VISA / Residing in Japan

Overview and Evaluation of FY2014 International Workshop on Acceptance of Foreign Nationals and Their Integration into Japan:

Foreign Nationals and Foreign Human Resources in the Field of Medical Care - Beyond Language and Cultural Barriers -

March 9, 2015

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 On February 25, the Ministry of Foreign Affairs (MOFA) co-hosted a workshop titled above with the International Organization for Migration (IOM) and Katsushika City at the Iris Hall of the Katsushika SYMPHONY HILLS under the auspices of the Council of Local Authorities for International Relations (CLAIR) (approximately 250 participated in the workshop including Mr. Kazuyuki Hamada, a member of the House of Councilors, experts from both Japan and abroad, officials from foreign embassies in Japan, and ordinary citizens).
 Following the opening addresses by Mr. Yasuhide Nakayama, State Minister for Foreign Affairs, and Mr. Katsunori Aoki, mayor of Katsushika City, as well as a keynote speech by Amb. William Lacy Swing, Director General of IOM, a presentation was made by Prof. Som-arch Wongkhomthong (Thailand), Director of Bangkok Hospital Hua Hin, Bangkok Dusit Medical Services Public Company Limited. Then, Ms. Ejercito Pinky Alvarez, a certified care worker from the Philippines, and Ms. Noriko Muramatsu, a Japanese medical interpreter, presented their experiences. In the latter half of the workshop, experts from both Japan and abroad held active panel discussions to deepen and share awareness of the issue.

1. Overall overview and evaluation of the workshop

  • (1) In his keynote speech, Amb. Swing, Director General of IOM, pointed out as follows: (A) Since people move in at an unprecedented scale these days, negative sentiments towards foreign workers and immigrants are expanding in the developed countries based on certain impressions, which are not necessarily based on the facts, that foreign workers or immigrants may have an adverse effect on the employment opportunities of the existing residents or the national identities may be damaged by them; (B) However, significant shortage of medical personnel will be inevitable in developed countries such as Japan and the U.S. due to a low birth rate and an aging population, and the employment of foreign national medical personnel will be unavoidable for the medical system in such countries also from a viewpoint of social integration of foreign nationals; (C) Construction of a multinational/multicultural medical system is a key and this would further attract superior foreign human resources; and (D) Historically, immigration has been inevitable and necessary, and overall it has played a rather positive role in our society. For these reasons, it was pointed out that the government would be expected to promote balanced views based on the historical evidence and facts.
  • (2) A Thai expert who graduated from the Faculty of Medicine of the University of Tokyo and is well-versed in both Japanese and international medical contexts (Prof. Som-arch) delivered a presentation in which he mainly stated as follows: Although the level of medical treatment is high in Japan, judging from the current conditions such as medical costs, its geographical condition and the number of foreign language speaking medical personnel including English speakers, Japan is not necessarily a favorable country in terms of medical tourism; from the viewpoint of active utilization of foreign human resources, it is almost impossible for a foreign national doctor or a nurse to obtain the Japanese license by taking exams in Japanese language, while the conditions are better in the field of caretakers; even in such a situation, foreign human resources could possibly work as medical interpreters and it would be important to raise such human resources to make Japan’s medical system more fulfilling and attractive.
  • (3) A Filipino care worker, who came to Japan using the framework of Economic Partnership Agreement (EPA), obtained a Japanese license as a care worker and is currently working in Japan (Ms. Ejercito Pinky Alvarez), stated her experience that she came over to Japan thanks to the encouragement from her ailing father to work in Japan, a medically advanced country. She felt lonely initially due to her Japanese proficiency being poor and was hurt by harsh words by some users despite understanding that these users acted in such a way due to their dementia. Yet, thanks to full support from her colleagues and friends, she studied hard and passed the exam, and she is now working productively. A Japanese medical interpreter (Ms. Noriko Muramatsu) stated her experience that medical interpretation is not a fun job as she had seen or heard cases in which foreign nationals residing in Japan without joining a health insurance program had died because they could not self-pay the medical costs and thus were unable to receive necessary treatment for their chronic diseases. She also mentioned her fear of being involved in the life and death of other persons. She has continued her activities because of her anger against the fact that foreign nationals who have paid taxes cannot receive necessary medical treatment. However, volunteers tend to be treated lightly and interpreters are recognized as just an acquaintance of the patient even in the medical setting. In such a condition, foreign nationals with Japanese roots who aim to become medical interpreters often burn out as they cannot make their livings. Therefore, she added, proper treatment and income as a professional are necessary for them.
  • (4) In the panel discussion (for details, see “2” below), discussions were held by a leading foreign national medical interpreter, a foreign national doctor who has been operating a clinic in Japan over a long period of time, an official from a foreign embassy in Japan, a member of the press and a former local administration personnel mainly on the following three points: (A) How medical care should be and “medical care for foreign nationals in the global era,” (B) “Medical interpretation,” and (C) Contributions to the society by foreign human resources in the medical care field and the future “direction of utilizing foreign medical care professionals.”
  • (5) Medical care is an important issue not only for Japanese people whose society is progressively aging, but also for foreign residents in Japan and foreign nationals who visit Japan for sightseeing or other purposes. Amid the condition where the number of foreigners is expected to further increase toward the 2020 Tokyo Olympic and Paralympic Games, construction of a system in which both the Japanese and foreigners can receive medical treatment irrespective of their nationalities is required, and such a system must be sustainable even after the year 2020. For this purpose, discussions were held and suggestions were made from various viewpoints on the limitation and issues of the current Japanese medical system as well as on necessary conditions for the foreign nationals, including medical interpreters, to be able to work actively in the medical setting going forward, which resulted in the sharing of participants’ understanding of the issues.
  • (6) State Minister Nakayama stated that Mr. Koji Terashima, a sign language interpreter, cooperated in the workshop and Mr. Terashima told State Minister Nakayama his wish that sign language be recognized and positioned similarly to foreign languages from the perspective of overcoming the language and cultural barriers, the sub-title of the workshop. Mr. Aoki, mayor of Katsushika City, stated in his address that 3% of the city’s population, which amounts to 15,000, accounts for foreign nationals, and that the overall population of the city, which is 450,000, is aging. In such a condition, a “comprehensive support system” is necessary and roles to be played by foreign nationals will be greater. Therefore, he will aim to improve Katsushika to be a city where many foreign nationals are willing to visit and live.

2. Overview of opinions suggested in the panel discussion

(chair: Prof. Yasuhide Nakamura, International Collaboration of the Graduate School of Human Sciences in Osaka Univ. and President of Japan Association of Medical Interpreters (JAMI))

  • (1) In Kanagawa Prefecture, a system for dispatching volunteer medical interpreters (MIC) was constructed for the first time in Japan through cooperation between the prefecture and an NPO. Currently, 175 interpreters of 11 languages have been dispatched to 66 hospitals for a total of 5,000 cases. Although candidates for medical interpreters must complete intensive lessons and pass examinations as well as practical training to be registered as medical interpreters, the hospital pays only 3,000 yen for the dispatching of one interpreter, which indicates the work of interpreters is regarded as almost like a volunteer activity. Moreover, doctors and hospital personnel still do not highly recognize them. It is necessary to enhance the medical interpretation system by recognizing and positioning the medical interpreters as professionals instead of just an attendant. It is necessary to recognize medical interpretation as part of medical services and to cover such interpretation costs by medical insurance. Furthermore, it is also necessary to maintain/expand the hub medical institution system that the Government of Japan is building. In such local hub medical institutions, medical interpreters of major languages must always be stationed as professionals (as in the case of the Bangkok Hospital Hua Hin), while the current dispatching system like the MIC should be reserved to deal with minor languages. If a system in which medical interpretation is properly appreciated both socially and economically is constructed, it could be regarded as a goal by foreign human resources (Ms. Hideko Mizuta, Executive Director of Kanagawa International Foundation).
  • (2) What is required of a globalizing society is to be able to offer medical treatment to everyone in peace irrespective of one’s nationality. In such a situation, the role taken by a medical interpreter who enables communication between a foreign national patient and a doctor is particularly important, and the interpreter needs to be a member of the medical team. No matter how good a team doctors and nurses might form, appropriate treatment cannot be given when they are unable to verbally communicate with patients, and in the worst case the patient could die. Medical interpretation requires appropriate training as a professional and rewards for interpretation services must be paid. In the U.S., the importance of medical interpretation was not initially recognized, similar to many other countries. Japan is also required to improve the condition in the country to meet the international standards concerning medical interpretation. Foreign residents in Japan face many restrictions regarding their employment due to the issues of Japanese reading and writing, but in the field of medical interpretation, they can work without such restrictions. (Ms. Izabel S. Arocha, Former Executive Director of the International Medical Interpreters Association (IMIA))
  • (3) (A) The issue of medical insurance is as important as the issue of communication in terms of medical treatment for foreign national patients. 23.2% of foreign residents in Japan are not covered by any insurance and they can hardly bear high medical treatment expenses in Japan. If such foreign nationals suffer any infectious disease, which should be treated properly under a normal circumstance, they will not receive medical treatment. If, as a result of this, they transmit the disease to other people around them, that can be a big social problem. Moreover, 90% of foreign nationals who are without health insurance and suffer a chronic disease such as high blood pressure or diabetes stop their treatment in the middle. Therefore, the enhancement of medical insurance is necessary. (B) In terms of the medical interpreter, volunteers cannot cover enough and professional interpreters are necessary. Therefore, their rewards should be paid by way of the point system for calculating medical treatment fees. However, while it is possible for large hospitals to hire full-time medical interpreters, small local hospitals cannot afford it. To solve this problem, I suggest the utilization of a medical clerk system, which was introduced about three years ago to bring a medical clerk who has a certain degree of knowledge of medicine and who will act as a facilitator in a medical situation. My suggestion is that a medical interpreter course be added to schools raising medical clerks so that the medical clerks can also acquire linguistic abilities. In this case, the advantage is that they can work as medical clerks when there are no foreign national patients. (C) I came to Japan 45 years ago to study, and after graduating from university, I could not return to Afghanistan, my motherland, because of the invasion by the Soviet Army. For this reason, I later opened a clinic here in Japan and recognize myself as an example of the utilization of foreign human resources. Many of the patients at my clinic are foreign nationals, but there are also some Japanese patients. The uneven distribution of doctors is a huge problem in local areas and I visit villages without a doctor 300 times a year. In my own country, I provide consultations for about 400,000 people for free and conduct activities such as the construction of schools. (D) In terms of the foreign nationals and medical treatment, understanding of cultural/religious differences is also important. When examining a Muslim woman, it is a taboo to roll clothing up above her chest or patting a child on his/her head could also be a problem in some cases. (Dr. Khaled Reshad, President of Medical Association KENSHIKAI Reshad Clinic, Shimada City in Shizuoka Prefecture)
  • (4) The United Kingdom, based on its own experience in the London Olympic/Paralympic Games and its current condition where 12% of the population, which amounts to 8 million, are foreign nationals and the number of foreign national medical personnel reaches 1 million (of them, 100,000 are doctors), can cooperate with Japan, which sets an ambitious target of attracting tourists under the condition where the population is decreasing. Though there is an example of utilization of foreign nationals such as Ms. Pinky, I would like to suggest some issues between Japan and the U.K. There is a framework that allows doctors of Japan and the U.K. to work in both countries based on an agreement in 1964. The U.K. recognizes the Japanese medical license as it is and sets no limits on the number of Japanese medical doctors to be accepted as long as they present the results of the language proficiency test called the International English Language Testing System (IELTS) to prove their language ability (15 Japanese medical doctors are currently working in the U.K.). On the other hand, when a doctor from the U.K. applies to work in Japan, sufficient information and explanations are not given in English. In addition, not only are the assessment procedures not transparent and take more than a year, the applicants are required to answer questions regarding things that even the applicants or a related party do not remember such as the total lecture hours whilst in the medical school or the lot area of their schools. Moreover, the number of doctors that can work in Japan is limited to seven (four British doctors are currently working) and they can work only in three designated hospitals in principle. If the Government of Japan considers the utilization of foreign medical doctors with outstanding expertise, I think that they need to consider improving such procedures. I would like to coordinate with the Ministry of Health, Labour and Welfare for the improvement of the condition in the future. (Ms. Julia Longbottom, Minister (Deputy Head of Mission), British Embassy Tokyo)
  • (5) In the current condition, it is difficult for foreign doctors to work in Japan. Internationalization is crucial if the government intends to expand medical care into a growth industry of Japan. Revision of the system is necessary to allow superior foreign medical doctors to work in Japan more easily. Regarding the care workers, it is said that there will be a shortage of 300,000 care workers in 2025, when the post-war baby boom generation becomes 75 or older, and in such a condition, I think that we have no choice but to rely on foreign human resources. While the quality of such human resources of course must be assured, I also hear laments that, excellent Filipino nurses could not pass the examination and had to return since the EPA sets the bar too high, leaving a big hole to fill in. If the government intends to utilize foreign human resources, it would be important to develop a system in which foreign nationals can receive medical treatment without anxiety. It would be necessary to deepen the understanding of Japanese hospitals and among Japanese medical personnel towards accepting foreign nationals. I also think that we will have to discuss the overall system design and continue to consider the division of responsibilities to be taken by different hospitals, such as a hospital, which deals with daily medical care for foreign patients and which accepts medical tourism, even if not all medical institutions can deal with foreign nationals. (Ms. Makiko Tatebayashi, Deputy Editor of Medical News Department, The Yomiuri Shimbun Tokyo)
  • (6) Prof. Nakamura, the chair, made his comments and the summary of the discussion is as follows:
    • There are many foreign nationals in Japan and many of them suffer from serious illnesses such as cancer.
    • Though the level of medical care is high in Japan, it is not in a form for foreign nationals to be able to utilize without anxiety. An understanding of medical interpretation is not sufficient. Medical insurance for foreign nationals is also a very difficult issue.
    • Many foreign nationals are already working in the practical setting of caretaking. However, it is necessary to consider as to how we can create a setting where foreign national caretakers can work more actively in the future.
    • Understanding of cultural/religious differences is also certainly important. I have worked in Pakistan as a pediatric doctor for a year, but had never examined a woman whilst there. Some hospitals even have separate entrances for men and women.
    • Medical interpretation in the U.S. has 30 years of accumulated experiences. In a hospital in the U.S., a sign language speaker was in the same section as foreign language speakers, such as Spanish speakers.
    • In modern day medical treatment, not only traditional medical personnel such as doctors and nurses, but various different professionals also make a team. As suggested by Dr. Reshad, there seems to be different ways in which foreign human resources can actively work or can be utilized such as by adopting the point system for calculating medical treatment fees or by employing foreign human resources as medical clerks, etc. A system that requires superhuman efforts such as the one Ms. Pinky had made or that becomes feasible only with dedication from people nearby will not work well, and the adoption procedures for foreign human resources should be conducted in a more normal way. The issues that Ms. Longbottom pointed out are examples of “The devil is in the details” and there are probably points that we need to improve by carefully reviewing the details of the system.