Nursing for the older people
in Japan
1. The Aging of the Japanese Population

Japanese Nursing Association

1. The Aging of the Japanese Population
2. Nursing for the Older People: Current
Situation and Challenges (to beissued soon)
3. The Japanese Nursing Association in
Action(to be issued soon)2

Glossary•

Population aging rate: Ratio of people aged 65 andover to the total population••

Birth rate = Number of births / Population  1,000
Total fertility rate: Sum of the age-specific birth rates
of women aged between 15 and 49

3

An Aging World: Percentage of People
Aged 65 and over in Selected Countries
45

40

35
Australia
Canada30

Japan
United Kingdom
United States ofAmericaIndonesia

25

Philippines

20

Viet Nam
India
Malaysia

15

Thailand
China

10

5

0

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World
Population Prospects The 2010 Revision,
National Institute of Population and Social Security Research, Population Projections for Japan (January 2012) for data
for Japan after 2010.

Population aging is a worldwide phenomenon.
Japan is aging faster than any other countries.
4Population aging rate inJapan:
24.1%(As of October 1, 2012)

Life expectancy at
birth
Healthy life
expectancy

maleLife expectancy
at birth
Healthy life
expectancy

female

0

20

40

79.4
70.4 Gap of
9years85.9
73.6 Gap of
12 years

60

80

100
(Years of age)resources :Population aging rate: cabinet office , Annual Report on Aging society 2013
Life expectancy at birth: Ministry of Health, Labour and Welfare, Abridged life table for Japan 2011
Healthy life expectancy: Grant-in Aid for comprehensive research on cardiovascular and lifestyle related diseases form
the Ministry of Health, Labour and Welfare. Study of the future prospects on healthy life expectancy and costeffectiveness of the measure for the life-style related diseases. Representative of the study group ; Syuji Hashimoto.

The Japanese population has been aging rapidly. The population aging rate reached24.1% in 2012. The life expectancy at birth for the Japanese is the one of the longest
in the world. The gap between the life expectancy at birth and the healthy life
expectancy, which represents the average period of no health-related constraints indaily life, is about 9 years for men and about 12 years for women.

5Why is the Japanese society
aging rapidly?
• A rise in the population aged 65 and over due to anincreasing life expectancy at birth• A fall in the youth population due to a declining
birth rate
Resource: Cabinet office , Annual Report on Aging society 2013

After World War II, infant and youth mortality fell significantly due to a better living
environment, improvements in diet and nutrition, and the advancement of medical
technology. The mortality rate for the older people, who are 65 and over, has been on
the decline since WWII. Overall mortality has recently been on the rise, because thepercentage of the older people is increasing in an aging society.
Decline in the number of children in Japan: The total fertility rate was 1.39 in 2011.
The declining birth rate is caused by a range of factors: an increasing percentage ofunmarried people, the tendency to marry and have children later, more and more
women willing to work, and growing job insecurity as highlighted by an increase in thenumber of non-regular workers.
References:
Cabinet Office. Annual Report on the Aging Society 2013.
Cabinet Office. Declining Birthrate White Paper 2013.

6

Japan is entering a long period of
population decline.
(%)(person)
140,000

70.0

120,000

60.0

100,000

50.0

population
estimates
age 0-19

80,00040.0

60,00030.0

40,00020.0

20,000

10.0

0

0.0

age 20 -64

age 65-74

age 75 andover

Resource: National Institution of Population and Social Security Research,
Population Projection for Japan (January 2012)

The number of the older people will rise while
the total population will fall.

Japan entering a long period of population decline. According to projections by the
National Institute of Population and Social Security Research, Japan’s total population is
expected to drop from 128.06 million in 2010 to 86.74 million by 2060. A rise in thenumber of the older people amid a declining total population means that the elderly
ratio will continue to go up.

7

The first baby boomers will be
65 years old and over by 2015.

The first baby boom between 1947 and 1949 in the aftermath of WWII resulted in theannual number of live births reaching around 2.7 million. These first baby boomers
will be 65 years old and over by 2015. On the other hand, the youth population,
which constitutes the bottom of the population pyramid, will continue to fall due to a
declining birth rate.
Reference: Cabinet Office. Declining Birthrate White Paper 2013.

8

The birth rate in Japan willcontinue to fall.
Transition of birth rate
(per 1,000 of the population)(%)(projection data after 2020)

9

1.45
1.44
1.43
1.42
1.41
1.4
1.39
1.38
1.37
1.36
1.35
1.34
1.33
1.32
1.31

8
7
6
5
4

3
2
1
0
2012

2020

2030

2040

2050

Birth rate
Total fertility rate

2060 (year)

Resource: National Institution of Population and Social Security Research, Population Projection for Japan (January 2012)
The 2012 data is from Vital Statistics published by the Ministry of Health Labour and Welfare

Given a declining birth rate and a low total fertility rate, the youth population willcontinue to fall, resulting in the ratio of older people going up.

9

As the population ages, the age compositionof population in Japan will change greatly.
70%
60%
58.1%

50%

47.3%

40%

age 0-19

39.9%

age 20-64

30%

age 65 and over

20%
10%

24.1%

17.7%
12.7%

0%
Resource: Population estimates(as ofOct. 1st, 2012) by Ministry of Internal
Affairs and Communications,
Population Projection for Japan( January 2012) by National Institutionof Population and Social Security
Research

2012

2060

One older person is
supported by 2.4
working-age people.

One older person will besupported by 1.2
working-age persons.

On average, one older person was supported by 2.4 persons in the working age
bracket(20-64 years of age) in 2012. By 2060, one in every 2.5 of the Japanese
population will be 65 years and over. One older person will be supported by 1.2 persons
in this bracket by that year.
10

As people get older, the more affected
their daily lives are.
Proportion of people aged 65 and over who say their daily life isaffected by subjective symptoms(multiple answers allowed) (per 1,000 people)

total

activities of daily living

age 60-64

go outage 65-69
age 70-74
age 75-79

work/housework/studies

age 80-84
age 85 and overphysical activities

othres

0

100

200

300

400

Resource: National livelihood survey 201011

People see their daily life more affected with aging.
The traditional system of mutual help based on thefamily is weakening.
(1,000 people)

Transition of the number of age 65 and overbased on the family form (estimated number)

35 00030 00025 000

20 000
15 000

10 0005 0001986 1989 1992 1995 1998 2001 2004 2007 2010 2011 2012living with non-relatives
living with unmarried children
a married couple only
Notes:
1. The figures for 1995 exclude those of Hyogo Prefecture.
2. The figures for 2011 exclude those of Iwate, Miyagi, and Fukushima
prefectures.
3. The figures for 2012 exclude those of Fukushima Prefecture.

living with relatives
live with son/dauter and his/her partner
one-person households
Source: National livelihood survey 2012 by Ministry of Health
Labour and Welfare

Traditionally, Japanese people often lived with their elder parents and even their
grandparents and took care of them. More recently, however, the percentage of threegeneration households has been decreasing, and the size of the average household has
been shrinking due to increases in the percentages of nuclear families and one-personhouseholds. The percentage of older people who lived with their child(ren) dropped
from nearly 70% in 1980 to 42.3% in 2012. By contrast, the percentage of people aged
65 and over who live alone or with their spouse only has been on the rise. A 2012
survey shows that aged households accounted for 21.3% of all households.
People aged 75 and over more likely live alone or with their child’s family than those
aged 65-74.
12

Social Security System
in JapanJapan’s social security system are roughly
divided into four component pillars:social insurance, social welfare, public
assistance, and public health. The coresocial insurance scheme are healthinsurance, pension insurance, labor
insurance, and long-term care insurance.

13

Health Insurance System
The health insurance system of Japan guarantees universal
coverage in accordance with the National Health Insurance
Act. Under this system, everyone has access to appropriate
health care at any time and anywhere in Japan.
Patient(insured person)

Medical institution
See a doctor/
Pay part of fee

Health care service

Government

Premiums

Share of Public funds- National Health Insurance- Health Insurance Managed by
Association- Mutual Aid Association- Seamen’s Insurance-Health Insurance Managed by
Japan Health Insurance Association
Healthcare system for the later-stageelderly

Payment of medical
expenditure

Charging medical
fee

Payment of medical
expenditure

chargeScreening and payment institutions

Source/Reference: Summary of Health System in Japan by Ministry of Health Labour and Welfare, accessed at
http://www.mhlw.go.jp/seisakunitsuite/bunya/kenkou_iryou/iryouhoken/iryouhoken01/index.html in
September 18 ,2013.

The National Health Insurance Act was first established in 1938, laying thefoundations for a universal health insurance system. By 1961, the national healthinsurance system was fully introduced. Under the system, Japanese citizen have to
be covered by any of the following healthcare insurances: (i) the employee’s healthinsurance for employed individuals, (ii) the National Health Insurance for the selfemployed and unemployed, and (iii) the health insurance for people aged 75 andover.
With a monthly premium payment to their insurers, the insured are eligible forhealth care services from health care facilities for a fixed-rate copayment. Healthcare facilities in turn claims medical fee to screening and payment institutions andreimbursed for the remaining expenses by the insurers. Health care expenses arecharged on a fee-for-service basis. Medical fees for which health care institutions
claims are calculated by adding up the points of the individual practices.
14

The Older people and Health Care
Transition of number of estimated patients by age group(1,000 people)

In-patient

Out-patient

700

3500

600

3000

500

2500

400

2000
age 0-14300

1500
age 15-34

200

age 35-64

1000

100

age 65-74

500

0age 75 andover0Resource: Survey on patients 2011 by Ministry of Health, Labour and Welfare

People are more likely to be hospitalized as they get older.
For statistical purposes, the Ministry of Health, Labour and Welfare (MHLW) divides
inpatients (severities, etc.) into five categories: (i) “life-threatening,” (ii) “small risk to life
but requiring inpatient treatment,” (iii) “to be discharged when acceptance condition ismet” that means the condition of patient allow him/her to leave the hospital but still in
hospital because the environment including housing and human resources after thedischarge is unsettled, (iv) “hospitalization for examination,” and (v) “others.” The higher
the age-group of inpatients gets, the more likely they are “to be discharged when
acceptance condition is met.”
15

National Medical Care Expenditure
Per Capita(1,000 yen)

1 200.0

1 000.0

800.0

600.0

400.0

200.0

0.0
(age)

1,000 yen = US$10.25(as of August 21, 2013)

Resource: National medical care expenditure 2010 by Ministry of
Health, Labour and Welfare

On average, Japanese people pay half of their lifetime health care expenses after
they turn 70.

16Changes in National Medical Care
Expenditure(hundred million yen)

400 000
350 000
300 000
250 000
200 000
150 000
100 000
50 00001955 1975 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Resource: National medical care expenditure 2010 by MHLWNational medical care expenditure accounts for 7.8% of gross domestic product (GDP)and 10.71% of national income (NI).
MHLW estimates that, of the annual growth rate of about 3% for medical careexpenditure in recent years, about 1.5 percentage points are contributed by the aging
population and the remaining 1-2 percentage points are contributed by advancing
health care.
17

Long-term Care Insurance System
The long-term care insurance system allows the insured toreceive long-term care services for a copayment of 10% of theexpenses when they need such services.
Insurers: Municipal governments
The insured: (i) People aged 65 and over and (ii) People aged
40-64, both of who pay the insurance premium.
Eligibility for long-term care services under the system:
Aged 65 and over

Aged 40-64

Those who are in need for longterm care due to being
bedridden, dementia, etc or
who require assistance in daily
life.

Those who are in need for longterm care or assistance in daily
life due to age-related illnesses
including terminal cancer,
rheumatoid arthritis, just to
name a few.

The long-term care insurance system was launched in 2000 under the Long-Term Care
Insurance Act as one of the social insurance system. The scheme aims to support longterm care for older people by society as a whole. As the population ages, the numberof people requiring long-term care are increasing and the duration of long-term carebecome longer. The system was established to cope with the changes in the structureof family such as growing number of nuclear families and aging of family carers.
18

Long-term Care Services• Facility service• Home-based service:
Home visit nursing, home visit long-term care, home
visit bathing, day rehabilitation, day care service, shortterm stay, Rental service / purchase of equipment for
long-term care, etc.

• Community-based service
Periodical round, multifunctional long-term care in asmall group home, home-visit at night for long-termcare, etc.

Services under the long-term care insurance system are largely divided into facility
services, home-based services, and community-based services. Facility and homebased services are designated and supervised by the competent prefectural
government, while community-based services are designated and supervised by thecompetent municipal government.
Facility services are provided to those staying at nursing homes for the elderly andsimilar facilities. Home-based services are essential services to keep older people live
at home, including visiting nursing and day care services. Community-based services
include services provided at group homes for people with dementia as well as theservices mentioned above.

19Government Reponses to an
Aging Population
Comprehensive Reform ofSocial Security and Tax

20In anticipation of a super-aged society, thecomprehensive reform of social security
and tax has been underway.
Securing stable revenue sources and soundnessof public finance
Implementing fundamental tax reform with afocus on raising the consumption tax
Enhancing the social security to support all
generations- Support for children and child-rearing- Reform of health care and long-term care
- Pension reform- Measures against poverty and economic
disparities

Japan is facing a number of changes in the social environment, including an aging
population with fewer children, changing employment pattern, poverty and widening
economic disparities. Social security benefit expenditures have been increasing rapidly
for the past two decades. They are expected to rise further as the population ages. An
increase in social security benefit expenditures has widened the gap between such
expenditures and revenues from social insurance premiums. This gap is filled by large
amounts of public funds, which means an ever-growing national debt. These situation
point to the need for comprehensive reform of social security and tax toward building asustainable social security system.
21

Directions for the reform of Health Careand Long-term Care
When get sick

After discharged<Community based comprehensive caresystem >Acute care hospital
advanced medicine including
emergency and surgery
Early discharge

Sub-acute / subacuterehabilitation
hospital

Focused on
rehabilitation→
early recovery

Local partner
hospital
Everydayhealth care
Primary care
physicianHome
Required staff at acute care settings
will be increase to 1.6-2 fold ofcurrent staff in FY2025

Comprehensive
management- Hub for thecollaboration
among home
based medicine- Community
general support
center- care manager

Healthandmedical careLongterm
care

Visit a Attend a
hospitalcare
Home visit
facility Home visit
medicine/
long-term
nursing
care/ nursing

Living place

Home/ Elderly housing with care

Facilitating thesmooth transition
from medical tonursing careconsultation andcoordination ofservices

Users of home based medicine
and nursing
FY2012 170,000 people/day
FY2025 290,000 people/day

Senior citizen’s club/ long-term careprevention/ livelihood support etc.
Livelihood support/
Preventive long-term care
support
Users of in-home /Home based
long-term care
FY2012 3,5million people/day
FY2025 5,2 million people/day

Note: It is assumed that the geological unit for community-based comprehensive care represents a “middle-school” area with apopulation of about 10,000.
Source: Public relations office, government of Japan; Comprehensive reform of social security and tax, accessed at http://www.govonline.go.jp/tokusyu/201208/naniga/img/jujitsusaku_01_l.gif in September 18,2003.

The Japanese government states that by around 2025, it will solve the issues with theexisting system of health and long-term care service delivery that have been identified
so far and build a new service system that supports residents in a multi-layered andintegrated manner through division of function and coordination.
Specifically, the government aims to ensure that health and long-term care services aswell as preventive services and housing are provided at the daily living area. The local
base hospitals will be covering wider area, and advanced health care services such as
emergency medical services and cancer-related services will be provided at theprefectural level.
It will also work to improve home based health care and long-term care and increase
the number of health care staff including emergency care staff so that people haveaccess to health and long-term care in familiar settings.
22