain. “Community-based comprehensive care," which is promoted as a solution to aging
and low birthrate, introduces the idea of primary health care that involves citizens of the community to
exercise their rights to access the necessary medical and welfare services. We can positively evaluate
this new idea; however, the government should be held accountable for citizens' access to medical andwelfare services.
The Japanese systems still have potential, if implemented properly and to their full capacity, toprovide completely universal coverage to its people if the redesign includes transparency and dialogue
with marginalized communities, rather than resorting to privatization. At the same time, the government
needs to allocate resources to educate and inform the public, especially its vulnerable communities,
about the systems such as public medical insurance, social welfare and public assistance programs.
Education and information dissemination can effectively help the vulnerable communities develop
literacy as they attempt to navigate the services offered to find what they need in a timely manner.
It is time to review the system, identify the key obstacles for consumers and find the pathway touniversal health coverage that leaves no one, especially vulnerable people, behind.

21. Overview: Loopholes of Japan’s UHC: The more vulnerable, the harder the access(1) Objective
Universal Health Coverage (UHC) has become an important pillar of international health policy sincethe 2010s. The World Health Organization (WHO) defines UHC as "a situation in which all people haveaccess to the quality insurance and medical services they need without facing financial hardships.
Japan is internationally recognized as having achieved a high level of UHC. However, the marginalized,
their support groups, and other concerned parties have reported that people in economically,
institutionally, socially and culturally vulnerable situations in Japan are experiencing many difficulties
when accessing health and medical care. In addition, the coronavirus (COVID-19) pandemic, whichbegan in 2020, has resulted in limited resources in testing, treatment and prevention. It also affected
those who were not vulnerable prior to the pandemic because demand has exceeded supply and UHC
became unfeasible. Access to measures to treat non-communicable diseases and other infectious
diseases was also hampered as the COVID-19 response impeded other health services.
This research was conducted in response to the State of UHC Commitment called for by UHC2030, aninternational organization dedicated to the realization of UHC, and "Civil Society Consultation based oneach country" called for by the Civil Society Engagement Mechanism (CSEM), a network of civil society
participants in UHC2030. It is an attempt to collect and analyze more comprehensive information fromnot only the government but from civil society and other stakeholders on the progress of UHC in eachcountry and on the implementation of the ambitious Political Declaration adopted at the UN High-Level
Meeting on UHC in September 2019. The countries subject for the Voluntary National Review, which ispart of the UN's SDGs Progress Review in 2021, were selected for this research. In collaboration with
the NCD Alliance, PHM and UNAIDS, CSEM then invited a "Civil Society Consultation" in each country.
In the end, civil societies in 20 countries in regions such as Asia and the Pacific, Sub-Saharan Africa,
the Middle East and North Africa, North and Latin America, Eastern Europe and Central Asia conducted
the consultation. This research was conducted in Japan as part of this initiative.

(2) Methods
We interviewed 19 experts in public health-care systems and public health administrations, and leadersand members of various demographics and social groups (hereafter "communities") in institutionally,socially, economically and culturally vulnerable situations about the challenges of access to health andmedical care under COVID-19 in Japan. All interviews were conducted online for 60-90 minutes due to
COVID-19. Two consultation meetings followed, with 17 of the interviewees, to clarify the current statusof health care access especially among vulnerable communities. During the two-hour consultation
meetings, we explained the main objective and the results of the interviews in a plenary session,
followed by discussions in small groups to provide a more multifaceted analysis of the findings. In orderto protect the privacy of the collaborators, their names and names of organizations are kept anonymousin this report. They are identified in the descriptions of their activities.

(3) Japan’s Public Medical Security System
Japan is internationally regarded as a country that has achieved a high level of UHC. Contributing tothis are public medical insurance (health insurance and national health insurance), supplementarysocial welfare systems and public assistance among Japan's social security systems. The public
assistance includes free medical care that is provided to those in need, based on the Public Assistance
Act that guarantees "the minimum standards of wholesome and cultured living" (Article 25 of theConstitution). On the other hand, medical costs of tuberculosis (TB) have been borne at public expense
since the days of the former Tuberculosis Prevention Law, while those for designated infectious
diseases such as COVID-19 are borne at public expense under the Infectious Disease Prevention and3Medical Care Law. In the social welfare system, the "medical care for independent living for thedisabled,” which is a public system to reduce medical costs for the physically and mentally disabled,
helps reduce the biggest barrier to accessing medical care; the out-of-pocket medical expenses. The
subsidies for medical expenses for the disabled provided by local governments (prefectures) also help
with the financial burden as they are funded by tax revenue. There is also the "free, low-cost medical
service," stipulated in the Social Welfare Act and the Corporate Tax Law, which designates medical
institutions to extensively provide medical care to the needy by reducing the amount of co-payment.
Public assistance based on the Public Assistance Act, especially medical assistance, is the mostcomprehensive guarantee of medical care for the needy. Thanks to this system, a certain level ofaccess to medical care is guaranteed even to the poorest in Japan: it is the foundation of UHC.
Those with economic hardships and medical needs must first rebuild their lives in order to accessmedical care in a sustainable manner. The government established housing subsidies and reviewed
the loans for the low-income residents after the number of impoverished people increased as a result of
the 2008 world recession. In 2013, the law for the independent support for the impoverished wasenacted to combine various systems and provide support according to the circumstances of each
person in need. The local governments set up sections and began implementing the support system.

(4) Vulnerable communities
This research looks at the challenges of these systems faced by vulnerable communities in accessing
health and medical care. From the high economic growth during the 1960s and 1970s until the early
1990s, Japanese society had a large middle-class that enjoyed relatively little economic disparity. This
middle class was created based on the long-term stable (often lifetime) employment adopted bycorporations that flourished during this period of high economic growth. Also contributing to this was
the highly homogeneous society that Japan has been building since the war ended. This homogeneity
was founded upon a nationality and family register system based on lineage, patriarchy, heterosexism,productivity and loyalty to corporations. As a result, the people and communities outside of thishomogenous system were not, even during this period, effectively treated as equal.
Since the 1980s and the stagnation of the Japanese economy, its aging population, the declining
birthrate and installment of the Labor Dispatch Act, which encouraged labor mobility, long-term stable
employment could no longer be sustained. All of these factors converged in a perfect storm of fallingincome, increased spending needs, and corporate lobby pressures that contributed to the breakdown of
the middle class and the increase of vulnerable communities. This trend is expected to continue in the
future.
Mental illness and mental instability are common among a wide range of marginalized people. This has
to do with the inherently unstable lifestyles associated with various hardships, such as childhood abuse,and the experiences of physical and psychological violence. In post-war Japan, mental health andmedical care for mental illness were perceived mainly as a public-safety issue, which delayed thequality improvement of medical care. In order for people to access health and medical care and work torecover physical and mental health, it is necessary for them to discover their own health and medical
issues, find and reach medical institutions that can help solve the problems, accept the care, andundergo at least a certain period of treatment based on trust. This process is achievable only by thejoint efforts of the service recipients and the service providers in welfare, health and medical institutions.
Vulnerable populations meet inevitable barriers when faced with challenges of medical institutions, theiraccessibility, and their costs. Availability of outreach programs for health and medical services andquality of care are both factors that discourage people from accessing medical and health services.
Also impeding them are the obvious or subconscious discrimination and micro-aggressions that canoccur when receiving care or a lack of effort to build trust. This research examines the impediments tohealth care by focusing on the existence of institutional, social and cultural barriers, in addition toeconomic barriers, such as medical costs.
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(5) Overall Issuesa) The greater the vulnerability, the greater the cost, time spent, effort, and patience
The most significant challenge found in this research is that the greater the vulnerability of an individual,
the greater the total cost in terms of funding, time, effort, and patience spent for their recovery throughhealth care services. Therefore, vulnerable people are more likely to abandon access to health care. In
fact, for those in long-term stable employment, still the majority in contemporary Japan, access tohealth care is almost automatically achieved through public health insurance. The premiums areautomatically deducted from their salaries, and the cost is usually registered unnoticed. People can
automatically access medical care by presenting their insurance card at the hospital and paying up to
30% of the medical costs on their own. If the cost is larger than a certain amount, the reduction system
for high medical costs sets the cap on the co-payment, and the patients need not pay more than thelimit. However, as soon as people become marginalized, access to health and medical care is blocked
and the cost rises sharply. One of the main reasons for this is that the social welfare system and public
assistance funded by tax revenues are not flexible enough for the users because the systems prioritize
the convenience of the administrators. The system is structured in such a way that it causes a large
mental and emotional burden for the applicants and is not convenient for the service users. The
information about how to apply for these services is also not easily available.

b) Lack of education or information about the social security system
In Japan, there is almost no opportunity to obtain comprehensive information about the social security
system, including public medical insurance, social welfare, and public assistance. Social security istaught in civics classes in junior and senior high schools, but the Education Ministry’s teachingguidelines rather prioritize the issue of "improving and stabilizing social security in an aging society withlow birthrates" rather than the systems’ main objectives, mechanisms, and ways to apply for andimplement them. Opportunities to learn and raise awareness of these issues are scarce. As a result,citizens lack a basic understanding of their country's social security and social welfare systems.
Because few people have a prior knowledge of how to properly utilize these systems including social
welfare and public assistance, they essentially have to gather information on their own and negotiatewith local government offices before applying for them.
These systems were established with an aim to guarantee the basic human right to "healthy andculturally affluent, minimum standards of living." However, the government has failed to administer
these systems in accordance with this aim. In particular, public offices have long administered thesesystems with the goal of reducing the number of recipients and cutting costs as much as possible as apriority, rather than providing necessary support to applicants. The information about public assistancecirculating on social network services (SNS) and other media is biased, emphasizing the difficulty toaccess and encouraging people in need to give up applying. The true objective of the public assistancesystems is not widely shared, leading to the spread of misinformation. In fact, information about public
assistance available on SNS contains false and fake information, which is one reason people aresteered away from applying.
While Japan's public medical care system, which makes UHC possible, is highly regarded by theinternational community, the lack of effort to educate and inform citizens about the system only
undermines the stability of the system. We need to raise awareness among policymakers.

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2. Discussions: Barriers to health and medical services in Japan(1) Economic barriersa) Low-Waged Unstable Employment and Access to Health and Medical Services
In Japan, over the past 30 years, the number of full-time workers in long-term, stable employment hascontinuously decreased due to deregulation and other factors. On the other hand, the number of
informal workers has increased from 15.3% in 1984 to 38.4% in 2020. The informal employment ratevaries greatly by gender and age, with women making up 56.0% in 2019, compared to 22.8% for men.
While informal employment among men is higher both for youth (under 24 years old: 21.6% in 2019)
and the elderly (65 and above: 73.3% in 2019), the number of women working in informal jobs starts
increasing at the age 35, reaching 51.6% between the ages 35-44; 57.7% between ages 45-54, and82.0% for 65 and above. For people aged 65 and older, the percentage is 82.0%. There is also a gap inwages between regular and non-regular workers. According to 2019 statistics, the average monthly
wage of regular workers, including those in the public sector, is 325,000 yen. That of non-regular
workers is 212,000 yen (65.2%), which amounts to a difference of nearly 100,000 yen. Gender alsopresents a gap, with the average monthly wages of regular male employees at 351,000 yen, compared
to 269,000 yen for regular female employees (76% of men’s). In terms of irregular employment, men
earn 235,000 yen on average, compared to 189,000 yen for women (80.4%).
For people with precarious employment and low wages, the burden of premiums for public healthinsurance and pensions weighs heavy. The premiums are set at a fixed rate of 14-18% of wages, whichis regressive for lower income groups and constricts their disposable income. They must pay 30% of
the medical expenses on top of the premium. In the case of the National Health Insurance (Kokumin
Kenko Hoken) and the National Pension Plan, in which self-employed and small business employees
are enrolled, they may have to pay the full amount of medical expenses by returning their insurance
cards or replacing them with "short-term insurance cards” if they fail to fulfill their premium payments.
“What people let go as soon as they become impoverished is their health insurance. And thisbecomes a problem when they get sick. Women working at street corners (prostituting) are mostoften not paying into the National Health Insurance. Many have not transferred their residency, andthat adds extra burden when trying to join back.” (a journalist reporting on labor and women inpoverty)“If you keep failing to pay insurance, you cannot go to see doctors and must buy medicine over thecounter. It costs more without the insurance. (a member of support group for domestic abuse
survivors)b) Gender disparity and failing systems, medical services outside of insurance coverage
Unstable employment and declining wages have had a particularly serious impact on women. As seen
above, the number of informally employed women is more than double that of men. Furthermore, theirwage is only 80% of that for men, which has a significant impact on access to health care, especially forsingle women and single mothers. Since the National Health Insurance program is administered on ahousehold basis, children in poor households are not able to receive medical care due to their parents’failure to pay premiums. Women and children are also hesitant to access health care if they haveabusive men who are heads of their household.
Many medical services in Japan are covered by public medical insurance; however, a number of
preventive and testing services are not. Another major problem for women is the cost of abortion is notcovered by public health insurance, except when the pregnancy is caused by sexual assault. Even then,it is only covered when reports are filed and approved. Filing a report inflicts a huge mental burden and6anguish on the woman, which discourages women to report in the first place. This has resulted in
marginalized women abandoning newborns because they could not get an abortion when they needed
one. Mental health problems (mental illness) are common among vulnerable populations, but sincemost psychiatric counseling is not covered by insurance, many people shy away from getting
counseling.
“When a woman is having a baby, she can make do as long as she has a residence. There is no
public assistance for getting an abortion for someone without a stable residence. If she receives
welfare assistance, the funds will be provided as long as it is an unwanted pregnancy or one causedby sexual assault. However, unless a woman is a sexual violence survivor without social welfare
assistance, she must pay for it on her own. This results in murdering newborns. Providing publicfunds for abortion would help reduce child abuse.” (a member of support group for domestic abuse
survivors)“If parents have held off on paying health insurance and their children wanted to go see a doctor,
they would have to initially pay the full cost and get reimbursed. Once this happens, they would nevergo back to a doctor.” (a case worker for youths)“It’s best if health insurance pays for counseling. Mental illness cannot be treated only with medicine.
Many young people need counseling and other medical treatment that are not covered by insurance.
(a member of support group for young women)c) Impact of COVID-19
Japan’s impoverished are strongly affected by the social and economic consequences of COVID-19.
Even after the pandemic, the government has not been able to increase testing, quarantine andtreatment capacities. Testing is sporadic, unsystematic and difficult to understand how to access.
People are not eligible for free, government-provided testing and must pay for the cost unless theyshow symptoms such as high fever or they are considered as having close contact with COVID positive
patients. If they get tested at a local private clinic, the cost can be 20,000 to 30,000 yen. Medical care
for COVID-19 also becomes free if the result turns out positive. Otherwise, they must pay the fee.
Meanwhile, the public health centers are constricted due to the COVID-19-related duties, and they havesuspended free HIV anonymous tests since last April. This discourages people from getting tested for
HIV and leads to an increase of HIV patients who learn about the infection at the onset of AIDS. Duelargely to the increase of COVID-19-related medical needs, other medical needs were impacted,
thereby impeding access to health and medical care, not only for HIV but also for non-communicablediseases (NCDs).
“When people are hospitalized at mental institutions, they are asked to get a PCR test. If they cannot
receive a government’s test, they must pay about 25,000 yen for it. Unless they pay, they cannot be
hospitalized.” (a member of support group for young women)“The Japanese government does not place importance on public health policies. That is why the
number of public health centers was halved. When the pandemic spread, the government could only
think about Corona and nothing else. With so little capacity, they ended up abandoning HIV tests,
and no one is accounted for. (a member of community center for HIV awareness)(2) Systemic Barriers 1：Nationalities and patriarchy
For people living in Japan with various vulnerabilities, systemic barriers are one of the major
impediments to accessing health and medical care, coupled with economic barriers.

a) Foreign residents of Japan

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Among the foreign residents in this country, about 83,000 people live without any visa, as of the
beginning of 2021. Out of those, tens of thousands of people have a "Designated Activities" visa (1-3months) or "Short-term" visa (90 days or less). They are systematically excluded from public medical
insurance, social welfare, and public assistance and are only covered for some infectious diseases
such as TB by public subsidies for medical expenses. “Free and low-cost medical services” for the
impoverished have allowed a certain level of access to foreigners, but the number of hospitals thatprovide such services is limited. makes the access even more difficult. Due to the government's policy
to promote "medical tourism," many major public hospitals have raised the fees two to three times foruninsured foreigners compared to those for the Japanese, treating them as wealthy "medical tourism"
customers. As a result, uninsured patients with serious health conditions flooded free and low-cost
medical services, causing the cost of treating uninsured people to exceed the budget allocated for freeand low-cost treatment at many hospitals. Moreover, due to the deterioration of hospital management
after the pandemic, numerous hospitals have excluded foreigners from the service, making it extremely
difficult for foreigners living in Japan to receive care through free and low-cost medical services.
The Japanese government has adopted a "no exception" policy in which all undocumented foreigners
are detained, regardless of grounds. Although some are released on "parole" due to prolonged
detention or poor health, they are prohibited from working. They must also report any outings acrossprefectural borders. Many people suffer from physical and mental illnesses due to extended
incarceration with no fixed term, but access to medical care inside detention facilities is inadequate.
Accessing medical care for parolees is also extremely difficult because they live with limited support
from friends and civil society and are excluded from almost all public medical security systems.
The nearly 400,000 technical interns currently working in Japan under the technical training program forforeigners face labor issues such as low wages and restrictions on transferring jobs. Under the guise of"technical training," they also have problems accessing healthcare. Normally, pregnancy, TB or any
other diseases should not affect the legal status of "technical trainees,” but prior to their departure, theirsupervising organizations in their home countries or employers in Japan tell them that they must
discontinue the program if they become pregnant or that they will be dismissed if they contract TB.
They are not told about their rights or how to exercise them. So they cannot consult anyone or accessmedical care when they become pregnant, which, in many cases, has led to unsafe abortions. . There
have also been cases of people being sent home without treatment for contracting TB, even though
they could have received treatment in Japan at public expense. The Japanese government hasrepeatedly expressed that it would not adopt an "immigration policy" for such technical trainees and has
not made any legal amendments such as expanding the program or establishing the "designated skills"
visa. There is little support for the trainees and other foreigners to stay in Japan. As a result, thetrainees are less informed about social security and often lack support from local communities. They
are often placed at a disadvantage compared to other foreigners when faced with health and medical
problems such as pregnancy and illnesses. This is the result of systemic and policy inadequacies.
“Those without visas or only with permits for less than three months are not eligible for medical
insurance and social welfare or any other support system. Nor are they eligible to work. Under suchcircumstances, they don’t even have the least they need to lead a basic life and, therefore, areendangered. They are faced with the most hardships.” (a member of advocacy group for foreign
residents)“The people who have been detained suffer from mental illnesses, namely depression. Their mental
health deteriorates as they are only given drugs without ever receiving adequate medical treatment
inside the detention centers. Even when they are out on parole, they can hardly ever access doctors
as they are not able to afford the high medical cost without insurance. (a member of advocacy groupfor foreign residents)“’Medical tourism’ continued to be promoted where resident foreigners were not getting sufficient
access to medical treatment. Medical institutions began to serve richer tourists from outside Japan8

than impoverished foreigners living in Japan. As a result, the poor are flooding the hospitals that offer“free and low-cost medical services,” straining the hospitals’ finances and causing more hospitals to
discontinue such services. A vicious cycle is perpetuating.” (a doctor who treats foreigners)“The technical trainee program was designed on the principle that the government would not adopt
an immigration policy, so all the trainees must return home at the end of the training. Foreign
residents rely on communities of their own people when faced with problems. However, many
trainees come from countries that do not have communities in Japan. They are vulnerable in that theyfall out of any systems or communities. Many are dismissed or forced to go home when they were
infected with TB or got pregnant. The government should prevent unfair treatment by establishing asocial system to accommodate multicultural communities before it accepts them. Because there is nosuch system, it overlooks policies that allow exploitation. (a doctor who treats foreigners)b) Public medical security system built on a household basis
Japan's social security system has basically been administered on a household basis. In the case of a
nuclear family -- a husband, wife and children -- which is common in Japanese households, the head of
the household is often the husband. There are cases, especially in health insurance, where women andchildren delay access to health and medical care for fear that the man or other members of the family
will find out about it. This poses a systemic barrier to access, particularly in cases of pregnancy andmental illness and other issues related to sexual reproductive health/rights (SRHR).
On the other hand, with regard to public assistance based on the Public Assistance Act, the inquirysystem (see next page) to verify whether any family member can provide support to the applicant, haspushed many people away from applying for the subsidies. The inquiry system was introduced in thename of reducing the users of public assistance to ease public expenditures and eliminating anyone“illegally receiving the subsidies.” This has resulted in delays in applying for medical assistance anddelays in access to healthcare.
In addition to the public medical security system in times of peace, most of the financial aids andbenefits related to COVID-19 and other disasters are distributed on a household basis in principle. So
the emergency allowance of 100,000 yen, which was provided by the government under the pandemic
and supposed to reach each person, went to each household instead. This is why many survivors of
spousal violence could not receive the money: The money was deposited in the husbands’ accounts.
“Many of our clients leave their health problems untreated due to ‘parental barriers.’ It means thatthey don’t want to tell their parents. They’d rather not go to the hospitals if their parents could learn
about it through health insurance. Survivors of parental abuse in high school, for instance, experiencethe ‘parental barriers’ like this. Many of them who have witnessed the way their parents lived or were
disturbed by the relationships between their mothers and the mothers’ partners often endure healthproblems because they don’t want to tell their parents.” (a care worker supporting youths)“The problems with ‘parental barriers’ occur even outside of impoverished households. The families
who (have sufficient income to) own homes face more serious issues, though a very few reach out for
help. Children of such families are often convinced this is only happening to them. Or the people who
consult youths respond in a condescending tone because they are not used to responding to suchcases. This type of attitude hinders children from speaking up. And that delays a proper response as
it is difficult to identify the problem.” (a care worker supporting youths)“The children are supposed to make their own decisions, but the members of medical institutions
sometimes even demand to speak with the parents. Medical institutions tend to be defensive in thisway. (a member of group supporting young women)

9(3) Systemic barriers 2：Challenges in the social security systema) Design and Implementation of Social Welfare and Public Assistance
People who cannot afford medical expenses but are not covered by public health insurance (healthinsurance, national health insurance) need to sign up for social welfare and public assistance(especially medical assistance) to access medical care. Needless to say, people who try to apply forthese programs have some vulnerability. However, these systems are not designed for easy access forsuch people. The problems lie in the "household-based" application structure noted in the previous
section. Under the deteriorating finances of the central and local governments, the state has been
particularly reluctant to provide public assistance for various reasons, rather than f proactively providing
benefits to those who need it. As a result, the barriers became larger , and the greater the vulnerability,
the harder it became to apply for and use the system. This has led to situations where people end up
accessing medical care only after their symptoms worsen.
“People who have stable employment most often understand how the system works. However, those
who do not quite understand it end up dealing with everything on their own. The more vulnerable they
are, the more laborious and time consuming it is to them as they have to put together many forms of
documents to apply for the assistance.” (a member of group supporting the impoverished)i.

Public assistance

Public assistance based on the Public Assistance Act is a comprehensive system that guarantees "theminimum standards of wholesome and cultured living," including the minimum living expenses(livelihood assistance), rent (housing assistance) and medical care (medical assistance). Medical
assistance, which provides welfare users with access to free medical services, is of vital importance inensuring medical care for the low-income and the impoverished due to the various vulnerabilities they
possess, and in realizing UHC in Japan as a service that "leaves no one behind.” However, the central
and local governments, which bear the cost of public assistance, have tried to minimize their financial
burden by conducting "shoreline operations" to shove applications away at city hall. They have also
launched campaigns on “illegal receiving” of subsidies to impose prejudice against welfare users. The
2014 amendment to the Public Assistance Act enforced the "inquiry system," where the welfare officechecks whether the applicant's relatives have the ability to support them. Because of this, many
marginalized people avoid applying for public assistance. In Japan, only between 9% and 20% of lowincome households who are eligible for public assistance actually receive it.
Even at local welfare offices, hiring of workers that specialize in welfare has slowed down, while local
governments are increasingly placing non-regular and temporary workers in charge of employment
support. Non-regular employees, while suffering from low wages and unstable employment themselves,
are working without any expertise in welfare. As the number of staff is reduced, the amount ofresponsibility per person rises, meaning each person must take care of many users alone and isoverworked as a result. These people then tend to fall into confrontational relationships with welfare
users.
“Even prefectural capitals don’t hire people with expertise in welfare. Hence, many work without ahigh level of awareness or sense of mission. Moreover, full-time staffers in the offices are replacedwith precarious workers. Many of these informal workers end up directing their anger toward welfare
users -- the more vulnerable of the society -- because the yare frustrated about their unstable working
conditions. The under-represented are divided, and it causes the poor to shy away from applying for
welfare assistance. (a care worker supporting the impoverished)“When welfare assistance users go see a doctor, they show their cards and tell the receptionists they
are using public assistance. The receptionists then call the welfare office to confirm before they canaccess medical treatment. Many say this process is humiliating so they don’t want to go to the10hospitals. There are even some medical institutions where receptionists purposely identify welfare
users in a loud voice. That doesn’t make them feel like they ‘want to go’ back.” (a member of groupsupporting domestic abuse survivors)ii.

Independence Support System for the ImpoverishedThe number of poor people rose since the 2008 world recession. In 2015, the government launched theIndependence Support System for the Impoverished' with the aim to help people rebuild their lives bycombining and utilizing multiple systems that met their needs before receiving public assistance. A
consultation counter was set up in each local government to provide necessary public services alongwith services offered by NPOs, etc. Especially for those who are unable to seek medical care, thesystem can refer them to free and low-cost medical services. The system helps to rebuild lives byoffering special loans for welfare funds and housing security benefits to pay for rent. This examines theavailability of systems and the support people need with various vulnerabilities in order for them torebuild their lives. The quality of this consultation services varies greatly depending on municipalities.
One municipality, for example, is able to provide companionship and support to young people who areexperiencing hardship, while another municipality can only offer a counter for applications for housing
benefits.
“Japan’s social welfare program is not accessible unless someone applies for it. One must file aproper application after finding the program (out of all the other public services). The Independence
Support System for the Impoverished should be a service where counselors figure out the problems
impoverished citizens are faced with and set the right directions. It should be a partnership-type
support. However, there are some municipalities that resort to simply processing papers as the
support was reduced to formality.” (a case worker in support of the impoverished)“It was good to see the counters at local governments that deal with the Independence Support
System, but there are still very few options available for workers in social welfare. That’s why people
in need of help ended up relying on the loan for welfare funds. That generates more problems. There
are also problems that arise when the local governments outsource welfare consultation to theprivate sector. Social welfare has become a market for these private sector businesses as local
governments set bids too low.” (a member of support group for the impoverished)b) Public hygiene, medical system and Impact of COVID-19
i.

Weakening public hygiene and medicine for infectious diseases

When COVID-19 initially spread in the first half of 2020, Japan faced a problem due to a delay inexpanding testing, quarantine, and medical response. One of the main reasons for this is that the publichealth system administered by public health centers has suffered downsizing and restructuring since
the late 1990s. Other reason is that the number of beds for infectious diseases was massively cut
during the same period. The Community Health Act, which was revised from the Public Health Center
Act in 1994, led to the division of public health centers into those established by prefectures andgovernment designated cities with a population of more than 500,000 and those established by othersmaller municipalities. As a result, the number of public health centers was halved to 469 in 2020, downfrom 852 in 1992. The number of public health nurses and other staff is limited due to that. However,their responsibilities have broadened and diversified, and executing duties has been difficult evenduring ordinary times.
The number of beds for infectious diseases, which exceeded 10,000 nationwide in the early 1990s,
plunged to around 3,000 at the end of the decade, and further dropped to 1,800 in the 2000 s. As aresult, hospitals were unable to accept COVID-19 patients, which increased by the day. This disturbed
the cooperative relationship between public health centers and medical institutions as the centers were
not able to make referrals to the hospitals. There was no way to secure quarantine facilities. Depending11

on the region and timing, many COVID-19 patients were forced to stay at home.
“The government continued cutting the workforce at public health centers. It was not just public healthnurses but workers in hygienic and social welfare were reduced. Even in ordinary times, it’s beendifficult to do our tasks. Emergency situations with infectious diseases and natural disasters are
increasing. We need more workers or we can’t respond to these emergencies.” (a worker in an
organization for public hygiene)“Public health centers have had such a hard time dealing with hospitals under COVID-19. There arean unexpectedly large number of hospitals that refuse to treat Corona patients. Originally, hospitals
designated to treat infectious diseases were to accept Corona patients: They don’t want to spend
extra time and work preparing to treat these patients. (a worker in an organization for pulic hygiene)“Public health centers have been targeted for restructuring and downsizing, which put more work oneach person. The pandemic spread as public health was experiencing cutbacks. More outsourcing to
the private sector and imposed efficiencies has pushed many talented public health nurses to resign.
Mishandling of policies ended up causing damage to this system, but no one is accountable.” (amember of HIV prevention and awareness center in support of HIV patients)

ii.

Impact of COVID-19 on response to HIV

The vulnerable people are largely impacted in terms of meeting health and medical needs as testing,quarantine, and medical care are strained. HIV testing is one such need that has been disrupted due topublic health centers being overwhelmed. In Tokyo and many other areas where COVID-19 infections
have spread, HIV testing has been suspended since April 2020 as the public health centers wereinundated with contact tracing and other Corona-related work. As a result, the number of HIV tests at
public health centers nationwide has been halved to 68,990 in 2020 from 142,260 in 2019. Even inTokyo, the number of HIV tests plummeted to 17,370 from 32,016. In 2019, 26.4 percent of new HIV
infections were detected by the onset of AIDS, but in 2020 the figure rose to 33.0 percent.
“The HIV testing is conducted by the same department that responds to Corona at public healthcenters. Because available resources are limited, anonymous testing for HIV was suspended. And it
was suspended in all of the 23 wards in Tokyo.(a member of community center for HIV awareness)“It has become more difficult to get tested for Corona, which led to less testing. That’s why the
number of new HIV infections plunged. We can expect that the number of people who learn about
HIV infections through opportunistic infections in the future, in other words, through the onset of AIDS,
will increase. This is worrisome. In Kyushu or Tohoku regions, to begin with, half of the infected learn
about it at the onset of AIDS. We should all have the right to get tested for HIV even during the
pandemic.” (a member of HIV prevention and awareness center in support of HIV patients)
iii.

Disabled and Elderly Care and COVID-19

Elderly and disabled people also face difficulties. Due to the strained medical services, some elderly
COVID patients are forced to receive home care depending on the region and timing, despite the factthat they are at a greater risk of getting severely ill and dying from COVID-19. In some cases, elderly
people with dementia or disabilities are refused services at hospitals, but the support system for elderly
patient home care with COVID-19 is inadequate. In addition, during the pandemic, day-care and shortstay facilities that provide elderly with support for their daily lives are closed, and therefore, they could
not receive necessary care. Many elderly people cannot participate in rehabilitation exercises, resulting
in noticeable deterioration of their physical and mental functions. Prolonged care at home without
proper support inevitably leads to an increase in elderly abuse by family members. The government istrying to establish a "community-based comprehensive care system" based on the autonomy andinitiative of local communities in response to the increasing demand for care amidst declining birthrate12and an aging population. At the same time, however, the elderly’s rights to diverse and high-quality
medical and welfare services that meet their demands must be guaranteed by the government, and thismust not be overlooked.
People with severe physical disabilities have been able to live independently by obtaining face-to-faceassistance. In terms of avoiding the risk of COVID-19 infection, care-providers are trying to reduce
exposure by shortening the service or by not sending care-givers altogether. Disabled people areforced to endure a lack of support under this circumstance. Mentally disabled and intellectuallychallenged people have suffered from prolonged hospitalization or forcible institutionalization at mental
hospitals. It posed a serious issue as they were poorly treated. With the spread of the Delta variant, theoutbreak has become more serious. The closed nature of these mental hospitals interferes with full
disclosure of the situation inside.
“The impact of the coronavirus is big. There are many cases where hospitals refuse services topeople with dementia or disabilities. Families are experiencing heavier burdens due to insufficient
support for medical services at home or by home visit. Some elderly have no place to go as day-care
centers and short-stay facilities are closed. Their physical ability deteriorates because they cannot
work on rehabilitation exercises. Some have to put up with urine all over the house, or others sufferfrom not being able to come down the staircase. And these situations put a lot of stress on family
members and cause elderly abuse. (a member of elderly support and advocacy group)“People with mental illnesses face long-term hospitalization. Mentally disabled people also faceinstitutionalization. Even if they wish to live independently in the community, they were forced to livein the institution and became part of virus clusters. . If clusters are confirmed in an institution, people
are often refused access to medical services for infectious diseases and faced with the worst-casescenario, which exacerbates their condition and leads to death. Meanwhile, we should emphasizethat complete prevention measures would make it more difficult for clusters to occur, although there
is still a risk of infection by people coming in and out. (a member of disabled group)(4) Social and cultural barriers：gender, mental illnesses, access to healthcarea) Violence and mental illnesses based on gender
Apart from informal employment, low wages and lack of public financial support for SRHR services,many women experience abuse and sexual assault at home, and that causes gender disparities inaccess to healthcare and medicine. Domestic abuse causes mental illnesses and deterioration, whichinterferes with women’s access to necessary healthcare services.
When applying for social welfare programs available to victims of domestic abuse, they are required todisclose to government officials details about their upbringing, marriage, and parenting to determine
their eligibility. This process creates painful experiences for the applicants. If applicants are informal
workers, it is difficult to consult with the workplace about their mental or physical ailments for fear thatthey will be terminated or shoulder a financial burden. Due to the pandemic, it has become difficult touse public assistance programs such as social welfare and to access medical services.
Even when they have access to hospitals, women are more likely than men to experience harassmentand other problems. Doctors or healthcare providers may be told to review lifestyle, or they may deny
explaining about a treatment. The accumulation of such micro-aggressions (see footnote 7 on page 4)
becomes a social and cultural barrier when accessing health and medical care.
“Before blaming informal jobs or low wages, we must recognize that so many women experience
violence. They may have experienced parental abuse since childhood, sexual or power harassment
at workplaces, and spousal abuse when they get married. Many women suffer from damaged mental
health due to multiple types of abuse in their lives. (a journalist who reports on women and poverty
13and labor)“Up until the pandemic, people felt at ease receiving welfare assistance and going to the doctors
even for small health concerns. But hospitals are no longer easy to access due to Corona. Many are
troubled as it costs more to buy over-the-counter drugs.” (a member of group supporting DV
survivors)“Doctors don’t explain things to patients, even about the smallest things. They may be trying not to
confuse their patients or worry them. But just a little explanation could help lift a psychological burden,
so we often wish they’d be more considerate. (a member of group supporting DV survivors)b) Sex workers and access to medical care
Sex workers often face difficulties in accessing medical care and welfare assistance due todiscrimination, prejudice, stereotypes, and a lack of public understanding. Some local governments
distribute handbooks on sex work, which were put together by organizations of sex workers, to medical
institutions and public health centers and educate the staff. However, only a few put them into practice.
For instance, testing for STDs (sexually transmitted diseases) is only offered during the hours sex
workers cannot visit the public health centers. Testing should be provided at the hours and places thatare easy to access for the people who are concerned. Another problem is the exclusion of the sex
industry from government subsidies and even the application process for these subsidies. For example,
employees and owners of sex-related businesses could not apply for various benefits for Coronainduced loss.
“Women who work in the sex industry need to regularly get tested for STDs. But they hesitate to go to
the doctor or public health centers for fear of discrimination. Some women intentionally choose
remote hospitals to remain anonymous.” (a member of support group for sex workers)“It is reported that the pandemic spread from the entertainment district in Osaka City, which triggered
prejudice against sex workers. At first, they were excluded from government subsidies. Eventually
sex workers gained eligibility. However, when they had to apply for compensation due to theirchildren's school closure, they had to write the name of the school as well as their place of work andjob description. They also needed signatures from the business owners, but they couldn’t get thateither. (a member of support group for sex workers)c) Drug use and access to medical care
Drug use in Japan is divided into the use of illegal drugs such as stimulants and the use of prescribed
medication and over-the-counter (OTC) drugs at a users’ discretion. Recently, the latter use of drugs
has become more widespread. This is because prescription drugs can be purchased at low prices
through public medical insurance and OTC drugs can be purchased online. The instructions for how totake them are available via SNS.
Illegal drug users are often hesitant to access medical and welfare institutions for fear of being reported.
Mental disorders caused by dependency on illegal drugs are regarded as crimes, which makes it
impossible for them to receive disability pensions. This, in turn, makes it difficult for them to talk about
their drug use at medical institutions, which leads to inappropriate treatment and induces mental andphysical health problems. On the other hand, people who use prescription drugs at their own discretion
access hospitals to secure them and exacerbate their dependency. In many cases, drug addiction is
induced by mental disorders, mental illnesses, or trauma because they have been placed in vulnerable
situations. Since psychological counseling is rarely covered by insurance, it becomes too expensive
and inaccessible for low-income groups. Harm Reduction measures have not been adopted in thegovernment's drug policy, making it difficult for drug users to access appropriate welfare, health andmedical services.
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“Information on SNS plays a major role in how more young people are taking prescribed medicine
and OTC drugs. The use is not illegal, and people are concerned about income disparity and theirnot-so-bright future. If they can even temporarily overcome this fear with these drugs, the information
on SNS is essential for them” (a member of advocacy and support group for drug uses)“Access to care and support for trauma and painful experiences is insufficient in that psychologicalcounseling is not covered by public health insurance and expensive. This leads to an increasing
number of people seeking and resorting to prescription and OTC drugs. We need to make it easier toaccess (medical and welfare services).” (a member of advocacy and support group for drug uses)d) Discrimination and Prejudice on Social Welfare Assistance
The public assistance program has been implemented for so many years in a way that its objective has
led to a widespread sense of discrimination against the service users and also led users to internalize
this sense of prejudice against the program itself. Even the impoverished who actually need the service,
as well as health and medical services, do not recognize their eligibility for public assistance. Even if
they did, they are reluctant to apply for it. In the face of the economic crisis caused by COVID-19, theMinistry of Health, Labor and Welfare (MHLW) finally declared that “public assistance is the people's
right" and that it would respect the wishes of the applicants not to contact their relatives to ask whether
they can offer financial support even in the case of the infamous "inquiry system” requirement. However,
it is difficult to change a system that has been tainted for decades and the prejudices that have beeningrained.
“There is a serious risk facing the people who need help as they have not learned how society works.
Even if they are dismissed from work, they have no knowledge of the law that stipulates requirementsof dismissal that employers must comply with. They fail to apply for unemployment insurance as theylack knowledge of how the system or other systems work. It is necessary to teach about the safety
net in junior and senior high schools.” (a care worker in support of the impoverished)“Many people believe that one cannot discontinue social welfare assistance or one cannot be eligible
if s/he owns a car or a house. Many refuse to sign up for assistance if they wanted to work even alittle bit.” (a care worker in support of the impoverished)“People became more sympathetic (toward the poor) under the pandemic, and media coverage of thepoverty issue increased. It was a turning point when the MHLW declared that welfare assistance is aright. (a member of group supporting the impoverished)

3. Conclusion：Proposal for UHC that leaves no one behind(1) Challenges
The issues we found in this research regarding access to health and medical care for vulnerable
populations are as follows:a) With public medical insurance, social welfare, and public assistance that guarantee access tohealth and medical care in Japan, there is a paradox: the greater the vulnerability, the greater theeffort, time and cost to reach these services.
b) In Japanese public educational institutions, they don’t teach about these services enough, nor issufficient information provided in general. The government does not provide information about
these services, their meaning, or their guarantee of human rights. Nor does it provide information
about how people can use these services when necessary. Thus, people have to figure out how toapply for them only when they are faced with a problem without prior knowledge.
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The vulnerable populations’ access to healthcare is interfered with by the two challenges stated above
and institutional failures, as well as the barriers they face such as the following:
a)

b)

c)

d)

Economic barriers：The middle class that enjoyed long-term, stable employment is shrinking,and the number of people in informal and precarious employment with low wages is increasing.
The impact of this has been particularly significant for women due to gender inequality anddiscrimination.
Systemic barriers ： First, undocumented foreigners, especially those without residence, aresystematically excluded from most of these public services programs. Since they are administeredon a "household basis," it is difficult for women and children, who tend to be dependents, to use it
proactively. For the social welfare and public assistance, it is difficult to apply, and with regard to
public assistance in particular, rather than encouraging those who are eligible to apply for the
benefits, the government has taken measures to discourage them from applying. As a result, theprogram itself tends to be stigmatized.
Social, cultural barriers：In a society with strong homogeneity, people with heterogeneity havebeen left vulnerable due to discrimination, prejudice, and social exclusion. Many women invulnerable situations have been exposed to violence, including gender-based violence and power
harassment. Vulnerable groups, including men, also suffer from mental illness and mental healthproblems due to such violence and uncertainty. Together, these factors lead to hesitation andabandonment of access to health and medical care.
Low investment in public health and infectious disease control：Public health and infectious
disease control has been systematically weakened, especially since the 21st century.
Underinvestment has caused insufficient capacity. This is where the pandemic occurred, resulting
in the failure of countermeasures to expand supply to meet the rapidly increasing demand fortesting, isolation and medical care.

(2) Future prospectives and proposals
In order to overcome the above challenges and achieve Universal Health Coverage (UHC) that includes
people in vulnerable situations, we make the following recommendations. The sustainability of Japan's
public health insurance system has become an issue due to the declining birthrate and aging
population, and the system is under pressure from privatization. However, access to health and medicalcare for vulnerable groups cannot be achieved through profit-oriented privatization. We believe that theway forward for true UHC can be found in reviewing and redesigning existing programs based on thefollowing recommendations:a) Economic barriers: For those who have lost their jobs and are impoverished, as well as those whowork irregular or unstable jobs, to access social welfare and public assistance, it is necessary to a)
make it easier for them to apply for these services, b) adopt appropriate services for the needy by
combining the Independent Support System for the Impoverished and other services, and c)proactively disseminate information through commercial facilities and media that they usuallyaccess. It is also important to consider options of adopting health insurance coverage and otherpublic medical coverage for SRHR services, including abortion and psychological counseling.
b) Systemic barriers: Ensure that undocumented foreigners without residence receive the medicalcare they need, including emergency medical care. Reduce language barriers to the greatest extent
possible when they access medical services by offering medical interpretation. Proactively distributeinformation through social media and other media that foreigners living in Japan are known to use,so that they and multinational residents can access information. Remove the negative effects of thehousehold-oriented social security system.
c) Social and cultural barriers: Conduct a review of systems to reduce institutional andsocial/cultural barriers for vulnerable populations. Being mindful of multicultural diversity and genderequality, the government should also improve these services by considering care for the aged andthe disabled; treatment and care of HIV and other infectious and non-communicable diseases and16mental illnesses; prevention of abuse and violence; reduction of their negative impact; andreduction of health hazards due to drug use through dialogues with civil society organizations thatprovide support to these communities.
⮚ In carrying out a) - c), actively engage in dialogue with relevant stakeholders, such as theconcerned organizations, support groups, and experienced NGOs/NPOs and institutions
implementing the systems in the field as well as potential users. This is necessary tounderstand what impedes access to health and medical care, and then reform the system.
⮚ In implementing the system, the central and local governments should systematicallyaccumulate experience and knowledge to improve the system. They should do this throughactive dialogue and collaboration with the organizations -- support groups and experienced
NGOs/NPOs and users -- that actually implement and receive the benefits of these systems in
the field.
d) Underinvestment in public health and measures against infectious diseases: Strengthen thecapacity to respond to future crises, such as infectious diseases and disasters, by investing morein public health and infectious disease control and also by improving the systems of public healthcenters and local health laboratories. Ensure the capacity in prevention, testing, quarantine andtreatment to meet rapidly growing demand, especially in response to pandemics.
e) Education and information dissemination about the system: Public systems for access tohealth and medical care (public medical insurance, social welfare and public assistance) should be
sufficiently taught in compulsory education courses (junior high schools) and senior high schools.
People need to learn in their early years that these systems are part of their basic human rights
and accessing the systems would be a legitimate exercise of rights. Also, more time should beallocated to effectively teach how to apply for and utilize these systems by incorporating
participatory learning methods. The government should publicize the systems and raise awarenessin a way that anyone can access information about them anywhere.
To practice the true meaning of "UHC that leaves no one behind" in Japan, it is essential to rebuild its
public insurance and medical security systems into one that the growing vulnerable communities canproperly use by incorporating the systemic reforms in the ways mentioned above.

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