Gaia Series 86: Toward An Ideal Nursing Care Society

As Japan’s care industry faces crisis, grassroots carers and private firms forge competing futures for eldercare.

As Japan enters the era of the “super-aged” society, its care industry teeters under pressure. In this week’s Japan Hour, the camera follows a deeply personal and urgent story of two contrasting care models: One rooted in community compassion, and another driven by corporate efficiency and private investment. What emerges is a portrait of a nation grappling with how to care for its elderly — and who will be left to do the caring.

The programme opens in Chiba, where 75-year-old Miyoko Hagiwara, herself a senior citizen, rides a scooter to her next client’s home. A home care assistant, she visits a 97-year-old woman with advanced dementia. “My daughter always says, ‘I’m glad you are of sound mind. But be careful, seriously,’” Ms Hagiwara shares with a chuckle. Her care includes helping with daily maths and budgeting – simple tasks that are powerful forms of dementia therapy.

“She’s like my own mum,” Ms Hagiwara says tenderly. But her work takes a toll. “Two or maybe three [clients] a day… My body just can’t keep up anymore.” At her agency, more than half of the 40 carers are over the age of 60. Japan’s care workforce is itself ageing — a stark symbol of the nation’s looming 2025 problem: by next year, all baby boomers will be aged 75 or older, pushing the country deeper into a super-aged society.

The impact is already visible. In 2023, a record 529 home care agencies shut down. “With carers disappearing, that’s becoming truly difficult,” says Ms Megumi Kadowaki, head of nursing at the Chiba Worker’s Welfare Association. And yet, care services received virtually no increase in government funding in the latest budget. “The government is trying to improve it, but funding is limited,” a health ministry official concedes.

In Setagaya, Tokyo, this crisis takes an emotional turn. The NPO Wakaba has provided home care for two decades, reaching over 600 clients. Its representative, Mr Kikuo Tsujimoto, and co-director Ms Michiko Yamaoka, ran the organisation with a strong philosophy of community-based care. “This whole area is full of care recipients now,” Mr Tsujimoto notes during his rounds.

But Wakaba is shutting down. “Mr Tsujimoto said he was going to close down the company, which shocked us,” says one elderly client. “We couldn’t believe he’d shut it down. It was devastating.” Revenue has plummeted since 2015, down to a quarter of previous levels. New government policies have seen shifts shortened, unpaid travel time increased and the hourly pay has dropped. “Even if we want to offer more, we can’t if there’s no money coming in,” says Mr Tsujimoto, who had been covering debts personally while ensuring full-time staff earned at least three million yen a year. But the company has reached its limit. 

One of Wakaba’s clients is Mr Sato, a 50-year-old man who lost his vision due to diabetes. After his mother’s passing, he turned to Wakaba for help. They arranged for a carer who visits five days a week, providing over eight hours of care. The agency receives around 100,000 yen monthly for this service. “Before Wakaba stepped in, this room was full of clutter,” says Mr Daisuke Ogawa, his carer. Wakaba cleaned it at no cost, despite deep cleaning not being covered by long-term care insurance.

“I never wanted to do [care work],” admits Mr Ogawa, who entered the industry during the 2008 financial crash. “But care work only became fulfilling after I joined Wakaba. After we go in, things gradually become tidier and they live more peacefully. It makes us feel really happy too.”

Wakaba’s future now depends on a delicate handover. “The last thing I want is to split up our users and carers,” Mr Tsujimoto says. He enters new negotiations with a fellow NPO. “We want the users and staff of Wakaba to continue living as they are now,” he tells them. “But still, we are different people, a different organisation,” the potential successor replies. They agree to continue discussions. “I think we finally found a ray of light,” says Mr Tsujimoto. 

While Wakaba faces closure, a different story unfolds in Kanagawa. Tsukui, a major care firm operating 740 locations, was acquired by MBK Partners, an Asian investment fund. “They told us firmly that we should really think harder about getting paid fairly for our work,” says nursing care director Mr Hiroshi Yamane. Under MBK’s guidance, Tsukui launched a new care brand: A-Smile.

With an average employee age of just 31, A-Smile stands in stark contrast to Wakaba. “It just seemed like a fun place to work,” says one carer. “The pay’s been really generous,” adds another. Monthly salaries range from 312,460 to 393,360 yen, significantly above the industry average of 280,000 yen. For these reasons, since the company launched two years ago, it has received over 1,600 job applications to fill just 110 jobs. Their strategy to recruit young care workers are simple. As A-Smile’s Nursing Care Division Director Hiroshi Yamane put it, “We have to build care services where you can actually earn a living or young people won’t stick around”.

A-Smile also trains its carers in outreach to achieve its goal of being profitable in its fourth year of business. “We encourage 150 sales contacts a month,” Mr Yamane tells his team. “If you make 150 contacts, you’ll likely receive about 15 enquiries… around 6 or 7 [of those] are expected to convert into new clients.” Their first month at the Shonandai branch yielded 790,000 yen in revenue from 19 clients — well above the 490,000 yen target. The goal for the next month: 1.4 million yen.

But A-Smile’s approach to profitability goes beyond just outreach. Under Japan’s long-term care insurance scheme, home care is categorised into two types: household support, which includes chores like cleaning and laundry; and physical care, which involves hands-on assistance such as helping clients dress, bathe, or move. The latter pays significantly more, around 3,900 yen for 30 minutes, compared to 1,800 yen for household support. With a young, physically fit team, A-Smile deliberately prioritises physical care, which now makes up 80 per cent of their work. 

“We really want to avoid making those same mistakes,” says Ms Naoko Takahashi, branch manager. “Many agencies that operated under a high-volume, low-profit model ended up folding.” A-Smile aims to open 50 more branches in the next five years.

As Japan braces for the 2025 surge in elderly demand, the care sector is at a crossroads. Whether Wakaba’s spirit of human dignity can survive amid business imperatives remains to be seen. “Care work really shows who you are as a person,” says Mr Tsujimoto. “Your own way of living just shows up naturally in your work.”

For now, both the idealist and the entrepreneur share a common goal: ensuring people can age with dignity, in a system that still has heart.