AKITA, Japan — Every morning at 9, Keiko Sasaki walks the 300 meters to Masao Ito’s house, slides open the door and calls out his name. If he answers, she notes the time on a card, asks whether he has eaten, and checks that the kerosene heater is off. If he does not answer, she has a key.
Ms. Sasaki is 71. Mr. Ito is 88. Both live in a hamlet of 23 houses in the hills east of Akita city, where the nearest doctor is 40 minutes away and the care-home waiting list is 14 months. For her visits, Ms. Sasaki receives 3,000 yen a month, about $20, from the prefectural government, as one of 4,200 registered “watchers” in a program that Akita began in 2023 and that national officials now cite as a model for a country running out of people to look after its old.
Akita is the oldest prefecture in the world’s oldest large country. Thirty-nine percent of its 900,000 residents are over 65, a share that Japan as a whole is projected to reach in the 2050s, and the population has fallen by a fifth since 2000 as young people left for Tokyo and Sendai. The prefecture has 1 nursing care worker for every 4.1 people who need care, the health ministry calculates, and the ratio is getting worse by about 3 percent a year.
“We looked at the numbers and accepted that we cannot hire our way out,” said Hiroshi Takahashi, who directs elderly welfare for the prefecture. The watcher program, he said, formalizes something villages had always done informally, but with a register, training, a stipend and a direct line to the municipal care office. Watchers are mostly themselves between 65 and 75, what Mr. Takahashi called “the young old looking after the old old.” They receive a day of training in recognizing dementia, dehydration and falls, and a reporting card. In the past year, watchers reported 1,100 incidents, including 86 cases in which a resident was found collapsed.
The program costs about 150 million yen a year, roughly $1 million, less than the running cost of a single 50-bed nursing home. Researchers at Akita University who evaluated it found that in villages with watchers, emergency hospital admissions among people over 80 fell by 12 percent, and the number of residents found dead alone at home, a statistic Japan tracks closely, dropped from 41 to 23 across the participating municipalities.
Critics say the program pays women a token sum for work the state should provide, and that it will collapse as the watchers themselves age. Mr. Takahashi does not dispute the second point. “In 10 years Ms. Sasaki will need a watcher,” he said. “The program buys time. We are honest about that.” The prefecture is testing sensors on kettles and refrigerators that alert the care office if an appliance has not been used in 24 hours, and a shared minibus that brings residents to a weekly clinic.
Mr. Ito, a retired rice farmer whose wife died in 2019 and whose children live in Yokohama, said he did not think of Ms. Sasaki as a service. “She tells me the gossip,” he said. “If I die in the night, at least someone will know by 9.”
Ms. Sasaki laughed. “I am not here for the 3,000 yen,” she said. “But I keep the card. It makes it official that I come.”
A version of this article appears in print on Oct. 12, 2026, Section A, Page 4 of the European edition with the headline: In Japan’s Oldest Prefecture, the Government Pays Neighbors to Knock on Doors.
