• aged care policy;
  • family caregiving;
  • Japan;
  • long-term care insurance;
  • Singapore


  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References

Like Singapore, Japan is projected to age rapidly. Japan is the first country in the world where more than 20% of the total population is over 65. Even as Japan adapts from western Europe and America where population ageing is more advanced up till now, it has been pioneering its own aged care policy, given the differences in sociocultural and political contexts. Of particular interest is its introduction of long-term care insurance and its effectiveness in meeting the needs of the long-term care of the aged and their family caregivers. In this article I seek to compare and contrast Singapore and Japan in terms of their demographic changes leading to rapid ageing, and their respective policy and program responses to a rapidly ageing population, drawing lessons from the Japanese experience.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References

People in 16 countries in the world have a life expectancy at birth of 80 years or more, of which only two are in Asia, namely, Japan and Singapore (World Health Organization, 2006a). Japan ranks at the top, with a life expectancy of 82 years for both men and women. In addition, Japan is the first country in the world where more than 20% of the total population is over 65 (Higuchi, 2001). It thus has to create its own aged-care policies and is not able to copy from others (Ogawa, 1997), though in the past it has looked to Western welfare states for policy models with which to meet the challenges of an ageing population (Peng, 2002). As such, it will be a nation that other countries will watch to see what lessons can be learnt from its care of older persons.

This article is organized in three parts. The first part describes and compares the demographic changes in Singapore and Japan, focusing on population ageing (see Table 1 for other demographic aspects). The second part reviews public policy and program responses to the long-term care of the aged in both countries, examining the division of responsibilities of aged care between the individual, the family, and the state. The last part draws on lessons to be learnt from Japan, given its bold policy direction toward mandatory insurance and universal coverage of older persons in the provision of long-term care.

Table 1.   Demographic data for Japan and Singapore
Demographic indicatorsJapanSingapore
Population (mid-2006) (millions)127.84.5
Projected population in mid-2025 (millions)121.15.2
Projected population in mid-2050 (millions)100.65.3
Births per 1,000 population910
Deaths per 1,000 population84
Net migration per 1,000 population020
Infant mortality rate2.82.1
% of population<15 years1420
% of population 65+208
Life expectancy at birth (both men and women)8280
Life expectancy at birth (women)8682
Life expectancy at birth (men)7978
% urban79100
Population density per square mile87618,652

Rapid ageing of populations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References

Of great interest to policy-makers, government bureaucrats, and families in Japan is the rapid ageing of its population and its population decline. In 1950 only 4.9% of its population was aged 65 and over (United Nations, 2005). In 1971, Japan officially became an aged society, with 7% of its total population aged 65 years and over (7% or more is considered by the United Nations to be a marker of an aged society) (Peng, 2002). Singapore attained the status of an aged society in the late 1990s, with 7.2% of its population aged 65 years or older by the year 2000 (Singapore Department of Statistics, 2006). In 25 years, that is, by 1996, the figure doubled to 14.6% in Japan (United Nations, 2005). This rate of population aging is considered rapid, when compared with countries such as France, which took 115 years for its aged population to increase from 7% (in 1865) to 14% (in 1980) (Kinsella & Velkoff, 2001). As of 2005, the total Japanese population is 127.76 million, of which 21% are aged 65 and over (Ministry of Internal Affairs and Communications, Bureau of Statistics, 2006). Its aged population is projected to reach 34.0% in 2040, that is, about one in three will be aged 65 and over.

Singapore’s total population of 4.48 million (as at the end of June, 2006) is very small and is among the smallest in the world, in comparison with Japan’s 127.76 million (1 July 2006) (Singapore Department of Statistics, 2006). The proportion of aged persons (65+) is also comparatively small. Its aged population was projected to increase to 8.4% in 2010 (Inter-Ministerial Committee on the Ageing Population, 1999) but it already reached 8.5% in 2006 (Singapore Department of Statistics, 2006). Singapore’s aged population is projected to increase further to 13.5% of the total population in 2020 and 18.7% in 2030 (Ministry of Community Development, Youth and Sports, 2006).

The ageing of populations in Japan and Singapore is due to two similar demographic trends: a declining birth rate and increasing longevity. The total fertility rate in Japan fell dramatically from 3.65 in 1950 to 1.25 in 2005 (BBC News, 2006; Foreign Press Center Japan, 2006). The total fertility rate for Singapore also decreased sharply from 3.07 in 1970 to 1.25 in 2005 (Singapore Department of Statistics, 2006). Both countries thus belong to a group with critically low levels of fertility (defined as a total fertility rate of ≤1.5), together with the Republic of Korea, Hong Kong, and Macao (Gubhaju, 2007).

In Singapore, life expectancy at birth (both sexes) increased from 60.4 years in 1950–1955 to 78.6 years in 2000–2005 (United Nations, 2005). The corresponding figures for Japan are 63.9 and 81.9 years. For policy-makers, families, and individuals, one of the implications of population ageing with increased longevity is whether the added years are healthy and if not, upon whom will the dependency for care fall. According to World Health Organization, Japan is the world’s healthiest nation where the typical Japanese lives free from disability until the age of 75 (Usui, 2003). The healthy life expectancy for men in Japan and Singapore are 72.3 years and 68.8 years, respectively (2002 figures) and for women, 77.7 years and 71.3 years, respectively (World Health Organization, 2006b).

Where care of frail and dependent elderly is required, most of the responsibility for care falls on women. This is well documented in family caregiving literature. However, women’s capacity to continue to bear the responsibility for care is contingent upon the demand for their participation in the labor market. In Singapore, women’s workforce participation increased from 28% in 1970 to 54% in 2006 (Singapore Department of Statistics, 2007). For Japan, the labor force participation rate for women (all age groups) decreased from 50.9% in 1960 to 48.2% in 2000 but increased for the age group 20–59 (National Institute of Population and Social Security Research, 2006). Although more women join the workforce, the responsibility for care continues to be borne by them, but also increasingly challenged by them, given the high social, emotional, and financial costs of caregiving. The opportunity costs for women dropping out of work to care for aged parents and parents-in-law is substantial (Horlacher, 2002). Even more burdensome is the Japanese caregivers’ mindset that caregiving is a “totalizing” role, meaning it encompasses nearly all of the caregiver’s life (Long & Harris, 2000, p. 31).

In the next section, the care of older persons is reviewed through the perspective of division of responsibilities and redrawing of boundaries for care by the individual, family, community, private market, and the government. At the heart of the policy debate on long-term care of older persons is how the financial costs can be shared between the individual, the family, and the state (Izuhara, 2006) and the reciprocal impact of formal care and informal care.

Policy and program responses to long-term care of the aged

  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References

As in most other countries, both in the East and the West, the family in Japan and Singapore is traditionally responsible for care of older persons. The welfare policies of both countries strongly emphasize family care as the key to aged care, with government assistance targeted at the aged poor and those without families. But Japan has moved in a different policy direction toward greater state responsibility, whereas Singapore is resisting greater state involvement. This section begins with a review of the situation in Japan, followed by that in Singapore.


Family care

In Japan, middle-aged women have traditionally been providing nursing care at home for infirm elderly relations (Ogawa, 2003), reinforced by societal values of filial piety, conformity to group opinion (Yamamoto & Wallhagen, 1997), and the Japanese concept of sekentei, referring to “an individual’s concerns about behaving in a socially acceptable manner as judged by others” (Asai & Kameoka, 2005, p. 114). The cultural norm dictates that wives of sons, particularly first-born sons, should take care of frail and dependent parents-in-law. Elderly men who become bed-ridden are more likely to be cared for by their wives (61%) and daughters-in-law (21.7%) but daughters-in-law (50.4%) are more likely to become the caregivers of elderly women than their husbands (11.4%) (Nishio, 1994). When interviewed, women caregivers describe their experience as “caregiving hell,” as they refrain from using welfare or private sector services due to the strong ideological expectation that they will assume the caregiving role, concern about privacy, their husbands’ disapproval of of the use of outside help, and the lack of assistance from their husbands and other family members (Hashizume, 2000; Higuchi, 2001, 2004).

In the past, the period of care between the retirement and death of older parents has been about 5 years but by the 1990s, Japanese couples can expect to co-reside with one of their parents for more than 20 years after their retirement (Endo & Katayama, cited in Horlacher, 2002). Furthermore, many caregivers are themselves getting old. The Ministry of Health and Welfare reports that half of all caregivers of disabled older persons are themselves 60 years old or older (Jenike, 2003).

Together with the cultural norm of family care there is a strong stigma against the use of formal care, where institutional homes represent the most extreme example of formal provision (Yamamoto & Wallhagen, 1998). Consequently, the proportion of older persons (65+) living in institutional homes in Japan, is only 1.6% versus 9% in Sweden, 5% in the USA, and 4% in Germany (Ogawa, 1997). In contrast, the average length of stay in hospitals is comparatively long. In 2003, it was 36.4 days in Japan versus 13.4 days in France, 10.9 days in Germany, and 6.5 days in the United States (OECD, cited in Ogawa & Matsukura, 2005). Between 1963 and 1995, about half of all in-patients in hospitals were 65 years and older and about one-third of them had been hospitalized for more than one year (Campbell & Ikegami, 2000). The phenomenon of older persons staying for lengthy period in hospitals without a critical medical condition is known as social hospitalization (Izuhara, 2006) and is due to several factors: hospital care is comparatively cheaper than home-based and nursing home care (Sodei, 1997); it is less stigmatizing to place older parents in a hospital than in a residential care facility (Ogawa, 1997; Ogawa & Matsukura, 2005); there is a lack of nursing institutions intermediate between hospitals and homes (Ogawa, 1997); home care services are under-developed and home modification is at an inadequate level (Izuhara, 2006). To control social hospitalization, various measures have been instituted; for example, the development of geriatric health-care facilities to facilitate the transition from hospitalization to home care, but these were not effective (Hiraoka, 2006).

There is also a cultural preference for three-generational living arrangements to facilitate intergenerational support, though statistics suggest a declining trend over the years. In 1980, 69% of those aged 65 and over co-resided with their children (National Institute of Population and Social Security Research, 2006). The proportion fell to about 45.5% in 2004. Those living alone increased from 8.5% in 1980 to 14.7% in 2004 and for those living with a spouse, the increase was from 19.6 to 36.0 for the years 1980 and 2004, respectively. The steady decline in co-residence with adult children is due to elderly Japanese becoming healthier and wealthier (Horlacher, 2002). Younger generations are also differentiating between living together and caregiving; hence, they are looking for ways to provide care for their parents without co-residence (Lai, 2001). As such, the government has abandoned its efforts to promote three-generation household living arrangements (Peng, 2002).

The value of family care is without doubt reinforced by policy initiatives and public service provision. A welfare law for the aged was enacted as early as 1963 but it was targeted at low-income individuals with no relatives to take care of them. Hence, in the 1960s and 1970s, public support for home-based and community-based care was limited and provided only for the destitute. In the 1980s families providing long-term care of the frail elderly began to organize themselves to ask the government to expand public care support (Yamato, 2006). As the care for older persons is predominantly a burden for women, they began to speak up (Eto, 2001). The mass media and welfare experts also advocate support for such families. By the mid-1990s, the media has changed its tone from admonishing adult children to provide care for older parents to extolling the merits of professional care (Jenike, 2003), thereby promoting social acceptance in using social services (Asai & Kameoka, 2005). The idea of long-term care insurance took root in the Ministry of Health and Welfare in the 1980s, paving the way for policy reforms in the 1990s and the implementation of long-term care insurance (LTCI, kaigo hoken) and social care of the elderly in 2000 (Peng, 2002).

In 1989 the Gold Plan (formally known as “Ten-year strategy to promote health and welfare for the aged”) was instituted to expand care services such as home help, short-term stay (respite care), day care, and other residential facilities. The targets were revised upwards in the New Gold Plan in 1994. Nonetheless, as the demand for services is greater than the supply, the expansion under these two initiatives has not been able to meet the needs of long-term care, paving the way for a new service infrastructure beyond the New Gold Plan (Crume, 1997; Ihara, 2000). The steady expansion of services further imply that the government is beginning to recognize the need to provide long-term care support for all frail older persons and not just the aged poor or those without families (Campbell & Ikegami, 2000).

Socialization of care

The 1990s then marked the expansion of the “socialization of care” (a literal translation of the Japanese phrase, care no shakaika) with the state taking on a greater share of long-term care responsibility through the introduction of compulsory insurance, expansion of child care, new legislation on parental leave and family leave, and other support services for workers with family responsibilities (Peng, 2002).

Legislation for LTCI was passed in 1997 but implemented only in 2000. The Japanese government inaugurated the scheme using the slogan of “From family care to society care” (Tsutsui & Muramatsu, 2005). One of the aims of LTCI is to develop both for-profit and non-profit service providers to fill the gap vacated by Japanese families and achieve a broader mix of service providers (Izuhara, 2006). LTCI provides for 12 types of community care benefits (e.g. home help, bathing, home nursing, day service, respite care, home modification) and three types of institutional care benefits (special nursing homes, health service facilities, and geriatric care hospitals). LTCI benefits are in the form of services, with values ranging between US$500 to US$3,300 per month for six different levels of care (Campbell & Ikegami, 2003). Municipalities (cities, towns, villages, and special wards in Tokyo) determine the amount of insurance premium to be collected, which varies according to five categories of individual income of the elderly and averages US$329 for the year, as of 2003 (Ozawa & Nakayama, 2005). Eligibility for benefits is determined by the age and health status of care recipients rather than the non-availability of family care. Certification of the need for services and the classification of the level of needs required is based on an elaborate 85-item questionnaire and a standardized (by the national government) computerized assessment and panel of experts. Those classified as in need of support receive only community care whereas those classified as in need of care (at one of five levels) are eligible to receive both community care and institutional care services. There are two types of beneficiaries: those aged 65 years and older (type 1) and those between 40 and 64 years old who have health conditions associated with aging, for example, premature senility, Parkinson’s disease and rheumatoid arthritis (type 2). Insurance premiums cover 50% of the LTCI budget, with the other 50% funded by taxation through all three levels of government. Payment of premiums is built into existing social security system and is efficient in not requiring a separate financial infrastructure (Lai, 2001).

The LTCI program deviates from the traditional approach to aged care in several aspects: in the (i) shift of major responsibility from the family to the state; (ii) universal coverage of care, based on level of care required rather than income status; (iii) integration of medical care, nursing care, and welfare services within a single financing scheme; (iv) promotion of consumer choice by allowing service users free choice of care providers, including for-profit organizations; (v) provision for older persons to share costs through payment of insurance premiums and 10% co-payment; and (vi) expansion of local government autonomy and management (Campbell & Ikegami, 2000; Talcott, 2002). LTCI also introduces the concept of care management in which a new group of personnel – care managers – is tasked to develop care plans for the elderly. Another noteworthy breakthrough of LTCI is that it has opened the door to institutional care for middle-class families and enabled middle- and upper-class families to use long-term care services at lower rates of payment (Hiraoka, 2006; Matsuda & Yamamoto, 2001).


Family care

The 2000 census of population shows that most of the elderly aged 65 or over (about 88%) live with their spouse and/or children (Leow, 2001). Those living alone without a spouse or children constitute only 6.6% of this group. Furthermore, for 75% of the elderly, their main source of financial support is from their children, with women (84%) showing a higher dependence than men (63%) (Leow, 2001). However, as in Japan, the proportion of older persons living alone or with spouse only is projected to increase, as indicated by current trends. In 1995, 9.7% of this age group was living alone or with spouse only. Ten years later, this proportion increased to 19.9%.

Relying on the family’s traditional motivation to provide care and assistance is not realistic, given the changing trends towards smaller families, a desire for greater privacy and independent living among adult children, and the greater participation of women in the labor market. More formal policy measures are put in place to support family efforts in meeting needs relating to health, housing, and personal care. In Singapore, the government does not believe in making health care free but wants to get its citizens to save for it. Oolder persons with inadequate savingsmay rely on their children, who are encouraged to top up the central provident fund (CPF) accounts of their parents and to use their Medisave accounts to pay for the hospital expenses of their parents and grandparents. The CPF, established in 1955, is essentially a social security cum mandatory savings scheme whereby employers and employees contribute a percentage of wages to CPF savings accounts, held by individuals. The CPF contribution rates are revised from time to time in accordance with the prevailing economic conditions and the country’s economic policy to manage labor costs and sustain economic competitiveness. As of 1 October 2003, the employee’s contribution rate is 20% of wages, and employer’s contribution rate is 13%, for workers aged 50 and below (for other age categories, refer to the website of Central Provident Fund, The CPF contributions are allocated to three accounts with different purposes: an ordinary account that can be used to buy housing, approved investments in stocks and shares, and so on; a Medisave account that can be used to pay for health insurance premiums, hospital expenses, and certain outpatient treatment such as chemotherapy, radiotherapy, and renal dialysis, and a special account that is closed and transferred to a retirement account when the individual reaches official retirement age.

The Medisave account (introduced in 1984) is to meet the healthcare needs of CPF members and their immediate family members, including grandparents. The current cohort of older persons has a low Medisave savings balance, averaging US$3,478 (S$5,300), which may be inadequate (Ministry of Community Development, Youth and Sports, 2006). In addition, adult children are encouraged to buy health insurance for their parents using their Medisave accounts. As Medisave may not be sufficient for the high costs arising from chronic or major illness, CPF members can supplement with Medishield (an optional health insurance plan for major illnesses, introduced in 1990) or Medishield Plus (an upgraded health insurance plan introduced in 1994 to provide higher coverage and greater protection than Medishield). As at December 2004, 82% and 60% of people in their sixties and seventies, respectively, were covered under Medishield and other types of insurance products (Ministry of Community Development, Youth and Sports, 2006).

Collective responsibility of care

To prepare for the needs of an aging society the Singapore government has set up various national committees, the earliest of which was the Committee on the Problems of the Aged in 1982 and the latest being the Committee on Ageing Issues(CAI), set up in 2004. The overall approach of these national committees is aligned with the Singapore government’s aversion to a generous welfare state, and calls on older persons to be self-reliant and their family members to provide the care and support they need. Community organizations are mobilized to do their part to assist the elderly to remain in the community for as long as possible and to support the families in their caregiving tasks and responsibilities.

The CAI report, which was released in mid-2006, is no different. The Committee affirms the basic principle of collective responsibility of care established by the Inter-Ministerial Committee on the Ageing Population in 1999, by four key agents; the individual, the family, the community, and the nation. Singapore’s public policy emphasize “family as the first line of care” and the community as the “second line of support to enable families in their caregiving role” (Ministry of Community Development, Youth and Sports, 2006, p. 12). The role of the state stated ambiguously, is “to provide a framework that enables” the other three (the individual, the family, and the community) to “play their part” (Ministry of Community Development, Youth and Sports, 2006, p. 12). At policy level this means that the government sees itself as developing a high level of national preparedness for an ageing society, maintaining a competitive and vibrant economy, and facilitating social cohesion and “rootedness” (Ministry of Community Development, Youth and Sports, 2006, p. 11). In practice, this means that the government provides the minimal delivery of services, primarily for the very poor, through public assistance programs and Medifund (a means-tested financial assistance program for the poor who are unable to pay hospital and medical expenses). In the 2006 fiscal year, about US$26.2 million (S$40 million) was disbursed. Of the 290,000 beneficiaries, about one-third was above the age of 65 (Khaw, 2007). Furthermore, recipients of public assistance are entitled to free medical service at government polyclinics. Other Singaporeans aged 60 and above are entitled to a subsidy of 50% of the fees charged at government polyclinics. Individuals making use of step-down care (community hospitals, nursing homes, hospices, day rehabilitation centers, and in-home care services) receive varying levels of subsidies (25%, 50%, or 75% of fees), based on means testing.

Where long-term care principles are concerned, ageing in place (a reference to growing old in one’s home, community, and even in a residential facility) seems to be a key feature of the policy and program recommendations of the CAI. Hence, the four key areas of service development identified by the CAI revolves around living in the community and providing community support to families responsible for caregiving – elder-friendly housing, a barrier-free society, holistic and affordable health and eldercare services, and active lifestyles and well-being.

The CAI did not specify growth targets for service development in its report and so it is difficult to assess the adequacy of the service plan. It is estimated that only 3% of the elderly will require institutional care and 5% will need community care (Inter-Ministerial Committee on the Ageing Population, 1999). This may be an under-estimation, judging from the findings of the 2000 population census that indicates a lower level of functioning: 89% of the elderly are ambulant as compared to 8% who are semi-ambulant and 3% who are non-ambulant (Leow, 2001). Furthermore, ambulatory status is only one aspect of functional capacity. Assessment according to activities of daily living (ADL) is more comprehensive for service planning purpose. A more accurate projection of the need for services also requires multi-dimensional assessment that includes physical, cognitive, and mental aspects of healthy functioning. The service needs of those with dementia should be given special consideration, as they are physically mobile but cognitively poor, with worsening prognosis over time.

With respect to long-term care, Singapore implemented Eldershield in 2002 to provide basic insurance cover for Singaporeans with severe disabilities (i.e. those unable to perform three or more of six Activities of Daily Living, namely, mobility, feeding, transferring, dressing, washing, and going to the toilet). All Singapore citizens and permanent residents who reach the age of 40 and have a Medisave account are automatically enrolled in Eldershield, but those who do not wish to be covered may opt out. The insurance scheme provides cash benefits of about US$197 (S$300) per month up to a maximum of 60 months. The amount of benefits and period of assistance is currently under review, as both are considered inadequate in terms of meeting long-term care needs. As at the end of 2006 there were about 750,000 individuals covered under Eldershield, of which only 15% were aged 60 and above (Wong, 2007). However, this age category comprised 62% of the 2,366 successful claimants for Eldershield benefits. The low level of claims should also be reviewed to determine whether the criteria for claim eligibility are too stringent.

Comparative approach to long-term care insurance

Table 2 summarizes and compares the main features of Japan’s LTCI and Singapore’s Eldershield insurance. In Japan the state has changed its policy direction to assume greater state responsibility for long-term care, whereas Singapore still adheres to a policy endorsing strong family responsibility and both emphasize community care and minimize institutional care. As Singapore treads carefully, as in a minefield, Japan provides a useful case study on aged care policy, not only for Singapore but also for other countries.

Table 2.   Comparative approach to long-term care insurance
Program featuresJapanSingapore
Name of programLong-term care insurance (kaigo hoken)Eldershield
Year implemented20002002
Scope of coverageMandatoryAutomatic with provision to opt out
Coverage of age cohortGroup 1: 65 or over Group 2: 40 to 6440 or over
Payment of premiumsBy age and income of individualsBy age and gender (women pay more)
Type and cash value of benefitsService benefits, valued between US$500 and US$3,300 per monthCash benefits of US$197 per month up to 60 months
AssessmentBased on requirements for community care and institutional careBased on capacity to perform six types of activities of daily living

Lessons to be learnt from Japanese experience

  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References

The implementation of LTCI brings about many challenges (Ikegami, 2004; Saidel, 2004; Tsutsui & Muramatsu, 2005; Watanabe & Lai, 2001) and lessons for policy-makers and policy analysts but this article will consider only selected issues, as follows: formal versus family care, cash versus in-kind benefits for family caregivers, and the benefits versus the costs of LTCI.

Formal versus family care

The tension between formal and family care revolves around the possible erosion of family care as formal care expands and becomes more easily available to those who previously could not afford the more expensive formal care or were previously restricted from using public care. The introduction of a public, mandatory long-term care insurance in Japan is considered radical and surprising, from the perspective of Japan’s status as a welfare state laggard (Campbell & Ikegami, 2000).

Since its implementation in 2000 some scholars have attempted to assess the impact of LTCI on family care. The popularity of day care and respite care suggest that families juggle their responsibility for care and need for caregiving relief by having aged parents and parents-in-law out of the house for part of the day or year (Campbell & Ikegami, 2003). The utilization rate of in-home care services by the elderly living with children is lower than those for day care, possibly due to a general reluctance to have outsiders, such as home helpers, come into their homes, (Hiraoka, 2006). Among older persons, the underlying implication of failure to fulfill family obligations remains and some have difficulties adjusting to a situation of strangers coming into the home to provide personal and nursing care (Izuhara, 2006). Some caregivers have said that that public care cannot replace family care as the emotional and social ties of family members to the care recipients are important facets of caregiving (Jenike, 2003; Long & Harris, 2000) and that “home is the best place for the elderly” (Jenike, 2003, p. 184). Others argue that the quality of care, for example, the provision of rehabilitation and social participation that is available through day care, may be higher than that provided at home (Ikegami & Campbell, 2002).

It remains to be seen, therefore, whether formal care will replace or supplement family care in the years to come. With smaller family sizes and the increasing prospect of living alone or with a spouse only in old age, the availability of formal care may be a necessity rather than another option.

Cash versus in-kind benefits for family caregivers

The question of whether to provide cash allowance to families instead of benefits in the form of health and social services was a controversial issue in the policy debate leading to the implementation of LTCI.

The arguments for cash benefits include facilitating consumer choice, recognizing the labor of family caregivers, saving money by setting the cash value lower than the value of direct services, as in Germany, where the long-term care insurance program sets a cash payment at 50% of the cost of equivalent service (Campbell & Ikegami, 2003; Crume, 1997). The arguments against cash benefits are that demand for formal services will be lower, which will then limit the expansion of services, particularly formal community care services, which serve as an alternative to institutional care. They will reinforce prevailing patterns of family care by women who are “trapped” in co-resident living arrangement. Care services provided by trained personnel are better than that provided by family members, who tend to be overprotective and keep older persons in bed; and more families will apply for cash, whether they need it or not, whereas benefits in the form of services will be used only by those who need them (Campbell, 2002; Campbell & Ikegami, 2003; Ihara, 2000).

Feminists are strongly opposed to the cash option, considering the proposed payment of about US$169 to US$421 (20,000 to 50,000 yen) per month and the absence of accident insurance, as is provided by the German system, as indicating a nominal expression of appreciation rather than adequate payment for care work (Webb, 2003). There is also a concern that cash payment may not necessarily result in better care if it is absorbed into the general household budget, a problem that can be resolved using vouchers (Ikegami & Campbell, 2002). The final decision was therefore to opt for service benefits, even as many continue to disagree with this choice (Campbell & Ikegami, 2003).

Benefits versus costs of LTCI

During the policy-making stage, cost is not a major consideration as most of the LTCI expenditure, in the early years, will be replacing spending already in place for the health and social services budget (Campbell & Ikegami, 2000). Within the first 3 years of operation, overall expenditures were within the budget (Tsutsui & Muramatsu, 2005). However, the long-term financial sustainability of LTCI in meeting the need for long-term care is being questioned.

The proportions of older persons certified as eligible for services have increased from 10.5% of all older persons in 2000 to 16.0% as of December 2004 (Wiener et al., 2007), higher than the 12% ratio used for planning purpose (Mitchell, Piggott & Shimizutani, 2004). An examination of the annual LTCI expenditures further shows an increasing proportion of health expenditure incurred in community care, from 33% of total expenditure in 2000 to 45% in 2003 (Ikegami, 2004). Conversely, the proportion spent on institutional care decreased from 67% in 2000 to 55% in 2003. However, there has been an increase in institutional care in absolute terms, as the number of nursing-home beds has been growing at a rate of 10% per year (Ikegami, 2004). Furthermore, many nursing homes have waiting lists that are three to five times longer than before the introduction of LTCI (Shirasawa, 2004). The surge in applications for institutional care is the result of a reduction in the stigma for using such care and in-home care remains “inherently oppressive to women” (Campbell & Campbell, 2003, p. 4).

At the start of LTCI implementation, cost control was exercised through 10% co-payment and other measures, for example, not paying for meal charges in institutional care. To further manage costs, on-going revision of LTCI emphasized preventing disability and institutionalization, encouraging healthy and independent living, and promoting ageing in place through enhancing in-home and community-based services (Ministry of Health, Labour and Welfare, 2006; Tsutsui & Muramatsu, 2005). Benefits were reclassified as prevention benefit (support levels 1 and 2) and care benefit (care levels 2–5) and implemented with effect from April 2006.

In terms of policy benefits, there has been an increase of 59%in service providers from 95,892 in May 2001 to 152,264 in May 2005. The expansion of services is greater in home help, social day care, respite care, and “others” (such as the loan of wheel-chairs,) (Ikegami, 2004), with the greatest growth in group homes for people with dementia (Wiener et al., 2007). The growth in these services is attributed mostly to the entry of for-profit operators. Another indicator of policy benefits is the growing number of beneficiaries. The number of service users increased by 121% from 1.49 million persons in April 2000 to 3.29 million in April 2005 (Ministry of Health, Labour and Welfare, 2006). The number of community care users grew more, from 970,000 persons in 2000 to 2.51 million in 2005 (an increase of 159%), whereas institutional care users increased from 520,000 to 780,000 (an increase of 50%), respectively.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References

With aging populations the provision of long-term care is inevitable. In designing a long-term care system, there are various policy options to consider: (i) whether to use a tax-based, insurance, individual saving accounts, or mixed approach to financing; (ii) whether to cover care recipients based on income and assets, age or disability; (iii) whether to use care managers or medical/social service personnel for the assessment of eligibility for services; (iv) what form of benefits to provide – institutional care, in-home care, day-care and night-care in the community, or material support; (v) how to organize the provision of benefits – in-kind, cash, or voucher; (vi) who should deliver the services and what the mix of providers should be – public, non-profit, and/or for-profit organizations; and (vii) how to integrate long-term care services with other health and social services (Ikegami & Campbell, 2002; Jacobzone, 1999).

Given the mix of policy options available it is hard to ascertain whether Japan’s approach to long-term care is the best or is an example for other countries to follow, as such choices reflect issues such as societal values, institutional legacies, political will and economic realities. Its experience thus far and its continuing experiment to revise and strategize, however, provide useful lessons for those interested in adopting the same options. While the issue of costs and affordability looms large, it often involves a trade-off between private and public costs, including costs made by individuals, as in spending their lifetime savings, and families digging into household expenses and retirement savings. A key question, from a societal perspective, is whether the care system is efficient and fair (Ikegami & Campbell, 2002). If not, it is not just the current cohort of older persons with long-term care needs who are affected but society as a whole and generations to come. From an individual’s point of view a more important question is whether a long-term care policy is designed to meet only their basic needs or a better quality of life.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Rapid ageing of populations
  5. Policy and program responses to long-term care of the aged
  6. Lessons to be learnt from Japanese experience
  7. Conclusion
  8. References
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