We conducted secondary analyses of data for a diverse sample of foreign residents who attended free medical consultations offered by an NGO in various locations in Aichi Prefecture. Four-fifths of the participants were covered by Japanese public insurance; however, in the consultations with the volunteer doctors over one-fourth of the participants were advised to visit a medical facility. It was assumed that these individuals generally experienced barriers to accessing the formal health-care system. Risk groups regarding being advised to visit a medical facility or being referred to a medical facility were found to be people who are uninsured, people who are unemployed, and students. Of the 72 cases who were referred to a medical facility, the NGO received reply letters from medical facilities for just 11 cases.
We found that 81.7% of the cases in our dataset were covered by Japanese public insurance. Japan implemented universal public insurance coverage in 1961 (3), and in 2012 implemented a law to allow every person living in Japan, regardless of their nationality (but excepting visitors staying for three months or shorter), to receive coverage under a Japanese public insurance scheme (21). As there are numerous insurance schemes in Japan, it is difficult to obtain exact figures regarding coverage among foreign residents. According to reports from some local governments and NGOs, however, it has been estimated that approximately 80% of foreign residents are covered by a Japanese public insurance scheme (7, 8, 22). This shows a dramatic improvement in coverage in recent decades, as in 2004 a survey conducted by a local government reported that this figure was 64.4% (27). The result obtained through the present analysis is similar to the figures presented in these recent reports. Our data also suggest that sex and region of origin are associated with insurance coverage. In addition, those who were uninsured were likely to be advised to visit a medical facility, which was used as a hypothetical proxy indicator of having barriers to accessing formal health care. This is consistent with the findings of a previous study on access to health care among Nepalese residents in Japan (8). The findings of the current study raise four issues. First, one-fifth of the cases were not covered. Second, a high prevalence of non-coverage was found among some specific groups. These two points show gaps in UHC in Japan. Third, insurance coverage was considered to be associated with access to health care. Lastly, but importantly, although the majority of people who attended the NGO-organized free consultations were covered by public insurance, they needed to attend the free consultations, and a relatively large proportion of these individuals were subsequently advised to visit a medical facility. While reducing the number of people who do not have insurance coverage is important, other possible barriers, such as language and emotional barriers, should be identified and then removed, regardless of insurance coverage.
Previous studies on access to health insurance among Latin American residents and on access to health care among Nepalese residents in Japan did not find associations between access variables and employment status (7, 8). In contrast, our study suggested that unemployed people, including housewives, represent a high-risk group. Although it is difficult to speculate the underlying reasons, income, which was unknown in our dataset, may have an important effect. In addition, students were found to represent another possible risk group. In May 2019, 312,214 foreign students were living in Japan (28). Among these, 53.2% were studying at professional training colleges, university preparatory courses, or Japanese-language institutes (28); institutions for which the School Health and Safety Act generally does not apply. According to a 2009 survey conducted by the Association for the Promotion of Japanese Language Education, 66.5% of the respondents from Japanese-language schools had experienced illness or injury since arriving in Japan; of these, 2.3% had been hospitalized, 39.8% had visited medical facilities, and 2.7% had consulted their school’s medical personnel . Further, among this group the most frequent answer to a question regarding the types of treatment used was “self-medication” (44.3%) (29) Meanwhile, in a survey of students in Japanese-language schools in Tokyo, 48.7% of the surveyed students reported that they did not think they had access to doctors/health workers (30). In a recent survey by the present authors (not yet published) of Vietnamese and Nepalese students in Japanese-language schools in Nagoya, 20.9% of the surveyed students reported experiencing unmet health-care needs since arriving in Japan. Notably, access to health care may influence individual and public health outcomes. Foreign students in Japanese language schools have become a target population in regard to measures to address tuberculosis (31), with foreign-born people accounting for a major part of new cases among young generations (32). The government’s “300,000 International Students Plan,” has led to the arrival in Japan of a cohort of foreign students with diverse characteristics. A survey conducted by a governmental organization suggested that over three-quarters of privately-funded foreign students hold part-time jobs, among which almost 70% work over 15 hours per week (33); working such relatively long hours while also attempting to fulfill education responsibilities might explain the health-care-related vulnerability among this group. On one hand, systems to accept foreign students should be improved, but on the other, supporters of foreign residents need to recognize the vulnerability of this group.
Over one-third of the participants had lived in Japan for five years or longer. Length of stay in Japan was not associated with our hypothetical indicator of having barriers to health care; this partially disagreed with the findings of a previous study regarding access to health care (8). A possible reason for this is differences regarding target populations and indicators of access to health care. Official statistics show that the proportions of people with “general permanent resident” status and “long-term resident” status in Aichi Prefecture are higher than the national figures; in 2016, “general permanent residents” and “long-term residents” accounted for 42.9% and 14.6%, respectively, of the “mid to long-term residents” (foreign residents with the exception of “special permanent residents”) of Aichi Prefecture, compared with 35.8% and 8.3%, respectively, for the entire country (34). The high prevalence of long-stay foreign residents appears to be a characteristic of Aichi Prefecture, which may have been reflected in our participants’ characteristics. The evidence shows that the attendees of the free consultations included individuals who had lived in Japan for a long time, and these individuals showed no significant differences regarding being advised to visit a medical facility when compared with shorter-term residents. This implies that, for some foreign residents, barriers to health care exist, regardless of the duration of their stay.
Another important finding was that, after volunteer doctors sent attendees to health-care providers in the formal health-care system, few replies were obtained. There are at least two possible explanations for this. First, the patients may not have visited a medical facility as advised; and second, the doctors who received the patients did not issue medical information letters to the NGO. Among the returned letters, we found that some patients had been placed under observation. If these referred patients had not visited a medical facility within an appropriate time, their diagnosis would have been delayed. Practically, it is difficult to track referred patient and to check whether they contacted the formal health-care system. Under the government plan for “Promotion of Multicultural Coexistence,” various NGOs, along with local governments, are expected to take a role in addressing livability issues for foreign residents (35); however, to ensure access to health care among foreign residents, better communication between NGOs and the formal health-care system is required.
Cases in the dataset were not randomly sampled from all foreign residents in Aichi Prefecture. Although the free consultations are open to everybody, people with similar attributes might have attended as a group. Consequently, the participant characteristics determined in this research may have been biased. However, compared with the proportions of countries of origin listed for residents of Aichi Prefecture in the government statistics for the corresponding years (36), our data can be considered to better reflect the target population in the prefecture. A venue-based approach for sampling hard-to-reach populations would be an acceptable method of obtaining more accurate data (37, 38). It was reported that using only census and vital statistics may not be suitable for capturing the reality of the health situations among foreign residents (39). Official data describing access to health care among foreign people remain limited; for example, to the best of our knowledge there are no official data regarding the prevalence of uninsured foreign residents. As previous studies have suggested (7, 30, 40), migrants are likely to be mobile, meaning it may be difficult to study foreign residents through mail surveys with random sampling. Thus, analysis of alternative data, such as that used in our study, is needed. Although the information we used was not collected for research purposes, our findings are nevertheless informative. As we have shown, analyzing data from NGOs can strengthen understanding of, and foster improvement in, access to health care and health outcomes.
There were some limitations to this study. First, the data were entered by case (consultation), not by person. If the dataset includes many people who attended multiple consultations, the statistical findings may have been overestimated. However, because free consultations are held in different places in Aichi Prefecture over the course of the year, it is unlikely that the number of repeat visitors within one year would be large. Second, our assumption was that those who required free consultations and who were advised to visit a medical facility were likely to have barriers to health care in daily life. Therefore, “being advised to visit a medical facility” and “being referred to a medical facility” were used as a hypothetical proxy indicator of having barriers to the formal health-care system. It is possible that our assumption was invalid. Although some standardized indicators have been suggested for assessing access to health care, such as service utilization and unmet health care needs (41, 42), these are not always available in routine datasets. Therefore, we used a proxy indicator that was available to us and was considered to be reasonable. Third, as a result of language barriers, obtaining reliable answers to some questions from some participants was difficult. For example, occupation was an open-ended, self-report answer, and volunteers (interviewers) sometimes needed to infer attendees’ jobs from their responses. Despite these limitations, we believe that this study will be valuable because of its diversity of its participants. Using such datasets, we can grasp situations regarding access to health care among foreign residents. Thus far, a limited number of studies have been published regarding access to health care among foreign residents in Japan. One recent study employed purposive sampling at restaurants to sample Nepalese participants (8), while another study sought to use random sampling, but only targeted Latin Americans in one city (7). In the future, studies with randomly selected data, obtained through collaboration with local governments, will be required for more rigorous analyses.