GCOE Discussion Paper Series
Global COE Program

Human Behavior and Socioeconomic Dynamics
Discussion Paper No.240

Ensuring the Service Quality of Long-Term Care Provided
through Competitive Markets: The Experience of Care Workers’
Training in Japan

Yoshihiko Kadoya

February 2012GCOE Secretariat
Graduate School of Economics

OSAKA UNIVERSITY

1-7 Machikaneyama, Toyonaka, Osaka, 560-0043, JapanEnsuring the Service Quality of Long-Term Care Provided
through Competitive Markets: The Experience of Care Workers’
Training in Japan

Yoshihiko Kadoya*
Institute of Social and Economic Research, Osaka University
kadoya@iser.osaka-u.ac.jp
Feb 13, 2012

Abstract
Ensuring the service quality of long-term care provided through competitivemarkets is a major concern among the governments of OECD members. The public
officials in these nations recognise the importance of care workers’ training to address
this issue. However, most of them have hesitated to introduce comprehensive training
due to financial constraints. Analysing the experience of Japan, this paper reveals thatgovernments can ensure the financial sustainability of care workers’ training by aiming
at the best possible long-term care.
Key words: Long-Term Care, Quality Assurance, Care worker’s training, Japan, The United States* This paper has benefited from the discussion s and comments made by the participants of the 19th

IAGG World Congress, I particularly thank Dr. Lydia Li and Professor Yutaka Shimizu for their input
on care workers’ training in the United States and Japan.

1Introduction
Providing long-term care for older people (hereinafter, long-term care) throughcompetitive markets is inherently problematic (Lipsky, 1980; Nyman, 1994; Wiener etal, 2007; Donabedian, 1987; Hansmann, 1980). On one hand, governments of theOrganization for Economic Co-operation and Development (OECD) member nations
cannot afford to respond directly to today’s long-term care service needs. The
bureaucratic model that led to an adherence to prescribed procedures has experienced
rapid changes in society (Thomas, 2006). In this context, non-government sectors are
more flexible and specialized in the service field. Nonetheless, long-term care service
provision through competitive markets tends to leave the users vulnerable to the
profit-driven whims of private-sector providers. Unlike choosing a grocery store thatcan be easily replaced by others, the choice of necessary long-term care providers, suchas nursing homes, greatly influences people’s quality of life. In fact, a great number of
elderly people have suffered from unsatisfactory care for decades in the competitivemarket of care for the elderly (OECD, 2005).
A common cause of unsatisfactory care is the lack of care workers’ training.
The OECD (2005) surveyed twelve selected member nations’ public officers. All ofthem answered that “recruiting and training capable and skilful care workers” was apolicy concern (Table 1). Nonetheless, what makes this issue difficult to tackle is thatcomprehensive care worker training can be quite costly, as the necessary number of care
workers has been rapidly increasing in this aging era. The market nature of profit
maximisation prevents service providers (e.g., nursing homes) from making such
expenditures. Governments clearly need to intervene in this matter by partly/fully
covering such expense. Yet, governments may not be able to afford sustaining such anincreasing expense, particularly in current economic climates.
This paper, therefore, examines the provision of long-term care service throughcompetitive markets, considering care workers’ training as a critical factor in ensuring
quality of care. Two research questions guide the empirical research:
1. How does care workers’ training enhance the quality of aged care services?
2. How can governments finance the cost of care workers’ training?
To this end, the empirical study is divided into two parts. The first part
investigates the effect of care workers’ training. The second part examines the financial
sustainability of the training.

2

Table 1. Policy Concerns about the Quality of Nursing Home Care
Group of issues mentioned
Recruiting and retaining an adequately educated and skilledworkforce; improved qualification of staff
Implementation or further development of a quality assessmentand monitoring system
Co-ordination of care service
Building quality and amenity
Other supply constraints: downward pressure on fees/inadequate
fees paid to providers; lack of enough time for staff
Access to broader range of services, more differentiation
Other mentioning of “top concerns” (country specific)

Countries
Twelve countries that replied to this question
Austria, Korea, United States
Canada, Hungary, Germany
Hungary, JapanNew Zealand, United Kingdom, Korea (shortage of government
subsidies)
Norway, Austria (number of short-stay units)
Use of physical restraints (Japan); Number of liability claims;
lack of liability insurance for long-term care (United States)

Note: Data are based on replies from national administrators to the following question: “What are the top
three concerns in your country in terms of quality of institutional care?”Source: OECD (2005: 69)

Methods
The first part of this paper compares the cases of Japan and the United States,as these are the only nations that impose minimum training requirements for care
workers nationally. Then, the second part examines the case of Japan.
Overview of Care Workers’ Training
Many nations have already realized that the improvement of care workers’
skills and qualifications is significant to ensuring quality of care. As mentioned earlier,public officials commonly raise insufficient training for care workers as a policy
concern.
In reality, care workers’ training has been seriously overlooked in mostcountries. In fact, only the United States and Japan have imposed national minimum
training requirements for care workers. All other countries have yet to define fully whocare workers are, because care institutions in these countries can hire anyone to provide
long-term care1.
In the United States2 and Japan, on the other hand, training is required to be acare worker. Compare the situation to driving a car. One does not need a driver’s license
to drive a car on private property, but a license is required to drive on public roads and it
is illegal otherwise. Likewise, everyone in the United States and Japan can provide
long-term care to family members, friends, and others casually. Without required
training, however, one cannot provide long-term care through ‘public channels’, which
is Medicaid long-term care facilities in the United States3 and the universal long-termcare insurance scheme in Japan. It is illegal.
1“Care worker” mentioned here does not include medical staff such as medical doctors and nurses.
Some states do not require any training for the category of Personal and Home Care Aides.
3
In the United States, all long-term care facilities, including for-profit and non-profit ownership, arerequired to register with the local governments (state governments in most cases). Therefore, “publicchannels” here does not mean public institutions only.
2

3

Yet, the United States and Japan have very different approaches toward care
workers’ training. The training in the United States is concise and focuses on exercisingproper care and protecting care workers from their potential job risks, including injury.
In Japan, on the other hand, the training is comprehensive and focuses on understanding
care recipients in order to recognize their detailed care needs.
Definition of Care Worker
Table 2 reviews the definitions of care workers in the United States and Japan.
Although they have different names, their tasks are similar. They mainly give Activities
of Daily Living (ADL) supports to care recipients at care facilities (i.e., nursing homes)
and in recipients’ homes.
The roles of Nursing Aides and Assistant Nurses are, however, slightly
different due to the difference of long-term care systems in the two nations. In the
United States, Nursing Aides, Home Health Aides, and Personal Home Care Aides arecalled Direct-Care Workers. They all work mainly in long-term care industries. In Japan,
on the other hand, Nursing Assistants mainly work at hospitals, not in long-term careindustries, though Certified Care Workers and Trained Home-Helpers mainly work at
long-term care industries4.
The difference is rooted in the definition of ‘long-term care’ in these countries.
As Figure 1 shows, the means-tested long-term care scheme is uniquely in charge oflong-term care in the United States. In Japan, on the other hand, long-term care exists
across three different schemes. Whereas the universal long-term care insurance scheme
covers elderly-related conditions only, medical-related long-term care anddisabled-related long-term care are covered, respectively, by the universal healthcare
scheme (i.e., hospitals) and the universal disabled care scheme (i.e., disabled carefacilities).

4

Certified Care Workers and Trained Home-Helpers also work at later-mentioned disabled carefacilities.

4

Table 2. Definition of Care Workers in the United States and JapanThe United States (Direct-Care Workers)
Nursing Aides generally work in nursing homes, although somework in assisted living facilities, other community-based
setting, or hospitals. They support residents’ ADL, such as
eating, dressing, bathing, and toileting. They also perform
clinical tasks such as range-of-motion exercises and bloodpressure readings.
Home Health Aides provide essentially the same care andservice as nursing assistants, but they assist people in theirhomes or in community settings under the supervision of anurse or therapist. They may also perform light housekeeping
tasks such as preparing food or changing linens.
Personal and Home Care Aides5 may work in either private orgroup homes. In addition to providing assistance with ADL,
these aides often help with housekeeping chores, meal
preparation, and medication management. They also help
individuals go to work and remain engaged in theircommunities. Consumers directly employ and supervise a
growing number of these workers.

Japan (care workers)
Assistant Nurses generally work in hospitals, although somework in institutional care (i.e., nursing homes). They support
patients’ (residents’) ADL, such as eating, dressing, bathing, andtoileting. They also perform clinical tasks such as range-of
motion exercises and blood pressure readings.
Certified Care Workers “provide appropriate advice andcoordination as well as personal care to cope with physicaland/or mental situations of those who need help in daily life,
based on professional knowledge and skills”. (Certified Social
Workers and Certified Care Workers Law of 1987)
Trained Home-Helpers “are registered under the exclusive
qualification name of THH 6 ” (Enforcement Order Article
3-1(2), Long-Term Care Insurance Law). The tasks include a)“care services” such as the assist of eating, bathing, clothing,and moving; b) assisted housekeeping such as cooking, laundry,
cleaning, and shopping; c) mental care for care recipients andtheir family; and d) care advice for care recipients’ family
members (National Trained Home-Helper Council, 2010).

Note: ADL indicates Activities of Daily Living.
Source: Bureau of Labour Statistics (2010)

5

They have many titles, including personal care attendant, home care worker, personal
assistant, and direct support professional (the latter work with people with intellectualand development disabilities).
6
Although THH is a prefectural license, the required qualifications (training) aredesignated by the Ministry of Health, Labour, and Welfare.

5Figure 1. Differences in Long-Term Care Schemes in the United States and JapanThe United States

Means-tested
Long-Term Care
SchemeJapan
Universal Disabled
Care Scheme(including
disabilities-related
long-term care)

Universal Healthcare
Insurance Scheme(including medical
related long-term care)

Universal Long-TermCare Insurance forElderly Scheme(elderly-related
long-term care only)Part 1: Results
Much Longer Training Hours in JapanThe minimum training hours required to be a care worker in Japan is muchhigher than the required number of hours in the United States. Table 3 summarises therequired training hours in the two nations. The required training hours for a Certified
Assistant Nurse and a Certified Care Worker in Japan are, respectively, 1,890 and 1,8007
7

Concerning Certified-Care Worker, the required training can be replaced by 3 years of on-the-job
training at certified care facilities. In that case, however, candidates have to pass the national examinationin order to clarify that the candidate has completed the equivalent of the required training.

6hours, whereas that of their counterparts in the United States is only 75. The difference
is indeed about 24 times. The training of a Trained Home Helper in Japan involves 500
hours (150 for level 2 qualifications), whereas the training hours of the US counterpart
is 75. This time, the difference is not as significant, but Japanese training hours are stillnearly six times (or twice in the case of level 2) greater than are those in the UnitedStates.
Table 3. Required Training Hours in Japan and the United States
Position

Required hoursof training

Japan
Certified Assistant Nurses (CAN)
Certified Care Workers (CCW),
Trained Home Helpers (THH)
CAN: 1,890 hours
CCW: 1,800 hours
TTH: 500 hours(Level 2: 130 hours)*

The United States
Direct Care Workers (DCW)

75 hours(including 16 hours clinical training)

Source: Welfare and Medical Service Agency (2010b) and Bureau of Labour Statistics (2010).

Certainly, in the United States, many state governments add extra hours of
training to the federal minimum requirement. In fact, 27 states and Washington D.C.
require extra hours training. Among them, in 12 states and Washington D.C. the training
hours go up to 120 hours in total. In Japan, on the other hand, the training hours usually
do not differ by prefectures, although Assistant Nurse and Trained Home-Helper are
prefectural licenses (Certified Care Worker is a national license).
Nonetheless, there is an enormous difference in the number of required training
hours between the United States and Japan. Moreover, the minimum requirement inJapan is under consideration to expand in order to respond to diversifying care needs,
including dementia care. In fact, the training hours of Certified Care Workers haveincreased recently from 1,500 to 1,800 in 2009. In addition, the training hours ofTrained Home Helpers have increased from 250 to 500 and qualifications for level three
Trained Home-Helpers, requiring 50 hours training, were abolished in 20098. Level 2
Trained Home Helpers are now encouraged to complete a total of 500 hours of training.
Furthermore, the licenses of Trained Home-Helpers, together with Certified AssistantNurses, fall under criticism that the training hours are too short. According to theminutes of the Ministry of Health, Labour, and Welfare (1996; 2008a: 9), many policy
makers propose to abolish both licenses, in which case current license holders would be
required to upgrade to Certified Nurse9 and Certified Care Worker, respectively. In the
United States, the minimum requirements have not changed for some time, although
89The license expired in April 2009.
Certified Nurse requires 3,000 hours training and national exam.

7

some researchers propose to increase the training hours (e.g., Li and Ziemba, 2009).
Two Phases of Training Content
In both the United States and Japan, the purpose of the training is to acquire thenecessary skills and attitudes toward care recipients to provide good quality care. There
are, overall, two phases to achieve success. The first phase focuses on conducting
requested physical supports safely. This is the focus of the training in the United States.
The second phase focuses on picking up potential care needs and responding to them.
This is necessary, especially when providing care for the elderly with dementia. The
Japanese training is at this stage.
Phase 1: Case of the United States
To be able to respond to visible care needs, the first phase of training focuseson basic attitudes and physical skills. The attitudes trained here involve basic
legal/ethics matters, human rights, and communication. They are considered as
somewhat common sense in the profession. However, the skills trained in Phase 1 arerather specific. They include basic medical-related skills and transfer techniques. Sincecare recipients tend to be frail, basic medical-related skills are always necessary in caseof emergency, though care workers are responsible only for first aid and not for medical
treatment. As for transfer techniques, the training in Phase 1 includes not only giving asmooth support, but also protecting care workers’ health. Throughout the ADL supports,
care workers often need to lift care recipients. Although the weight of care recipientswidely varies, care recipients are much more delicate and often heavier than, forexample, the materials at a construction site. In fact, Direct-Care Workers have thehighest injury rate among occupations in the United States (Zontek, Isernhagen, andOgle, 2009). Back injuries, especially, are very common10. The training in Phase 1,
therefore, covers basic attitudes and skills for visible care.
The majority of the training content in the United States can be classified intoeither basic attitudes or skills. Table 4 indicates the content of the training in the UnitedStates. Concerning Nursing Aides, resident rights belongs to basic attitudes, whereas
clinical training, basic nursing, personal care, and basic restorative are about skills.
Certainly, mental health, social service, and care of the cognitively impaired may be
exceptions, but overall the content belongs to Phase 1. As for the case of Home Health
Aides/Personal and Home Care Aides, information regarding personal hygiene is about
attitude. Safe transfer techniques, reading and recording vital signs, infection control,
10

In Japan, about 70% of care workers suffer from back pain (MHLW, 2008b).

8

and basic nutrition indicate the skills.
Table 4. Training Content in the United States
Title
Nursing Aides

Home Health Aides/ Personal and Home
Care Aides

Content
Clinical training
Other skills
basic nursing
personal caremental health and social service
care of cognitively impaired
basic restorative
resident right
Total
Covered area:- Information regarding personal hygiene- Safe transfer techniques- Reading and recording vital signs- Infection control- Basic nutrition(+ 16 hours Practical training*)
Total

Hours
16
59

75
75

75

Note: * is required in many states.
Source: Bureau of Labour Statistics (2010)

Phase 2: Case of Japan

Aiming at picking up potential care needs, Phase 2 training emphasises themental aspects of care and communication. As a significant number of care recipients
suffer from dementia and other cognitive impairments, many care needs are invisible.
Elderly people may require help to go to the bathroom, an assist to change their position
in bed, or support to change their clothes. If they cannot properly deliver their will dueto their cognitive conditions, such needs can be easily overlooked. In order for care
workers to recognize these potential needs, they must understand elderly peoples’
mentality and communicate effectively with them.
This not only helps care recipients, but also protects care workers’ health. Carework is, indeed, a very mentally draining task, because care recipients’ mental statuses
tend to be unstable. As most care recipients are living in the last stage of their lives, they
inevitably face fear of death while in care. According to Kübler-Ross (1969), there areusually Five Stages of Grief as a pattern of adjustment to human death. These are denial,
anger, bargaining, depression, and acceptance. This means, at each stage, care recipientscan be very emotional and care workers must face and deal with these dramatic
reactions while giving care. The survey of Kawamura (2008) reports11 that about 28
percent of care workers receive “physical and verbal abuse from care recipients”; this isa significant work concern. In such an environment, it is very important - for both carerecipients and care workers - that care workers are capable of dealing with such
11

The survey was conducted in Japan, but it is thought that the concern was shared in the United Statesand other countries because the core workers’ tasks are quite similar.

9emotions by communicating with care recipients effectively.
The focus of the Japanese training has shifted to this in Phase 2. Table 5 shows
the required training content for Assistant Nurses, Certified Care Workers, and Trained
Home-Helpers. As in the training of Assistant Nurses, the mental aspect of carerecipients is covered by several subjects such as Psychology of the patient, Psychiatricnursing, and Psychiatric nursing (practice); a total of 175 hours are spent on those issues.
Moreover, in order to understand care recipients further, the practical subjects havespecial focuses on recipients’ groups such as adult/elderly and mother and child. A totalof 595 hours of training are devoted, specifically, to adult and elderly care in order tounderstand their particular needs and issues. In the training of Certified Care Workers,
these aspects are more clearly emphasised (Table 6). Besides practical training, many
subjects deal with understanding human mentality. Topics include human dignity andindependence, human relationships and communication, understanding society,leadership and human relations, social studies, communication skills, understanding
dementia, understanding disabilities, and mental and physical structures. Indeed, 460
hours, about 26% of the total training, are spent on such matters12. Comparing this tothe previous version of training content, the difference is clear.
Table 7 indicates the required Certified Care Workers’ training, in effect prior
to 2009. The focus of the training was “practical skills” rather than dealing with mental
aspects of care. There were only three mental-related subjects: social welfare of thephysically and/or mentally disabled, psychology of the elderly and disabled, and mental
health. The training duration was only 120 hours, about 8% of the current totalrequirement. The focus on Phase 2 is also clear in the training of Trained Home-Helpers(Table 8). Most subjects, besides the practical part of the training, deal with
understanding care recipients and their mentalities. Understanding the mission of life
support and dignity of care recipients, understanding dementia, communication, andskills on care provision are typical examples of such subjects. In sum, the focus ofJapanese training is on understanding and communicating with care recipients. This is
how Japan trains care workers to identify potential care needs.

12

As for the selective subjects, each training hour is calculated by the total hours divided by the numberof subjects (i.e., x=120/6).

10

Table 5. Required training of Assistant Nurses in Japan

Special

Basic special

BasicSubject
Language arts
Foreign language
Other general education
Human body function and structure
Diet and nutrition
Medicine and nursing
Illness
Infection and prevention
Care and ethics
Psychology of patient
Structure of healthcare and social welfare/ Nursing and law
Basic nursing
General consideration of nursing
Basic nursing skills
General consideration of nurse practiceNursing for adult/ Nursing for elderly
Nursing for mother and child
Psychiatric nursing
Nursing practice
Basic nursing
Nursing for adult/ Nursing for elderly
Nursing for mother and child
Psychiatric nursing

Type
LectureLectureLectureLectureLectureLectureLectureLectureLectureLectureLecture

Hour
35
35
35
105
35
35
70
35
35
35
35

LectureLectureLectureLectureLectureLecture

35
210
70
210
70
70

Practice
Practice
Practice
Practice

210
385
70
70
1890

Total

Source: Welfare and Medical Service Agency (2010b)

Table 6. Required Training of Certified Care Workers (from 2009)
Subject

Ment
al &

Care

Human and Society

Understanding humans
Understanding society
Selective subjects

Human dignity and independence
Human relationship and communication
Understanding society
1.
Life science studies
2.
Mathematics and logical thinking on human relationand social life3.
Basic life skills (e.g., life culture, and living skills)
4.
Leadership and human relations
5.
Social studies (sociology, political science andeconomics)
6.
Various social welfare scheme

Basic careCommunication skills
Life support skills
Care process
Comprehensive care workshop
Care practice
Understanding dementia
Understanding disabilities
Mental and physical structure

Hour
30
30
60
120

180
60
300
150
120
450
60
60
120

Source: Welfare and Medical Service Agency (2010b)

11

Table 7. Required Training of Certified Care Workers (prior to 2009)
Subject
Introduction to social welfare
Social welfare of the elderly
Social welfare of the physically and/or mentally disabled
Rehabilitation
Practical skill of social work
Practical skill of recreation instruction
Psychology of the elderly and disabled
Introduction to domestic science
Nutrition and cooking
Practical training of domestic science
Introduction to medicine
Mental health
Introduction to care work
Practical skill of care work in general
Practical skill of care work (according to each disability type)
Practical training of care work
Supervision of practical training of care work
General education

Type
LectureLectureLectureLectureLectureSeminarSeminar
LectureLectureLecturePractice
LectureLectureSeminarSeminarSeminarPractice
Seminar
Lecture

Hours
60
30
30
30
30
30
60
60
60
30
30
60
30
60
120
120
450
60
120

Type
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/Seminar
Lecture/SeminarPractice

Hours
30

Source: Welfare and Medical Service Agency (2010b)

Table 8. Required Training of Trained Home-Helpers
Subject
Understanding the mission of life, support and dignity of care recipients
Understanding the system and services available for frail elderly and disabled people
Understanding the disease and disability of frail elderly and disabled people
Understanding dementia
Communication and skills on care provision
Skills on life supports and housekeeping
Collaboration with medical and nursing staff
Social welfare skills on care
Planning and assessment for life support
Ethics and tasks as care worker
Practical training of care work

30
30
30
90
30
30
30
30
30
140

Source: Welfare and Medical Service Agency (2010b)

License Examination
Whereas the completion of the training usually means qualification for the
license in the United States, training completion in Japan may only indicate
qualification for a license exam. First, the Japanese Assistant Nurse candidates (i.e.,
those who complete the required training at designated institutions) must pass theprefectural exam to get the license. The examination for Trained Home-Helpers is to beabolished, but the level 2 exam, which allows the successful candidate to skip a part of
the required 500 hours of training, will remain. The exam for Certified Care Workers,

12however, is implemented universally13. As seen in Figure 2, there are now six routes tobe a Certified Care Worker and the exam will soon be implemented in all routes. In
addition, the exam is not just a formality process. The subjects range widely (Table 9)
and only half of the candidates pass the exam every year, as shown in Table 1014.
Figure 2. Six Routes to be Qualified as a Certified Care Worker
Qualification of Certified Care Workers

More than 6 months National
Training (from 2012)

National examination (from 2012)
Special training school(1-year course)
Specialtraining
school(2-4-year
course)Graduationfrom schoolof social
work atuniversity

Graduationfrom special
training
school for
Certified
SocialWorkers

Route 1

Route 2

Route 3National examination

Graduationfrom special
training
school forChildren
Day CareWorkers

Route 4More than 3
years
practices
related tocare work*

Graduationfrom special
training
school forChildren
Day CareWorkers

Route 5

Route 6

Graduation from high school

Note: The step in the dotted boxes is to be implemented in April 2012.
* “Practices related to care work” here means on-the-job training through the non-licensed part of nursing
home tasks, such as cleaning rooms and cooking meals for care recipients.
Source: MHLW (2010a)

Table 9. Subjects of Certified Care Worker Exam
Paper Exam
Compendium of Social Welfare
Elderly Care
Disabled Care
Rehabilitation
Social Welfare and Care Support Skills
Organising Recreation Activities
Psychology of Elderly and Disabled people
Domestic Science
Medicine
Mental HealthCompendium of Care Work
Care Skills
Care Skills on Various Occasion
Practical Exam (corresponds to the paper exam, especially the subject of “Social Welfare and Care Support Skills”)

Source: MHLW (2010a)

13
14

Until 2012, the exam will have been only for the candidates in route 5 and 6.
The exam is an absolute evaluation, not a comparative assessment.

13

Table 10. Exam Pass Rate of Certified Care Workers (2006-2010)
Year
2010
2009
2008
2007
2006

Examinee
153,811130,830
142,765
145,946
130,034

Successful Examinee
77,251
67,99373,30273,60660,910

Successful Ratio
50.2%
52.0%
51.3%
50.4%
46.8%

Source: MHLW (2010b)

Part 1: Discussion
Care Workers’ Training Contributes to Ensuring Quality of Care with Two Phases
The purpose of Part 1 was to investigate how care workers’ training ensuresquality of care. Analysing the cases of the United States and Japan has provided
theoretical evidence that care workers’ training has two phases and that both arerespectively useful to ensure quality of care. Whereas Phase 1 standardises the carequality of addressing overt needs by ensuring proper care attitudes and physical skills(e.g., transfer techniques), Phase 2 enables care workers to respond to potential careneeds by teaching different aspects of care recipients’ mentalities and training
communication skills to recognize, address, and discuss potential care recipients’ needs.

Part 2: Results
Challenge to the Sustainability of Care Workers’ Training
An empirical concern is that the care workers’ training may not be sustainable.
In the case of Japan, while the population of care recipients is expected to continue toincrease, the content of training has become more comprehensive. Can Japan keep thispace for the next decade of an aging society?
Certainly, a part of the answer may be influenced by some unique factors of theJapanese aged care system. The care workers are highly motivated. In Japan, theexperience as care worker is a necessary step to be a policy maker in the field of care.
Starting as a care worker, there are certain career steps necessary to be involved inpolicymaking (Figure 3). In addition, compared to other countries, the salaries of care
workers are good and expected to increase progressively15. As a result, despite thedemanding training requirements in Japan, the care workers’ labour shortage issue is not
as serious as that in the United States and many other countries. In fact, whereas theUnited States relies on immigrants for 23% of care workers16 (PHI, 2010), the

15 Unlike the cases of other countries, the care workers’ salary in Japan is designated by law and is nearly
equivalent to those of public officials. For reference, the care workers’ salary in the United States is so
low that more than 41 percent of the care workers’ households rely on some kind of public benefit, suchas food stamps (PHI, 2009).
16 PHI defines immigrants as those who are born outside the United States.

14

immigrant-dependent ratio in Japan is nearly zero17. This might certainly be because of
the language barrier of Japanese but, as seen in Table 10, the number of license
applications (i.e., examinees) has increased.
Figure 3. Career Steps of Care Workers in Japan

Note: Coloured box indicates a national license, whereas a white box means a prefectural license.
Both licenses are, however, interchangeable with meeting the requirements. For example, Trained
Home-Helpers are eligible to apply for Certified Social Worker qualification; Certified Care Workers
can apply for Certified Care Manager qualification.

Nonetheless, one must consider the government’s motivation to train care
workers. Even if care workers are motivated in Japan, it is costly for the government totrain the candidates for care workers and to maintain the long-term care system.
Certainly, to ensure quality of care is an important task of governments, along with theobjective of OECD: “achieving the highest sustainable economic growth andemployment and a rising standard of living in member countries.” Particularly, however,it may be that Phase 2 training, shown in the case of Japan, is too much of a burden on
governments.
17

Certainly, the Government of Japan gave 3-4-year training scholarships to 208 Indonesian candidates
for the Assistant Nurse/Certified Care Workers program in 2008 as “the first trial” to accept foreignlabour in the field. In the following year, 2009, the government also gave similar scholarships to 280
Filipino candidates for the Assistant Nurse/Certified Care Worker program. However, as of November
2010, none of them has yet received these licenses. In Japan, there are about 382,000 Assistant Nurses(MHLW, 2006), 81,000 Certified Care Workers, and 31,000 Trained Home Helpers (MHLW, 2009).
Estimates suggest that almost all of them are Japanese natives.

15Government Motivation to Train Care Workers
Phase 2 of care workers’ training can be sustainable. Indeed, the training has
had great spill over effects on care-related industries in Japan. This section analyses themechanism, investigating the case of Japan.
Long-Term Care in Economic Growth Strategy
As explained earlier, the purpose of Phase 2 training is to pick up potential careneeds. In economics or/and business terms, this can be rephrased as ‘market research.’
The government of Japan, particularly the Ministry of Economy, Trade, and Industry(hereinafter, METI), draws growth strategy utilising the care workers’ skills of picking
up potential care needs.
With this strategy, the livelihood support robot used in the long-term careindustry has great potential. The livelihood support robot means the robot that helps
humans in long-term care, housekeeping, and in the safety and comfort of daily living(AIST, 2007). According to Japan Society for the Promotion of Machine Industry(2008), the market for the livelihood support robot can be expanded to 1,453.4 billion
yen (institutional use: 901.2 billion yen [11.2 billion USD]; home use: 552.2 billion yen[6.9 billion USD]) by 2030.
The government of Japan recognises this potential. In 2010, the research of the
Ministry of Economy, Trade, and Industry, Japan (METI) revealed that the future
growth of the Japanese robot industry is expected to rely heavily on service uses (Figure4). The livelihood support robot will be a core division of service use in the near future(Table 11). Certainly, METI does not provide the clear definition of the livelihood
support robot “Service” in Table 11. Yet, if it includes “Long-Term Care,” “Roomcleaning,” “Transportation (business use),” “Transportation (home use),”“House-keeping support,” and “MIMAMORI communication” in the table, the sales ofthe livelihood support robot is, in 2035, to increase up to 1.9807 Trillion Yen which
occupy about 20 percent of the total 9.7 trillion yen (121 billion USD), Japanese robot
industry.

16

Figure 4. Overall Japanese Robot Industry Market Prediction (2015-2035)

Trillion JPY

10.0
9.0
8.0

Service

7.0
6.0

Agriculture, Forestry, andFishieries
RT product

5.0
4.0
3.0

Manufacturing

2.0
1.0
0.0
2010

2015

2020

2025

2035

Year

Note: RT indicates Robot Technology
Source: METI (2010)17

Table 11. Japanese Robot Industry Market Predictions (2015-2035) (Detailed)
Major Division
Manufacturing

Robot
Technology(RT) product

Agriculture,
Forestry,
andFisheries

Service

Division
Middle Division
Conventional
industrial robot
Next-generationindustrial robotRTelectric
appliance/ homeequipment
RT automobile
RT ship
RT railway
RT construction
machineAgriculture

Forestry
Fisheries/
aquaculture
Medical careLong-Term Care
Healthcare

Room cleaning
Security

Receptionist
DeliveryTransportation(business use)
Heavy-duty
supportFood industry

Logistic
Examination/
maintenance
Education
Amusement
RescueProspecting
Transportation(home use)
Hobby
House-keeping
supportMIMAMORI/.
communication

Predicted Market Scale (Billion yen)
2020
2025
2035
1,052.4
1,092.6
1,102.7

Calculation

Small Division
-

2015
936.5

Assembly robot(Automobile)
Robot
cell
(Electric
machine)
-

32.4

99.2

239.3

798.8

Pattern 4

32.9

104.8

248.8

827.9

Pattern 4

92.8

285.9

488.0

557.9

Pattern 5

-

50.9
15.9
2.5
14.9

103.3
28.1
4.6
29.8

208.3
44.4
7.4
57.6

737.0
72.9
12.8
175.0

Pattern 5
Pattern 5
Pattern 5
Pattern 5

Land-use
agriculture
Garden firming/
facility firming
Daily firming/
animal firming
Agriculture
logistics
-

1.1

2.3

7.3

27.6

Pattern 5

0.9

3.9

15.0

92.7

Pattern 4

10.2

29.4

49.8

58.8

Pattern 3

27.3

60.3

81.2

85.8

Pattern 3

1.7
5.4

8.4
16.8

30.4
41.7

87.2
114.2

Pattern 4
Pattern 4

4.3

13.6

31.7

53.4

Pattern 3

6.5

21.0

38.3

41.4

Pattern 3

13.4
3.3
137.6
5.4

39.7
14.6
146.1
16.1

82.5
41.4
157.6
44.0

220.6
183.7
181.7
148.0

Pattern 4
Pattern 4
Pattern 3
Pattern 3

2.2
21.0

12.7
61.0

54.1
124.9

428.7
268.9

Pattern 3
Pattern 5

1.7

21.0

70.3

163.2

Pattern 4

0.2
0.7
5

0.9
3.0
116.2

3.9
13.2
619.0

46.5
81.1
675.9

Pattern 3
Pattern 3
Pattern 3

-

1.5

4.3

12.0

229.9

Pattern 3

Food handlingFoodprocessing
Palletizer/
depalletizer
House
Socialinfrastructure
-

17.9
8.1

67.5
30.5

143.2
79.3

164.0
174.3

Pattern 3
Pattern 3

21.2

41.0

86.5

152.3

Pattern 2

4.6
21.6

9.8
103.8

15.7
218.8

21.3
180.5

Pattern 1
Pattern 4

11.9
21.1
0.8
1.7
2.1

24.3
35.7
6.0
7.3
49.8

36.1
57.6
29.1
25.7
265.3

45.0
122.2
67.0
81.1
289.7

Pattern 1
Pattern 1
Pattern 1
Pattern 3
Pattern 3

-

22.3
-

71.6
-

1498.5
15.7

215.7
85.8

Pattern 1
Pattern 3

-

0.3

1.1

3.6

34.1

Pattern 3

Operation
supportPharmaceutics
supportSelf-support
Care support
Fitness
Healthmonitoring
Machinesecurity
Institutional
security-

Pattern 2

18

(Table 11 continued)
Division
Major Division
Middle Division
Robot Total
Livelihood Support Robot(occupancy rate in the total)

Small Division2015
1,599.0
31.7(2%)

Predicted Market Scale (Billion yen)
2020
2025
2035
2,853.3
5,258.0
9,708.0
250.2
1,109.9
1,980.7(8.8%)(21%)(20%)

Calculation

Note: Author indicates the livelihood support robot in bold face. The last row is added by Author. The
original source describes the number in increments of 100 million, but this table shows the number inincrements of 1 billion. The term MIMAMORI is hard to translate, but roughly, it means “to stand watch
over frail elderly and/or small children and to offer help when necessary” in English.
Methodology: The prediction is calculated by the logistic curve model formed by the adoption number,household adoption rate, replacement cycle, and price transition of the anagogic (in terms of price andutilisation) product in the past market of each division.
- Pattern 1: stochastics of the existing stochastics data
- Pattern 2: stochastics based on the existing market performance- Pattern 3: stochastics based on the model curve of the anagogic robot- Pattern 4: stochastics based on the market needs- Pattern 5: stochastics based on the model curve of the anagogic RT productSource: METI (2010)

The government has heavily committed to the promotion of the livelihood
robot that collaborates with care workers. The commitment originally began with the
METI’s policy of the “21st Century Robot Challenge Program” in 2001, a year after
universal long-term care insurance was implemented. Since then, the focus on the
livelihood support robot has grown stronger. In 2009, the government set up the action
plan to back up their activities (Table 12).
Table 12. Action Plan to Promote Livelihood Support Robot by Government of Japan
20092010-2011

2012-20132014-

The livelihood support robot project by METI (1.6 billion yen)
Introductory Period
Safety check (METI)
Risk assessment (METI)
Test at care facilities (METI, MHLW)LTCI system maintenance for robot introduction (MHLW)
Test at special ward (e.g., Tsukuba-city)
Primary introduction
Test of care worker robot (e.g., power suite) (METI, MHLW)Power suite test with normal healthy subjects (METI)
Planning of mobility-robots (related Ministries)
Major introduction through B2B (Business to Business) market
Implementation of robot-use promotion policy (MHLW)
Setting up robot assessment agency (METI)
Implementation of the telecommunication system for robot use (MPMHAPT)

Note: MPMHAPT means
Telecommunications.
Source: METI (2010)

Ministryof

PublicManagement,

Home

Affairs,

Posts,

andResearch and Development
The experiences of well-trained care workers in Japan are greatly utilised in the
research and development of the livelihood supports robot. First, robot makers, robot
users (i.e., care workers and care recipients), universities, local governments, thinktanks, insurance companies, venture capitals, and leasing companies have formed acollaborative body named the Association of Robot Business Promotion. The

19

association offers the members various collaborative opportunities such as businessmatching (Figure 5). Furthermore, the New Energy and Industrial Technology
Development Organization (NEDO), a government agency, supports the establishmentof ethical and safety guidelines (NEDO, 2008). Collaborating with robot makers anduniversities, the National Institute of Advanced Industrial Science and Technology(AIST) conducts research in Tsukuba city, a special word of long-term care. Many
universities, especially, take advantage of their care worker training functions on theircampuses. As mentioned in Route 2 in Figure 2, some universities hold care workers’
training schools, called Care Worker/Social Worker School. Since the needs oflong-term care have been increasing, today 179 universities have such schools within
their campuses (Table 13). As many of the teaching staff at the schools have care worker
experiences18, it is very convenient for the researchers in these universities to utilise thedetailed needs of long-term care in their research.
Figure 5. The Association of Robot Business Promotion

228 members (as of April, 2010): robot makers, robot users (i.e., care workers and carerecipients), universities, local governments, think-tanks, insurance companies, venture
capitals, and leasing companies
President: Takeshi Uchiyamada (Vice President of Toyota Motor)
Organisation:

Managerial body

Department of Safety
and Quality Control

Department of Business
Matching

Department of PR and
Planning

Observers: METI, CAO, MPMHAPT, MHLW, and MLIT
Note: METI: Ministry of Economy, Trade, and Industry
CAO: Cabinet Office
MPMHAPT: Ministry of Public Management, Home Affairs, Post, and Telecommunications
MHLW: Ministry of Health, Labour, and Welfare
MLIT: Ministry of Land, Infrastructure, and Transport
Source: METI (2010)

18and/or they have a very close relationship with care workers.

20

Table 13. University with Care/Social Work School in Japan
Area
Hokkaido
Tohoku
Kanto
Koshinetsu
Hokuriku
Tokai
Kinki
Chugoku
Shikoku
KyushuOkinawa
Total

Number of Universities with
Care/Social Work Schools
8
13
55
6
2
21
34
16
6
16
2
179

Source: Welfare and Medical Service Agency (2010a)

Robot Utilisation Cases
Because of robot business promotion, many livelihood support robots havecome into service. After many years of research and development, some have begun togrow in popularity and others are starting to be involved in overseas export. With thesesuccesses, many companies have accelerated their investment in the development of thelivelihood support robot.
Case 1: Robot Suit HAL (Hybrid Assistive Limb)
Robot suite HAL, developed by Yoshiyuki Sankai at Tsukuba University, canassist the wearer’s movement. Bioelectric sensors attached to the skin monitor signals
transmitted from the brain and control the robot suit (Sankai, 2006). With this suit, care
workers can easily lift care recipients because care recipients have enhanced physicalcapabilities.
Collaborating with Tsukuba University and NEDO, Cyberdyne Inc19 released
the robot suit in the market in 2010. According to Yomiuri Online20, as of the 20th ofAugust 2010, HAL had already been introduced by 37 hospitals and nursing homes inJapan. The article also refers to the half-paralysed elderly who can ascend stairs,
wearing HAL.

19
20

A venture company founded by Yoshiyuki Sankai, who developed the robot suit.
Online version of Yomiuri newspaper.

21

Image. Robot Suit HAL

Photos up: HAL for the use of disabled
Photo down left: Walking with HAL
Photo down right: Care giving with HAL
Source: NEDO (2010)

Case 2: Therapeutic Robot PARO
The therapeutic robot, PARO, developed by AIST, is designed to have positive
psychological effects on the people attracted to it because it reacts to the people and/or
develops its character as the people take care of it. According to AIST (2006) and Wada,
Shibata, Musha & Kimura (2008), interacting with PARO improves brain function, as
measured and analysed in the brain waves of elderly patients with cognitive disorders.
Robot therapy with PARO, therefore, may mediate or prevent cognition disorders.
The use of PARO may also enhance quality of care. That is, the use of PARO
makes it possible to implement a humanistic method of care giving. Takanori Shibata,
Senior Research Scientist at AIST says, “Elderly people with dementia, especially iftheir condition is severe, may get agitated and violent, and be unable to settle down.
Previously, such patients were sedated, and even now, that is sometimes the case inEurope and America. In Japan, such patients are sometimes physically restrained. Ifsuch patients have contact with PARO, however, they often settle down almost
immediately, smile, and feel good. Although the use of PARO may not be 100%
effective, it has no particular side effects” (Diginfonews, 2010).
In Japan, as of 2010, 1,300 PARO robots had already been released, and the22sales had been extended to overseas. Care facilities in Denmark and other European
countries have started to introduce PARO. PARO is expected to be sold in the UnitedStates in 2010, as PARO was certified as a medical product by the Food and Drug
Administration (FDA) (Diginfonews, 2010).
Image. Therapeutic Robot PARO

Source: Wada et al (2008)

Not just research institutes or venture companies research the livelihood
support robot. Major Japanese companies such as Toyota Motor, Honda Motor, Fuji
Heavy Industries, Panasonic, Mitsubishi Heavy Industries, Toshiba, Fujitsu, NEC,
Yasukawa Electric, and Hitachi have also developed livelihood support robots. Amongthem, Panasonic aims at 100 billion yen (about 1.25 billion USD) service robot sales in2015 (Impress Watch, 2009). In addition, in 2010, another major technological company,
Canon, announced its entry into the service robot business (Yomiuri News Paper, 2010).

Part 2: Discussion
Possible Research Limitation
The motivation of the Japanese government cannot directly apply to that ofother governments. Japan produces about 70% of the world’s industrial robots (METI,
2009: 174). It may be unique for Japan to have robots as its basic industry.
However, the idea of synergizing care workers’ training to ensure quality ofcare and market research for future industries is applicable to other markets. As in thefield of long-term care, all OECD member nations are facing rapidly increasing aging
populations. All markets related to the elderly, not just the robot one, are very
promising; it is worth conducting ‘market research’ while providing the best possible
long-term care through comprehensive care workers’ training.

23

Conclusion
Identifying two phases of care workers’ training, this paper first supported thesignificance of care workers’ training for ensuring the quality of long-term care. This
paper also found that governments could ensure the sustainability of care workers’
training by aiming at the best possible long-term care. Analysing the case of Japan, theresearch discovered that hidden care needs uncovered by trained care workers boosted
the national economy. That is, the care workers’ efforts to provide the best possible
service elicited potential service needs and industries responded to those needs.
The impact of these findings projects on the discussion of increasing long-termcare needs. For some time, increasing long-term care needs have been perceived rather
negatively, because they create a litany of public expense. Highlighting the positivesocial effects of increasing long-term care needs, however, the experiences of Japan
provide a mechanism to make the service provision sustainable. The more training ofcare workers, the more hidden needs uncovered. Then, the elicited needs boost theeconomy. Importantly, the collaboration among governments, long-term care providers,and industries benefit them all, bringing financial sustainability for governments, bettercare for providers, and new business for industry. Certainly, connecting elicited
long-term care needs and the robot industry might be unique to Japan. However, theprinciple of a market economy that elicited needs to stimulate industrial activities isapplicable to every market.
For further research regarding these findings, multidisciplinary research may berequired. To strike a balance between market contestability and service quality
assurance, research needs to include several views: economics and business,engineering, medicine (including long-term care and nursing), education, and public
policy. The challenges – and the rewards – are, indeed, multidisciplinary.

24

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