From global point of view, developed countries have a high level of medical care, making acute illnesses fully treatable. However, the daily care of chronic illnesses has shown various issues, involving government, medical care, welfare, and local communities [1]. Furthermore, the aging and declining populations of many countries will have a significant impact on the future direction of society. Our team has been deeply involved in Japan's medical and welfare policies and practices, including meaningful discussions with the Ministry of Health, Labor, and Welfare (MHLW) [2]. Our Heisei Medical Welfare (HMW) Group has 14,000 staffs and 9,000 beds, and has been involved in medical and welfare practice, research, education, and proposals [3]. Drawing on this experience, we propose in this paper the potential of "multifunctional community hospitals" to address medical, welfare, and population issues in rural, depopulated areas.

Looking back at the history of healthcare system in Japan, the implementation of the long-term care insurance system in 2000 marked the beginning of a new healthcare administration. To summarize the changes over the past quarter century, the number of some types of facilities have increased [4]. They included Special Nursing Home for the Elderly [5], Fee-based Nursing Home for the Elderly, Geriatric Health Services Facility (long-term care insurance) facilities [6], and others. By observing the general changes for 21 years in Figure 1, the number of users of facilities and homes for the elderly has risen sharply. Among these social and medical changes, three most prevalent facilities are i) Special Nursing Homes for the Elderly, ii) Fee-based Nursing Homes, and iii) Geriatric Health Services Facilities. In the case of ii), the facility number revealed the most rapid increase, from 41,582 to 611,056 over a 21-year period. This would be a defining and impressive feature of Japan in recent medical administration area.

Figure 1: Number of Users of Facilities and Homes for the Elderly.

Furthermore, the 4th category, Housing with Services for the Elderly, has quadrupled in the 11 years from 2012 to 2022, from 70,999 to 278,320 [7]. A characteristic of these facilities is that the residents are relatively financially able to make a large financial contribution. In Japan, these facilities are more common in urban areas than in rural areas. The 5th category is Group Homes for Elderly with Dementia [8]. In Japan, with the aging population in recent years, issues such as the onset and response of dementia in the elderly, admission, hospitalization and/or entering nursing home have become important. The number of such facilities has increased 17-fold in 21 years, from 12,486 to 215,400. This represents a major and pressing issue facing the elderly in Japan. Other facilities include low-cost nursing homes, care homes for the elderly in need of protection, long-term care medical facilities, long-term care type medical facilities, etc. In this way, one of the characteristics of geriatric medical care in Japan is the detailed and tailored response to the circumstances of the elderly.

Japan's MHLW is constantly considering, predicting, and responding to Japan's medical situation several decades into the future. In 2024, a study group on regional medical initiatives was held, during which future projections were presented [9]. Regarding medical demand in 2040, an increase in the number of people aged 85 and over who have combined medical and nursing care needs is predicted (Figure 2). In other words, between 2020 and 2040, emergency transports are expected to increase by 36% for those aged 75 and over and 75% for those aged 85 and over. Furthermore, during the same period, demand for home visits seems to increase by 43% for > 75 years and 62% for > 85 years.

Figure 2: Increasing Number of Emergency Transports and Home Visit Patients.

Japan is made up of four main islands, which are Hokkaido, Honshu, Shikoku, and Kyushu from North to South (Figure 3). The name of Shikoku means shi=four and koku= country, county, state, province, or prefecture. The authors live in Tokushima Prefecture, where the headquarters of the HMW Group is located [10,11]. The area discussed in this article is Naka Town in the southern part of Tokushima [12] (Figure 3). In Naka town, there were previously 5 administrative divisions, but they have now been merged.

Figure 3: Maps of Japan, Tokushima Prefecture and Naka Town.

Historically, the locations of medical and welfare facilities in these five small districts are shown (a, b, c, d, e) (Figure 4). This area is mountainous, including Mount Tsurugi (1,955 m), the second highest mountain in western Japan. However, the eastern edge of the area is bordered by the Pacific Ocean, making it a steep terrain. Medical and welfare facilities are shown in four colors: hospitals (purple), clinics (blue), nursing homes (yellow), and multi-purpose facilities (orange). For all these areas, there are only 40 hospital beds in one hospital, none in 7 clinics, 183 in 6 nursing homes of various types, and 139 in 3 community-based multi-functional facilities. The data were obtained as the total number in March 2025.

Figure 4: Map of Naka Town for Hospital, Clinic and Other Facilities.

A major problem in this region is the rapid decline and depopulation that has been occurring for several decades [13]. Detailed population trends for the 5 districts (a, b, c, d, and e) from 1955 to 2024 are summarized (Figure 5). In 2005, the five administrative districts merged to form one. The population of the entire region has decreased by less than one-third over the past 70 years, from 24,713 to 7,175.

Figure 5: The changes in the population in 5 districts.

In Japan, hospitals and nursing care facilities must comply with numerous standards and regulations by the MHLW. This system ensures that citizens can access medical and nursing care services with reassurance [14]. MHLW applies the same standards to large cities with 10 million population and also to depopulated areas with <1000 population.

In our depopulated area, several facilities have contributed maintaining people's health. However, population decline has given significant social, economic, and medical impacts. Fewer users and staff shortages at each facility threaten to disrupt existing systems. There is a real high risk that these facilities will disappear within a few years. If such situation continues a little while, we cannot maintain local communities.

From mentioned above, the authors and collaborators will propose a novel idea for combined system of medical care. It is called as “Community Hospital with multiple functions”. It is Gocha-Maze Hospital in Japanese, which means Gocha=various factors and Mase=mixture. The important perspectives idea include the followings [15,16].

• Around 30 beds would be enough for the main medical care center.
• Bed space area in some facilities will not be determined uniformly by MHLW.
• Various standards can be considered flexibly based on local conditions.
• Multiple service will be possible due to the situation of the patient and family.
• Inpatient treatment & care, day care, small-scale multi-functional service, and others.

Furthermore, various innovative ideas can be proposed for actual operation. Regarding the facility's location and building, a closed elementary or junior high school in a depopulated area can be renovated and used. The facility already has a large site and building, and local residents once gathered there. This could be utilized through a public-private partnership. Regarding working staffs and duties, doctors could be assigned to overlap with those at nearby hospitals, and nurses and care staffs could be assigned part-time, with local volunteers also working together.

Depending on the population size of the depopulated area, routine work, outpatient and in-home care could be provided, with hospitalization possible if needed. As to patient’s situation, short-term hospitalization or residential care would also be possible. Regarding day service and day care functions, several services can be provided on a same-day basis, such as rehabilitation, recreation, bathing services, and so on. Two shuttle vehicles would be secured to allow for flexible response. Convenience store and meal delivery services could also be included as part of daily life support. Administrative procedures and the use of “my number card” would be implemented. In the case of any disaster, the facility could serve as a base office, allowing for effective coordination with the government and other organizations. We have already prepared model facilities that will enable new proposals to be implemented (Figure 6).

Figure 6: Novel Model Facility with Multiple Functions.

Furthermore, the author published a book that compiles various beneficial ideas in the future [17] (Figure 7).

Figure 7: Latest Book Multifunctional Community Hospital (2025 August).

It is true that the proposals made in this paper raise many issues. Who will pay for the construction and renovation of facilities? To what extent can the government subsidize? People live in any depopulated area and have their daily lives. Caring for all people is essential for a civilized nation. In the summer 2025, the role of general practitioners came into focus in Japan. They are not organ specialists, but functional specialists, as coordinators of team medical care. They will build cooperative relationships with paramedical staff, government, and local organizations. We hope that everyone will work together to consider the future direction for themselves, families, neighborhoods, and communities.

Conflicts of Interest

The authors have read and approved the final version of the manuscript.

The authors have no conflicts of interest to declare.

Funding

There was no funding received for this paper.

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