Some fifteen years ago, Japan opened its borders to international health-caregivers. While the Economic Partnership Agreements (EPA) that Japan concluded with selected partner countries are essentially preferential trade agreements, they also opened a migration path for up to 1,000 health-caregivers per year, per country. Since the treaties have come into effect, Japan has been recruiting nurses and care workers from Indonesia (from 2008), the Philippines (2009), and Vietnam (2014) to be employed in hospitals and care facilities in Japan.
It is for two reasons that the EPA-administered migration avenue of health-caregivers to Japan constitutes a paradigm shift in Japan's migration policy. Firstly, Japan decided to follow a sector-specific and country-specific recruitment pattern. And secondly, Japan started to openly recruit labor in the not high-skilled segment. I should note that there is an intense so-called skill-debate in health-caregiving (Ogawa Reference Ogawa2012), and that the general understanding is that while nurses are skilled workers, care workers, for example, those working in elder-care facilities, are considered to be of a lower level of qualification. Also, it is important to acknowledge that there have in fact been side-doors for labor migration in the not-high skilled sector before, and these oftentimes turned out to have a country-specific dimension to it. One might think about the surge of international students from China in the 1990s, which fed many of the low-paying jobs in the hospitality industry, or the steeply rising number of Japanese Brazilians, equally in the 1990s, many of whom became factory workers in the automobile industry. These avenues were presented under different narratives, though, including the developmental logic of education and a spill-over of skills, and a humanitarian narrative of rightfully treating those of Japanese ancestry. In none of these previous instances, did the labor shortage in Japan play a part in the political discourse.
It was only with the implementation of the EPA-administered migration avenue for international health-caregivers that Japan started to openly acknowledge a sector-specific labor shortage and the need to strategically counteract it by the means of labor migration. Several reforms have since followed: the most comprehensive one being the introduction of a migration scheme for so-called specified skilled workers (SSW) from 2019 on. We should note, though, that despite this discursive shift and the following political reforms regarding the recruitment of international labor, what remains firmly unchanged is the fact that Japan still does not see itself as a country of immigration (Roberts Reference Roberts2018). No path has been laid out for them to become full-fledged members of Japanese society or even future citizens. This imbalance between increasingly wooing labor migrants without matching their inflow with integration measures is the source of many of the very practical problems and emotional strains that migrants face while living and working in Japan.
This edited volume on “Foreign nurses working in Japan: Assessments of the EPA program. Gaikokujin kangoshi: EPA ni motozuku ukeire ha nani o motarashitanoka”Footnote 1 does an outstanding job introducing to readers how the conditions of the EPA-administered migration system and their implementation in hospitals and care facilities across the country impact the living and working realities of foreign nurses and care workers in Japan. Another perspective of analysis presented in the volume is how the EPA program also shapes the workflow and the business development of the institutions that hire international caregivers. The book was designed under the leadership of two renown specialists in the field of international nurse migration to Japan. Yuko Ohara Hirano's work has a disciplinary home in the sociology of health and illness, and Michiyo Yoneno Reyes has a background in Asian Studies with a particular focus on Philippine Studies. In this volume, they act as editors and authors, and also have drawn in several high-profile scholars and care migrants as further chapter authors. This immediate engagement of care migrants, of course, is a distinctive feature to this volume and guarantees some rare close-up insights into their working and living realities in Japan. Reflecting the qualifications that this pool of authors brings to the table, the volume follows a multidisciplinary approach bridging nursing, anthropology, sociology, and economics. In nine chapters plus a preface and an epilogue, as readers we are presented some cross-sectional and longitudinal studies on the EPA caregivers. Some chapters follow quantitative, some qualitative approaches, and occasionally we do see multi-method approaches applied within a single chapter.
While also taking on an impressive variety of research topics that include the professional and emotional experiences of the nurses and care workers from all three EPA partner countries, as well as the economic development of the hiring facilities and their work culture, there is one common theme that runs through the chapters as a red thread. That is, the volume follows the general idea that push and pull factors drive global migration flows. This is a well-established concept, which is frequently applied in the economic strain of migration studies. It states that push factors such as an unavailability of jobs, low wages, but also maybe a low quality of life and political instability can serve as factors pushing workers out of a country. They can trigger somebody's wish to emigrate, in particular so, when there are countries nearby where the conditions listed above are relatively better. These “better-off countries” in the model are the pull-countries as they are attractive enough to pull in potential migrants. Scholarly work that applies the push/pull model tends to focus on macro-level developments, such as the impact of international migration on the domestic labor market of the receiving countries, on the role that remittances play for the sending countries' economic growth (Ishikawa Reference Ishikawa2017); or they even engage in an ethical debate over the justification of restricting emigration when the relative difference between push- and pull-countries increases to a level where it could seriously threaten the economic viability of potential push-countries (Brock and Blake Reference Brock and Blake2015).
With their edited book, Hirano and Yoneno place Japan on the map as a pull-country for international health-caregivers from Indonesia, the Philippines, and Vietnam. While they follow this well-established concept, they operationalize it in a strikingly innovative way. Rather than focusing on macro-economic developments, this volume puts center-stage the micro-perspective of migrants' experiences and the meso-perspective of their economic and social impact at the Japanese workplaces. One surprising finding perhaps is that on the micro-level, the economic push-factor for many migrants or even potential migrants is not just the monetary profit that comes with working in Japan, but the role that the work experience in Japan will play in the process of building an EPA caregiver's personal career. It has long been acknowledged that nursing is a “portable profession” (Kingma Reference Kingma2006, p. 2); in the light of demographic change in many industrialized countries around the globe, I would argue that the same now holds true for care workers, most importantly for elder-care workers. In other words, well-trained caregivers are a highly sought-after human resource, and Japan, should it wish to attract them in sufficient numbers, needs to welcome them with accessible migration schemes, attractive working conditions, and favorable living conditions.
However, many EPA caregivers experience the systemic and practical hurdles to building their career in Japan as too high, and the hardships in their private lives as too grave for them to commit to Japan as the place to build their future at. Thus, a very real option for many EPA caregivers, as it was revealed in several studies presented in this volume, is circular migration, that is the return to one's home country after a given period of working in Japan. Chapter nine by Hirano and Yoneno indeed provides much evidence for the conclusion that the work experience in Japan oftentimes translates into a career boost for returning migrants. Among the topics that reoccur in several chapters and that we may cluster as systemic and practical hurdles are, firstly, the high level of Japanese language proficiency that is required to be able to pass Japan's national exam of nursing or care work, and, secondly, a different culture of caregiving in Japan and the migrants' countries of origin. Regarding the hardships in migrants' private lives are several problems in the interaction with Japanese co-workers and general issues of loneliness.
Let us first have a closer look at the systemic and practical hurdles of caregiver migration to Japan. I have previously argued that the EPA-administered migration avenue is a system “designed to fail” (Vogt Reference Vogt2018, p. 2, italics in original). It is the requirement to pass Japan's national exam for nurses or care workers, which was made mandatory after strong lobbying by the Japan Nursing Association that poses the highest systemic and practical hurdle for EPA caregivers. A high level of Japanese language proficiency and a thorough understanding of Japan's caregiving culture are prerequisites to passing this written exam. In chapter two of this book, Yoneno offers an insightful literature review on how language proficiency is being studied as one hurdle to the success of the EPA migration avenue. She introduces works from the social sciences, from educators and researchers of Japanese language, and from nursing studies.
Beyond providing a comprehensive and thorough overview over the state of the art in all three fields, this chapter also is a highly welcome resource that tracks the several changes in the requirements of Japanese language proficiency that the EPA system has seen over time to adjust to the points of criticism that have been frequently voiced by practitioners, scholars, and policymakers. Yoneno also makes clear that language proficiency not only is a determining factor for the professional success of EPA caregivers, but also heavily impacts every aspect of daily life in Japan and hence is crucial to the process of integrating into society. This chapter also must be read as a very vocal call to us who engage in research to bridge disciplinary boundaries and to learn more actively from each other's work (p. 59). While this call is very directly spelled out in this chapter, it is also a theme that resonates with the multidisciplinary and multi-method composition of this edited volume at large.
In her chapter contributions, Hirano goes on to hypothesize that language proficiency is not the sole key to understanding why the passage rate in the national exams is worse for non-Japanese candidates compared to Japanese candidates. Hirano identifies differences in caregiving cultures as another major source for the comparably lower passage rate of non-Japanese candidates. There are two components to this cultural gap, the actual culture of society, and the educational content of nursing in the various countries, and oftentimes both components surface in an intertwined manner. In chapter three, Hirano demonstrates this by analyzing some of the actual questions included in the national nursing exam. A multiple-choice question with four options, only one of which was correct, read: “Which is a right rule for in-home nurse services?” (Zaitaku kango no gensoku de tadashii no ha dore ka.) 98.8% of Japanese respondents ticked the correct answer, which was “to respect the patient's individual lifestyle” (Koko no raifusutairu o sonchō suru). However, only 52.6% of the Filipino candidates ticked that answer; highly popular among them was the choice that read, “the final decision lies with the family of the patient” (Saishūteki na ishi kettei ha kazoku ga okonau) (p. 95). The significant gap that becomes clear through the responses to this one question alone highlights some prevailing differences in what Ochiai and Hosoya (Reference Ochiai and Hosoya2014) call the transformation of the intimate and the public in Asian modernity. This chapter showcases plenty of material like this and makes a strong argument for its concluding policy suggestion, which is to acknowledge the need to strengthen culture-sensitivity in the on-the-job training of EPA caregivers in Japan.
This call is backed up also by the introduction of two different models of nursing, the medical model, and the life model, as Hirano puts it. In chapter four, Hirano and Nugraha argue that a combination of the two models is a distinctive feature prevalent to the nursing profession in Japan. They introduce the case of an Indonesian nurse, who was alienated by the fact that the head nurse had asked her to clean some windows together with patients in a mental institution. While she felt that as a trained nurse her duty were solely the medical interventions, the Japanese head nurse explained that joined window cleaning should be understood as part of a therapy aimed at fostering patients' confidence in conducting daily chores (pp. 112–115). The gap between the medical model and a joint medical/life model, which, as Hirano argues is the dominant one in Japan, serves as a framework to explain the many clashes in daily work experiences for EPA nurses that are introduced in several chapters of this volume. Chapter six by Hirano, Nugraha, and Navallo, for example, focuses on different career paths of EPA migrants to Japan. We learn of care migrants who choose to go to Japan rather than take up a job opening in Saudi Arabia because of more social freedom associated with life in Japan, and of nurses who migrated as care workers simply because an opportunity to do so opened up. We also hear of care migrants struggling with deskilling in particular in the years before they pass the national nurse exam and are no longer allowed to perform tasks; they had routinely done in their home countries before.
Some of these experienced hardships spill over from the work life into the more private aspects of living in Japan since a feeling of de-appreciation at the workplace will inevitably have a negative impact on one's emotions. Issues of person-to-person interaction with the care migrants' Japanese counterparts and general issues of loneliness surface in several chapters of this volume. Chapter five by AnonuevoFootnote 2 is probably the strongest in this regard. We learn of the embarrassment that Filipino nurses in Japan feel when asked to engage in what they think are menial jobs, but what is apparently situated in the life model of nursing. This chapter also speaks to very practical issues that have a negative impact on care migrants' lives, such as the limitation for their spouses, should they follow them to Japan after the EPA migrants passed the national exam, not to engage in paid work for more than 28 hours a week, which is based on visa regulations. In some other cases, employers apparently advised care migrants against bringing their children to Japan because the Japanese school system was ill prepared for providing a multicultural environment.
While employers generally print a positive picture of the care migrants as members of their workforce, insecurities on their side persist. Chapters one by Ohno and Hiruma, seven by Tsubota, and eight by Hirano speak clearly to the employers' aspirations and struggles with the EPA system. They need to make substantial financial investments (even though the national government also shoulders their part) and commit to the EPA caregivers also by adjusting some of the workplace rules. Some facility managers would, for example, grant extended periods of leave to the EPA caregivers so that they can return to their home countries and spend family time there (pp. 172–173). And yet, the employers do not know how long these workers will stay in the workforce: will they pass the national exam, will they eventually leave Japan or change employers within Japan? In other words, will their investment pay off in the long run? Not only the caregivers, but also their employers are seemingly left in a state of insecurities under the EPA migration framework.
I argue that this is mostly because the Japanese government is not fully committed to ensuring the success of the EPA-administered migration avenue, which would include the establishment of structures allowing for sustainable workforce retention and for comprehensive societal integration measures. Instead, recent administrations have opened further avenues for caregiver migration to Japan, which now somewhat compete with the EPA system. These include the above-mentioned SSW scheme and the international trainee program, which used to supply unskilled workers to sectors such as construction and agriculture. As a result, the landscape of health-caregiver migration to Japan is becoming diversified and, moreover, caregiving is increasingly associated with low-skilled menial jobs. On the other hand, the Japanese government continues to promote robotic devices and ICT in health-caregiving to counteract the labor shortage in the sector. These initiatives, however, so far have only limited success, since many of the devices introduced to facilities have proofed unpractical in the daily work routines (Vogt and König Reference Vogt and König2021).
This leaves us with a rather troubling outlook regarding a sustainable personnel management in health-caregiving in Japan. Hadn't it been for the epilogue to the book, that is! In the epilogue, Hirano and Yoneno show how the EPA caregivers in Japan have experienced these past months of the covid pandemic. And while, yes, there have been many hardships, what I find striking is that several caregivers have pointed out that they now feel more appreciated by their coworkers and by the communities they reside in. Pulling through this crisis jointly has spurred a sense of comradeship, which, if I may add this, hopefully prevails beyond the pandemic, and positively impacts the workplace and community relations that the EPA caregivers, and other migrants in Japan, too, have built.
