Source: New Weekly
"I never expected that the nursing homes in Japan would be so backward."
This was the first impression of Akitsune Kawaguchi when he entered the elderly care industry in 2013. Before that, he worked for a Japanese manufacturing company's branch in Xiamen, accustomed to a mechanized and IT-driven work environment. If not for his uncle's invitation to return to Japan to help manage a nursing home in Toyama Prefecture, Akitsune Kawaguchi might not have realized that the Japanese elderly care model, seen as exemplary by many, was far from perfect.
In the following 10 years, Akitsune Kawaguchi, serving as executive director and special care nursing home director of "Social Welfare Corporation Kijuku-kai" (hereinafter referred to as "Kijuku-kai"), promoted the "3A care reform" (safety, security, comfort) in the nursing home and witnessed the real challenges faced by Japan's "ultra-aged society"—the seemingly impressive elderly care system is overshadowed by deep-seated crises such as insufficient national budget, severe shortage of caregivers, and lagging technological levels.
These personal experiences and profound observations were eventually recorded by Akitsune Kawaguchi in his book *High Tide of the Elderly*. In it, he meticulously outlines the development history of Japan's elderly care system, the complex long-term care insurance system, and his firsthand experience as a nursing home director.
[Japan] Akitsune Kawaguchi and Ling Yun, China Workers Publishing House · WanChuan, 2025-2
Japan is the country with the highest degree of aging globally. In 2024, the population aged 65 and above reached 36.243 million, accounting for 29.3% of the total population. In Toyama Prefecture where Akitsune Kawaguchi lives, the proportion of elderly people exceeds 30%. Occasionally, he sees cars occupying two parking spaces. "Such cars often have labels indicating they are driven by elderly drivers; the vehicles are old, covered with scratches and dents, which can imagine how many times this elderly driver has been involved in accidents," he said.
Currently, China's population aged 65 and above has exceeded 210 million, accounting for 15.4% of the total population. Compared to Japan, China's aging scale is larger and its pace faster. Is our society prepared for the impending tidal wave of the elderly?
In Akitsune Kawaguchi's view, China's elderly care industry is still in the stage of expanding service quantity. While there are some institutions providing excellent quality services, overall, the quality of services has yet to reach ideal levels.
"Japan's land area is small, with little regional disparity; whereas China is vast, with significant differences in development levels across regions. We cannot simply copy experiences." This is also why Akitsune Kawaguchi, who once studied history at Renmin University of China, wrote this book in Chinese, hoping to share Japan's experiences and lessons with more people, "so that both China and Japan can smoothly cope with the tidal wave of the elderly, ensuring that the elderly are taken care of and supported."
How much monthly income is needed to afford a nursing home?
The day we met, Akitsune Kawaguchi and I visited a leading chain elderly care community within the country. Upon entering the compound, the first thing we saw was a smart platform displaying real-time operation data from 24 communities nationwide: over 16,000 residents currently living here, with the majority aged between 80 and 90, including 2,000 "influential residents" such as academicians, school presidents, and retired officials.
Within the community, the rent for a one-bedroom apartment is around 8,000 yuan per month, excluding meal expenses; the rent for a two-bedroom apartment exceeds 10,000 yuan. The park landscaping is exquisite, hosting dozens of cultural and rehabilitation activities daily. However, such prices are undoubtedly out of reach for most ordinary people. In broader rural areas, finding a reliable nursing home under 1,000 yuan for elders without children nearby and unable to take care of themselves is extremely difficult.
Young people often say that they work hard now just so they can afford a nursing home in their old age. "Affordability" has become the greatest concern for many when imagining their future retirement life.
Some high-end elderly care community fee standards in China. (Photo/Taikang Community)
Compared to China, the biggest feature of Japan's elderly care model lies in its establishment on a nationwide unified long-term care insurance system. Residents start paying from the age of 40, determining whether they can enjoy long-term care support and what kind of services they can receive based on this. Ideally, the long-term care insurance system makes "old-age support" an institutional commitment.
For example, if a 65-year-old elder wants to apply for long-term care services, they must first undergo "long-term care certification." The assessment results are divided into "support needed" (levels 1-2) and "care needed" (levels 1-5), totaling seven levels, with higher levels indicating greater need for care.
Akitsune Kawaguchi served as a committee member of the long-term care certification review board in Shizuishu City for four years. Every month, he attended two review meetings, reviewing about 30 applicants each time. The review content includes the degree of self-care, whether they suffer from dementia, etc., based on information from investigators' observations, applicant and family-provided information, and doctor's diagnosis.
Although the law is impartial, after all, the reviewers are human beings. Occasionally, when encountering particularly tragic cases, some members may suggest, "Can we increase the care level by one grade?" If unanimously agreed, the level will be raised. Akitsune Kawaguchi recalled that during his four years of service, he encountered such situations three or four times. For the elderly, this means they can enjoy more nursing services.
Care workers attend to the elderly at home. (Photo/The Death Nurse)
Japan's long-term care system is extremely complex, even confusing for many locals. Therefore, after completing the long-term care certification, usually a "care manager" helps the elderly tailor a "care plan," which is then provided by the corresponding organization.
Long-term care services are mainly divided into three categories: home-based, community-based, and institutional. Home-based elderly care includes visiting care (door-to-door service), daycare, short-term stay, and "fee-based nursing homes," which are closest to the Chinese concept of nursing homes. Institutional elderly care is mainly divided into two types: one is "long-term care rehabilitation facilities" that provide rehabilitation training for the elderly, and the other is "special care nursing homes" (referred to as "special care") that exclusively serve severely disabled and demented elderly people.
In any case, the charging standards are basically uniformly regulated by the government, priced clearly according to project, duration, and care level. The elderly bear 10%-30% of the costs, with the rest covered by long-term care insurance. For example, a "visiting bath" (door-to-door bathing) costs 12,660 yen, which, at a 10% self-payment rate, amounts to approximately 63 RMB in renminbi.
In NHK's special program *Old Age Bankruptcy*, it was mentioned that many elderly people living on pensions already face financial difficulties. Even bearing a 10% self-payment burden, hourly services cost 500 to 1,000 yen. Once bedridden and requiring additional care, the excess costs are fully self-funded, exceeding 10,000 yen, and could easily lead to "old-age bankruptcy"—"when the money stops, the service stops."
[Japan] NHK Special Program Production Team, edited by Wang Jun, Shanghai Translation Press, 2018-8
Trapped in "Add-ons" as a Nursing Home Director
Chinese people value "returning to one's roots," and the "9073" elderly care pattern—90% home-based care, 7% community-based care, and 3% institutional care—is based on this concept.
The situation in neighboring Japan is similar, with approximately 60% of the elderly hoping to spend their final days at home. However, once professional care is needed, home-based care becomes difficult to implement, and ultimately most families still choose nursing homes.
"Special care" facilities offer high-quality services, low fees, and no prepayment required, resulting in long waiting lists. To ensure fairness, nursing homes must establish "admission evaluation committees" to decide priority admission. According to data from Japan's Ministry of Health, Labor, and Welfare, in 2022, among severely disabled elderly people with care levels 3-5, the waiting list reached 252,000 people.
Kijuku-kai, where Akitsune Kawaguchi serves as executive director, is a nursing home specializing in special care, also offering daycare and short-term stays, with 90 beds for special care and 30 beds for short-term stays.
People admitted to Kijuku-kai. (Photo/Facebook@Social Welfare Corporation Kijuku-kai)
In the 1990s, when Japan's population aged 65 and above exceeded 12%, the government introduced the "Golden Plan" (i.e., the "10-Year Strategy for Promoting Elderly Health and Welfare") to add 100,000 "special care" beds by 1999 to address the accelerating trend of aging.
Under this opportunity, Akitsune Kawaguchi's uncle founded Kijuku-kai. At that time, half of the construction costs for nursing homes were subsidized by the government. However, after the "golden period" of care ended, government subsidies were significantly reduced, and operators were unwilling to invest further in heavy assets. As a result, the growth rate of special care nursing homes slowed down. According to surveys by the Ministry of Health, Labor, and Welfare, in 2022, the profit margin of 16,000 special care facilities nationwide was -1.0%.
To increase revenue, nursing homes can only seek "add-ons," which are additional government subsidies. For instance, achieving a certain percentage of "care workers" qualifies for add-ons. Additionally, there are "add-ons" for specialized dementia care, oral hygiene management, excretion support management, and pressure sore management.
In contrast, if preventive measures against abuse and emergency plans are not set up, penalties ("deductions") will be imposed. "Just basic information alone," Akitsune Kawaguchi said with a wry smile, "has resulted in over 500 pages of electronic forms published by the Ministry of Health, Labor, and Welfare. Only the most basic information is listed, and understanding them requires referring to publishers' guidance manuals—it's really headache-inducing." However, he added, "But you can't avoid studying them." Add-ons determine the survival and financial capacity of nursing homes to push reforms.
Accompanied by a caregiver, this elderly person trims hedges independently. (Photo/Facebook@Social Welfare Corporation Kijuku-kai)
Not long after Akitsune Kawaguchi took office as director, he encountered a complaint incident. A large bruise appeared on an elderly person's chest, and the family became very angry, suspecting abuse. Akitsune Kawaguchi believed this was due to a mishap during the caregiver's relocation. At that time, Kijuku-kai's care work heavily relied on manpower, with caregivers lifting immobile elderly people dozens of times a day—from bed to wheelchair, from wheelchair to toilet, and back to bed.
The male-to-female ratio of caregivers at Kijuku-kai is about 2:8. The average weight of Japanese women aged 80 and above is 48 kilograms, while men are 60 kilograms, making it not easy to lift elderly people of such weight. Thus, lower back pain is the most common occupational disease among care workers. For the elderly, "lifting" is not an ideal method either; it can cause subcutaneous bleeding at best and fractures at worst.
However, without evidence, Akitsune Kawaguchi could only repeatedly explain and apologize, promising to take improvement measures. Eventually, the family accepted the apology but still moved the elderly person to another nursing home.
This unexpected event made Akitsune Kawaguchi resolve to promote "safe care." Starting in 2017, he implemented a "lower back pain prevention project" at Kijuku-kai, purchasing lifting equipment and care robots for relocation. Within three years, the lower back pain rate among caregivers dropped from 40% to 20%, and the number of reports of subcutaneous bleeding in elderly people decreased from 200 cases/year to 17 cases/year.
Today, caregivers at Kijuku-kai no longer need to "lift" the elderly. (Photo/Interviewee)
However, it wasn't until 2024 that the government introduced related rewards ("add-ons"). As a "pioneer," Kijuku-kai was unable to receive subsidies.
"There is a Japanese saying, 'Each institution is unique,'" Akitsune Kawaguchi said. Profit and welfare are relative concepts, and each institution provides different services and scales. "Finding the balance between profit and welfare is one of the most important tasks for nursing home operators."
"Low pay, heavy workload, exhausting work," who would want to be a caregiver?
Having been in the elderly care industry for over a decade, Akitsune Kawaguchi's most direct feeling is the increasing severity of the caregiver shortage. "How is your talent situation?" has almost become a routine greeting between nursing home directors upon meeting.
Akitsune Kawaguchi said that his uncle once told him that it was very easy to recruit caregivers around 2000, with one position attracting more than ten applicants. But by 2013 when he entered the industry, it had become a 1:1 replacement rate. Later, the number of applicants noticeably decreased; often, two people resigned but only one new person could be hired.
According to statistics from Japan's Ministry of Health, Labor, and Welfare, in 2023, the number of caregivers in Japan was 2.126 million, far below the required 2.33 million. With the arrival of the "2025 problem"—the "baby boom generation" born after World War II entering the "late elderly" phase at 75 years old and above, Japan's demand for caregivers will reach 2.43 million in 2025. If this gap is not filled, the long-term care insurance system supporting the aging society may become unstable.
In both China and Japan, it will become increasingly common for sixty-something people to care for eighty-something people. (Photo/Mother!)
On the contrary, the talent shortage problem in China is even more severe—according to the *2024 Survey Research Report on the Current Status of Elderly Care Workers*, the current number of practitioners in China's elderly care industry is only 500,000, with a shortfall of 5.5 million, and approximately 65% of practitioners are over 50 years old.
"Young people don't want to be caregivers because, fundamentally, the wages are low, social status is low, the work is tiring, and career prospects are unclear," Akitsune Kawaguchi pointed out bluntly.
According to a 2022 survey by Japan's Ministry of Health, Labor, and Welfare, the average annual income across all industries is 4.96 million yen, with caregivers (average age 42.4) earning an average annual salary of 3.628 million yen, and visiting caregivers (average age 49.1) earning even less, only 3.53 million yen, both below the societal average. In Japan, this income can sustain basic living but does not offer affluence, let alone offset the physical and mental stress brought by long-term care work.
To alleviate the labor shortage, the Japanese government looked overseas, attracting more foreign caregivers through open technical internships (so-called trainees) and specific skill visas. As early as 2016, Akitsune Kawaguchi's nursing home hired two Indonesian caregivers. "At one point, foreign caregivers made up 7% of our nursing home staff. There were also Chinese caregivers before; their advantage was knowing Chinese characters, making communication easier."
Japanese nursing homes have introduced more foreign caregivers. (Photo/NHK)
Akitsune Kawaguchi clearly felt that in recent years, the number of Chinese people going to Japan for caregiving has been growing rapidly, nearly doubling from 2022 to 2023. Additionally, many Chinese students studying caregiving hope to stay and work in Japan, obtaining permanent residency. According to data from the Japanese Long-Term Care Worker Training Facilities Association, among the 3,054 international students in 2024, students from Nepal, Vietnam, and Myanmar ranked top three, with China placing fourth with 233 students.
Some claims circulating on Chinese internet, such as "Japanese caregivers have the same social status and income as office white-collar workers, or even higher," seem somewhat detached from reality and overly idealistic in Akitsune Kawaguchi's view. Nursing homes starkly reveal the most real and sometimes unappealing aspects of later life. Caregivers face the elderly's daily eating, drinking, toileting, incessant emergency call bells ringing at night, and the unpredictable and sometimes aggressive behavior of those with dementia every day.
"When discussing Japan's elderly care, people rarely mention the negative aspects. Only by acknowledging the less-than-ideal parts can we learn from each other and avoid repeating past mistakes," Akitsune Kawaguchi said.
When inspecting elderly care facilities, Akitsune Kawaguchi always pays particular attention to details often overlooked—bathrooms are the places where the elderly are most likely to slip and have accidents, so he carefully examines floor materials, handrail designs, and the placement of call buttons. Surveillance equipment must also be considered: for children, surveillance means "care," but if cameras are too obvious, it may make the elderly feel "being watched."
At Kijuku-kai, "yuzu-yu" is provided on Winter Solstice. (Photo/Facebook@Social Welfare Corporation Kijuku-kai)
So-called service quality often lies in the minutiae. For elderly individuals with limited mobility, eating is one of the happiest moments of the day. However, many nursing homes, for safety reasons, grind food into liquid form, which is unlikely to stimulate appetite and may affect the elderly's nutritional intake in the long run. Improvement is actually simple: placing liquid food in molds and shaping it can pique the elderly's interest. "The key is to consider things from the perspective of the elderly," Akitsune Kawaguchi said.
"Japan's advocated elderly care model emphasizes self-help, mutual assistance, shared assistance, and public assistance," Akitsune Kawaguchi explained. Self-help means allowing the elderly to do what they can, mutual assistance emphasizes help among neighbors, shared assistance relies on long-term care insurance, and public assistance refers to guarantees outside of long-term care insurance, such as low-income assistance.
Last year, the popular Japanese drama *Two People Living Together* highlighted "neighborhood mutual assistance for elderly care" again—people began to imagine that staying at home doesn't necessarily mean being lonely in old age but rather living with like-minded friends and neighbors, taking care of each other.
Two 50-something single friends return to their hometown to live together. (Photo/Two People Living Together)
In *High Tide of the Elderly*, Akitsune Kawaguchi also proposed the community symbiosis model of "elderly care + ××," such as the combination of "elderly care + children" or "elderly care + disability."
Aoi Care, located in Kanagawa Prefecture, Japan, initially started as a closed senior home. Later, the operator decided to demolish the eastern wall, unexpectedly bringing new vitality—the nearby elementary schoolchildren discovered that passing through the campus could shorten their route to school, so they began to illegally enter Aoi Care to smuggle through side streets to get to school. After school, they played in Aoi Care's courtyard. Thus, the elderly were no longer just recipients of care but became "grandparents" to the children.
Another seniors' apartment, Ginmokusei, attracted children by setting up a small shop at the entrance selling very affordable snacks, starting at 10 yen, with 100 yen buying several items. Initially, only a few curious children stopped by; gradually, Ginmokusei became a gathering place for children after school. Some elderly people volunteered as shopkeepers, and Ginmokusei hired them. With work, the elderly found meaning in their existence and became more proactive in facing life. Even dementia patients making incorrect change would be patiently reminded by the children: "Grandma, you miscalculated. I bought five items at 10 yen each, totaling 50 yen, and gave you 100 yen, so you should give me back 50 yen."
Children buy snacks at Ginmokusei. (Photo/Ginmokusei)
This perhaps reveals the essence of the elderly care issue: systems are foundational safeguards, while the connections and warmth between people are the true remedies against aging and loneliness.
"Aging is a natural law that cannot be avoided and can only be accepted with equanimity," Akitsune Kawaguchi said. He and his Chinese wife haven't decided where to retire yet—maybe in China, maybe in Japan. For now, they just hope to enjoy life while they're still healthy, savoring the present to the fullest.
Original article: https://www.toutiao.com/article/7505215081542599203/
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