Countries in economic transition: the history and development of public health in China and Korea
Don Kyoun Kim and Shun-Zhang Yu
Public health in China
Public health in Korea
Improved national health in Korea
Determinants of health in Korea
Spectrum of diseases in Korea
Trends in health policy in Korea
Organization of public health in Korea
Korea’s medical policy
Medical care services in Korea
Public health services in Korea
Public health in China
‘Prevention first—put the stress on prevention’ is the motto of public health in China. This is not only the principal health strategy in China, but is also the basis of the ancient ideology of Confucianism. During the period 2838 to 2698 BC the origins of medicine in China were documented in a book called Shen Nong Bencao, which identified one hundred oriental herbs, thus establishing the art of Chinese medicine. Once the (unknown) author had tasted these herbs, and identified 70 different kinds of poisons in a single day, he drank tea to detoxify himself. Subsequently, Chinese people have claimed diuretic and rejuvenating properties for tea, and claim that it also reduces cholesterol levels. Since ancient times, Chinese people have used herbs and traditional medicine to cure diseases and have also established methods for prevention, especially the use of ideological proverbs of prevention. For example, the book of Su Wen (written around 900 BC during he Tang Dynasty), which is an important traditional Chinese medical text, noted that the wise man did not cure ‘post-disease’, but cured ‘pre-disease’. This book used a dialogue format between the Emperor and Doctor Qihuang; they explained the principles of yin and yang, together with the aetiology, diagnosis, and treatment of diseases. In the books Huai Nan Zi and Qian Jin Fang it is argued that the best doctor solves the problem before disease strikes, the intermediate doctor cures the early disease symptoms, and the worst doctor deals with the full-blown condition. Therefore prevention is of utmost importance, and is ultimately better than cure.
There are many records of epidemics in ancient China. The book of Su Wen recorded that during the period 147 to 218 BC there were at least nine serious epidemics. Epidemics tended to continue for several years, with some lasting for more than 10 years, and they showed periodicity. During the Tang Dynasty (618–907 BC), leprosy patients were isolated. Later, during the Sung Dynasty (960–1127 BC), a type of human vaccine was commonly used to prevent smallpox, long before Edward Jenner (1749–1823) formally developed the variolar vaccine. People also perceived that they derived good health from drinking boiled water, using primitive pesticides, and disinfecting items of food and clothing by methods such as boiling, fumigating, and steaming. These were especially practised during the May festival. Sewers and lavatories were built in palaces and the homes of noble families before the Qin Dynasty (221–207 BC). The book of Su Wen records that, during the Northern Sung Dynasty (960–1127 BC), patients were stricken with mercury poisoning and suffered trembling; also, stone workers who cut into rock were found to suffered lung damage from the powder which was produced during their work. To help to promote health, Chinese people like to follow regular exercise regimes and to preserve their yin–yang balance by perfrming exercises such as tai-chi (Chinese boxing).
In the early days of the new China, infectious diseases were rife throughout the country. For example, 3400 cases of plague and 43 000 cases of smallpox were recorded in 1950, 100 000 cases of relapsing fever were documented in 1951, and 1.04 million cases of measles and 2.93 million cases of malaria were recorded in 1952. Schistosomiasis prevailed in 12 provinces and cities and 400 counties, with a total of 12 million patients. During that time the national mortality rate was 25 per thousand, infant mortality was 200 per thousand, and the average life expectancy was only 35 years. As a result the government issued a number of policy statements and called upon the people to put prevention first. Ideas included the need to control schistosomiasis and to eliminate four particular pests (mice, mosquitoes, flies, and cockroaches). To prevent infectious diseases, the people were called upon to live more cleanly, and to attain health and safety through individual measures.
By 1995, the national mortality rate had fallen to 7 per thousand, infant mortality was reduced to 33 per thousand, and average life expectancy had increased to 69 years. Most infectious diseases, such as smallpox, relapsing fever, typhus fever, and kalar-azar, were controlled or eliminated. The morbidity rate from notifiable infectious diseases was 185 per 100 000 in 1995. The acute wild-type poliomyelitis virus was under control in China by 1995, but the vaccination and monitoring programme is still continuing. Since the period 1993 to 1998 about 630 million children in China under 4 years of age have received the poliomyelitis vaccination. After 40 years of effort, schistosomiasis was eliminated in five provinces and cities, and was under control in 70.5 per cent of counties.
According to statistical data published in 1993, China has 22 per cent of the world’s population but spends only 1 per cent of the global health budget. However, a large majority of the Chinese population now have access to basic health services at an affordable price. There are three main reasons for this.
By the late 1970s most of China’s rural population had access to basic health services via a three-tiered health network consisting of regional health centres at the provincial, county, and town levels.
There are three medical insurance systems: medical care for workers, government welfare for governmental staff, and co-operative medical care, which is a community-based prepayment scheme for villagers.
‘Barefoot doctors’ (now called rural doctors), who are trained as part-time health-care workers, work in 85 per cent of villages. The barefoot doctors have led public health campaigns and provided basic curative care. They have also organized mass public health movements and initiated practical schemes like promoting the destruction of the snails which transmitted schistosomiasis.
Since the 1990s, China has been transforming itself into a ‘socialist market economy’. This has involved evolving from collective to household agricultural production, phasing out price controls, reforming state-owned enterprises, creating a labour market, and developing new forms of enterprise ownership. Economic and gross national product has since increased rapidly and rural health services have been improving. The main changes have been a reduction in the reliance on state and collective funding, decentralization of public sector health services, and increased autonomy of health facilities.
During this period, rates of infectious disease have been falling, but chronic diseases have become more prevalent. According to the 1990s disability-adjusted life years analysis, the proportions of disability-adjusted life years for communicable, maternal, and perinatal disease were 6.3 per cent in Shanghai, 24.2 per cent in China, and 43.9 per cent globally. However, for non-communicable diseases these figures were 84.1 per cent, 58.9 per cent, and 40.9 per cent respectively. This means that non-communicable diseases have become a major health problem in China, especially in large cities. According to the standardized mortality rate in 1997, cancer ranked first among non-communicable diseases with a mortality of 72.3 per 100 000 (the three most prevalent cancers were of the lung, liver, and stomach), cerebrovascular disease ranked second (60.8 per 100 000), injury and toxication ranked third (27.4 per 100 000), and chronic obstructive pulmonary disease ranked fourth (26.15 per 100 000). After implementation of prevention measures leading to lifestyle changes, comparing rates in 1973–1975 with those in 1990–1992, oesophageal cancer decreased to 44.3 per cent and 14.2 per cent in urban and rural areas respectively, cervical cancer decreased to 78.2 per cent and 64.7 per cent, and nasopharyngeal cancer decreased to 39 per cent and 33 per cent. In urban areas, stomach and liver cancer also decreased to 20 to 30 per cent.
In the twenty-first century, the Ministry of Health intends to reorganize the three-tier health services, strengthen the programme of primary health care, and reform the medical care system (Bloom and Gu 1997). They want to focus on community health and promote more health measures concerned with ageing and younger people. Healthy cities will be used as examples for good chronic disease control, such as Qidong for liver cancer control, Ling Zhou for oesophageal cancer control, and Beijing for cerebrovascular disease control.
In 2001, the Chinese Ministry of Public Health decided to improve the medical care system. Firstly, all workers will establish a personal account for their own basic medical insurance, which is paid for by the employee and the employer. This personal account will pay for treatments such as outpatient visits and medicine for less serious illnesses. Secondly, ‘low-level high-coverage’ insurance means that the insurance system will provide cheap coverage for other common diseases. Most people will have this type of medical coverage, but other more expensive treatments will have to be covered by private medical insurance.
In 1997, China’s immunization programme covered more than 95 per cent of children, including vaccines for bacille Calmette–Guérin (tuberculosis), poliomyelitis, diphtheria–tetanus–pertussis, and measles. Moreover, inoculation with the hepatitis B vaccine has been achieved in 96.6 per cent of infants in urban areas and 40 per cent in rural areas, with the carrier rate decreasing to 1 to 2 per cent in some cities. However, sexually transmitted diseases, hepatitis, diarrhoea, and HIV/AIDS have been increasing.
In the twenty-first century, the public health services in China will address and manage health issues, whilst the government addresses social and economic reform. Meanwhile, new problems are developing such as how to deal with the health problems associated with rural migration to the cities, how to collect surveillance data on health, and how to further enhance disease control systems.
Public health in Korea
Korea is a peninsula located on the eastern part of the Asian continent. It is bordered by the Aprok River, Mount Paektu, and the Tuman River of Manchuria, China proper, and the Martine Province of Siberia in the north. To the east it faces Japan and the Pacific Ocean beyond the Dong-Hae (the East Sea), and to the west it faces the Hwang-Hae (the Yellow Sea).
Korean culture has been greatly influenced by China, and medicine is no exception. Chinese medicine has been imported since ancient times, and so the Korean traditional medical literature is written in Chinese. However, continuous efforts have been made to develop traditional medicine based on Korean thought (Huh 1997).
In 1728, Western medicine began to be imported through the Chinese versions of Western medical almanacs published in China. The treatment of Koreans using Western-style medicine began in 1877, when the Japanese Navy set up Chaesaeng Hospital in Pusan, Korea, to treat Japanese residents. The medical missionaries who came to Korea in 1884 also contributed to the introduction of Western medicine.
In 1894 the administration system of health was reformed on the basis of Western medicine. The Korean government established the Bureau of Hygiene in the Ministry of Home Affairs, which was responsible for medicine, prevention of infectious diseases, and vaccination.
The teaching of Western medicine began with the establishment of government medical schools and municipal medical schools by the American Christian missions in 1899. However, in 1905 public health and medical education in Korea became dependent on Japanese medicine, which was based on German medicine.
Before the end of the Second World War (from 1910 to 1945) the Korean Public Health Service, particularly environmental hygiene and the prevention of infectious diseases, was operated by the hygiene section of the Japanese police. It was enforced as a military colonial policy, with the position of medical doctors being elevated in the field of health and quarantine. They made full use of their knowledge of modern medicine in the prevention of infectious diseases, the eradication of endemic diseases, and quarantine at sea ports (Cha 1984).
At the end of the Second World War, Korea was divided into North Korea and South Korea. In South Korea, the Department of Public Health and Welfare of the United States Military Government Office introduced a broader sense of public health. Since then, efforts have been made to introduce a modern public health system, but a lack of health experts as well as unfavourable economic and social conditions have resulted in serious problems in public health improvement.
Radical changes in the public health service were initiated in the Fourth Five-Year Economic Development Plan (1977–1981). For the past 30 years rapid industrial growth has brought continuous economic development and sociopolitical changes in all aspects of Korean society, including lifestyle. Such changes have affected the health of the Korean people, both directly and indirectly, and the prevalence and types of diseases experienced.
The increase in national income, improvement in hygiene and nutrition, and successful family planning have resulted in a reduction in the birth rate. The development of medical care and the enforcement of health insurance regulations have enabled more people to receive medical benefits. Conversely, industrialization, population growth, urbanization, the increase in vehicles, and serious environmental pollution have resulted in an increase in occupational diseases, industrial disasters, and traffic accidents. In addition, diet has changed to one high in fat and calories, and chronic diseases (e.g. heart disease, cancer, and diabetes), mental disorders, suicide, murder, and infectious diseases have all increased.
The next section describes the history and development of public health in Korea and its future.
Improved national health in Korea
Korean national health has been improved over the past 40 years with the increase in income, the improvement of living conditions, and the development of better public health (Cho et al. 1998).
The average life expectancy of Koreans increased from 52.5 years (51.1 years for men and 53.7 years for women) in the 1960s to 73.5 years (69.5 years for men and 77.4 years for women) in 1995, an increase of about 1 per cent per year (Cho et al. 1998).
The crude birth rate was about 40 per 1000 people before 1945, and then fell slowly until 1953. The baby boom after the Korean War increased the birth rate, which reached its highest level of 43 per 1000 in 1960. Family planning, which was enforced at the beginning of the 1960s, reduced the birth rate to 14.6 per 1000 by 1997, while the natural rate of increase was 9.3 per cent (National Statistical Office 1998a). The net reproductive rate was 2.3 in 1960, and declined to 1.6 in 1975. This success of national family planning attracted international attention.
The crude death rate was 20 to 25 per 1000 in the early 1940s. This rate fell temporarily after 1945, but increased to 30 per 1000 between 1950 and 1955 as a result of the Korean War. Social stability, economic rehabilitation, and the spread of a modern health service helped to reduce the death rate to 13 per 1000 in 1960, 8.8 per 1000 in 1965, 7.7 per 1000 in 1975, 7.3 per 1000 in 1990, and 5.3 per 1000 in 1997. The declining trend is predicted to continue for some time, but the crude death rate is expected to rise again because of the changing age structure of the population with increased numbers of elderly people.
The infant mortality rate was about 60 per 1000 babies between 1955 and 1960, 45 per 1000 in 1970, 10 per 1000 in 1991, and 9 per 1000 in 1995 (National Statistical Office 1998a). The rate is approaching that of developed countries, i.e. 5 to 10 per 1000 babies (WHO 1988). This decline was not achieved suddenly during any specific period, but gradually over a long period of socio-economic development.
Korea’s proportional mortality indicator was between 25 and 26 per cent before 1945. This figure indicates high infant mortality and low life expectancy. The proportional mortality indicator continued to rise to 75.9 per cent in 1992 (National Statistical Office 1992a). This resulted in a change in the shape of mortality; the proportion of infant deaths declined while the proportion of elderly deaths rose.
The maternal mortality rate is closely related to nutrition and environmental hygiene, such as birthplace and parturition control, and the level of prepartum, delivery, and postpartum care. The maternal mortality rate in Korea was 30 per 100 000 people in 1990, and 20 per 100 000 in 1995 (National Statistical Office 1998a). This rate is lower than that of developing countries (100 per 100 000) but higher than that of developed countries (3–10 per 100 000) (World Health Statistics Annual 1988).
In the 1950s, the main cause of death was infectious diseases. This shifted to chronic degenerative diseases during the 1960s and 1970s. In the late 1970s, the main causes were chronic degenerative diseases such as malignant cancer, cerebrovascular diseases, hypertensive diseases, and chronic liver diseases due to the increased number of elderly people. The death rate due to traffic accidents increased markedly during the mid-1980s (Kim 1989). Causes of death are now distributed as follows: diseases of the circulatory system, 23.4 per cent; cancers, 22.2 per cent; accidents, 13.6 per cent; diseases of the digestive system, 6.6 per cent; diseases of the respiratory system and endocrine and metabolic disorders, 3.9 per cent (National Statistical Office 1997).
The proportion of chronic diseases rose from 20.5 per cent in 1992 to 29.5 per cent in 1995. Chronic diseases made up 55.4 per cent of all diseases in 1992, and 69.1 per cent in 1995 (Lee 1997). Peptic ulcer, gastritis, dental caries, arthritis, hypertension, and diabetes accounted for 43.5 per cent of all the chronic diseases suffered.
Korea’s health expenditure was 2.28 per cent of the gross domestic product in 1975, 4.26 per cent in 1985, 5.15 per cent in 1990, and 5.89 per cent in 1996.
One Korean medical doctor was responsible for 2207 persons in 1975, 1690 persons in 1980, 1007 persons in 1990, and 735 persons in 1997. There was one hospital bed for 451 persons in 1988, and one bed for 423 persons in 1997. The number of persons per bed and per doctor is decreasing gradually (National Statistical Office 1998b).
The calorie intake per day was 9 kJ (2150 kcal) in 1970, 8.6 kJ (2052 kcal) in 1980, and 7.8 kJ (1868 kcal) in 1990 (Ministry of Health and Social Affairs 1994a). This decreasing trend was confirmed in several surveys of people of various ages (Kim et al. 1989, 1993; Yoon et al. 1990; Lee and Kim 1994).
Determinants of health in Korea
The population growth rate in Korea decreased from 3 per cent in 1960 to 1 per cent in 1995 as a result of the low birth rate which was achieved by the family planning programme as part of the economic development plan. This decreasing trend is expected to continue and the growth rate is predicted to be zero in 2028. After that, the population will decrease (Chang et al. 1996).
The gross national product per person was less than US$100 during the 1960s. Korea’s recent remarkable economic growth increased annual personal income to US$802 in 1976, US$2242 in 1985, US$5883 in 1990, and US$10 037 in 1995. However, in 1997 it declined to US$9511.
The household distribution by monthly income in 1996 was as follows: the highest 21.8 per cent of households had a monthly income of US$1900 to 2500, the second highest 17.7 per cent had US$2500 to 3000, and the next 12.2 per cent had US$1500 to 1900 (National Statistical Office 1998b).
Working environment (Kim 1998)
The total number of workers in the 178 000 industrial plants employing five people or more was 6.6 million. Plants employing less than 50 workers accounted for 87.7 per cent of the total number of workplaces, and included 39.2 per cent of the total work force. Conversely, enterprises with more than 300 workers accounted for only 1.2 per cent of the total number of workplaces and 27.9 per cent of the total number of employees.
The increase in the number of workplaces and workers has resulted in an increase in industrial accidents and occupational diseases. According to the data from the Workers’ Compensation Scheme, during the period 1970 to 1988 the number of plants and workers increased by factors of 7.5 and 4.7 respectively, and the total number of people injured, disabled, or killed as a result of industrial accidents increased by factors of 3, 5.2, and 3 respectively. Since then, accidents have gradually decreased due to preventive policies introduced by the government. In 1994, 82 352 (1.1 per cent) of a total of 7 273 132 people were injured in industrial accidents; of these, 29 907 (0.4 per cent) were disabled and 2678 (0.03 per cent) died. The average frequency rate and severity rate of industrial accidents were 4.7 and 2.9 respectively. This is attributable mainly to poor safety facilities in factories and insufficient training of workers. The frequency rates were higher in the mining and construction sectors and smaller industries. As for the causes of accidents, large industrial plants had higher accident rates due to power-driven machinery, while accidents in small plants were mostly related to work performance.
According to a nationwide annual medical examination reported in 1994, there were 8568 cases (1.3 per cent) of occupational diseases amongst 672 406 workers employed in hazardous working conditions and 129 842 cases (3.7 per cent) of non-occupational diseases in the 3 526 564 people examined. Major occupational diseases included pneumoconiosis, noise-induced hearing loss, occupational dermatitis, lead, chromium, mercury, carbon monoxide, and organic solvent intoxication, and diseases caused by heat, high barometric pressure, radiation, and vibration.
Educational attainment of the population aged 25 years or more is as follows (National Statistical Office 1998b): among males, 41.4 per cent are senior high school graduates, 26.6 per cent are university graduates, 17.8 per cent are primary school graduates or have not received any education, and 14.2 per cent are middle school graduates; among females, 35 per cent are primary school graduates or have not received any education, 34.8 per cent are senior high school graduates, 17.1 per cent are university graduates, and 13.1 per cent are middle school graduates.
The rate of housing supply in Korea increased annually from 71.2 per cent in 1980 to 72.4 per cent in 1990, 86 per cent in 1995, and 92 per cent in 1997 (National Statistical Office 1998b). Households by type of housing are as follows: detached dwellings decreased from 95 per cent in 1970 to 59.8 per cent in 1995; during the same period, apartments increased from 0.7 to 26.9 per cent, while town houses and apartment units in private houses increased from 3.6 to 8.8 per cent. During the past 15 years, the number of detached dwellings decreased while the number of apartments increased by a factor of 38.4 and town houses and apartment units in private houses increased by a factor of 2.4.
A national survey of nutrient intake has been completed annually since 1969. Furthermore, various health indices, the distribution of selected health parameters, and nutritional status have been estimated every 3 years since 1998.
In 1962, the Korean Food and Agriculture Organization, after consultaion with nutritionists, biochemists, and clinicians, published recommended dietary allowances for Koreans. The aim was to educate people to the fact that nutrition is very important for improving physical fitness. It has been revised every 5 years, and the sixth version was produced in 1995 (Moon 1995). The recommended dietary allowances are the level of nutrition that satisfies the basic nutritional requirements.
The daily energy intake was consistent at about 8.4 kJ (2000 kcal) between 1969 and 1998. The energy intake from grains decreased from 84 per cent in 1971 to 65.8 per cent in 1991.
The daily protein intake increased from 60 g in 1970 to 80 g in 1990. Half of this intake was from animal protein. The fat intake per day was 13 g in 1971 and 35.9 g in 1994. Intake of other nutrients, except for calcium and vitamins, is increasing. In a survey of nutrition in 1994, energy, calcium, vitamin A, and riboflavin were below the recommended levels (Ministry of Health and Social Affair 1994a). Fewer calories were obtained from carbohydrates, while more calories were obtained from protein and fat. This survey indicated that the average Korean consumed 85 per cent of the recommended energy allowance, 121.8 per cent of the recommended protein allowance, and 91 per cent of the recommended calcium allowance.
The problems of nutritional status in Korea are as follows: (a) a disproportionate nutrient intake among different income groups and among various districts; (b) poor care of expectant mothers, infants, and the aged who are too weak to take in nutrition; (3) lack of food-related policies based on the national nutrition conditions.
The patterns of the Korean diet are changing: dining out and consumption of meat and instant foods are increasing, while consumption of rice is decreasing. Differences by income, social strata, and geographical region lead to disparity between some sectors. In addition, various basic data for nutrition are not well understood. The government and the general public have little comprehension of nutrition. Early nutritional control for the improvement of national health has been weak (S.S. Choi 1999a).
Korea has always been dependent on agriculture. However, during Japanese rule of Korea (1910–1945), the munitions industry was given priority over resources. Most of the heavy industries, such as the metal-working and chemical industries, were in North Korea, while the light industries, such as textiles, food, and printing, were in South Korea (Cho 1979).
After the Second World War, political conflict, social insecurity, and the Korean War (1950–1953) destroyed almost all the industrial facilities in South Korea. However, development of heavy industries, such as the fertilizer, cement, and metal-working industries, began in the 1950s . In the early 1960s, industrial complexes were founded in Pohang, Ulsan, Sasang, and Kumi under the supervision of the national government, which promoted industrialization in Korea and rapidly developed the Korean economy. The use of large quantities of fossil fuel increased exhaust fumes from factories which had poor refining systems. The discharge of unpurified waste water into rivers emerged as a serious social problem by the end of the Second Economic Development Plan (1962–1966). In fact, it was when the United Nations adopted a human environment declaration at the International Conference of the Environment that the environmental problems in Korea first attracted international attention.
As humans we are a constituent of the ecosystem, yet we are the main cause of environmental destruction. It has been recognized that people themselves are responsible for the preservation of the environment and the control of resources. In order to discharge this responsibility, the following statement about environmental rights, ‘All people have the right to live in a clean environment, and the government and the people should try to preserve the environment’, was enacted as Article 35 in the Constitution of the Sixth Republic. At the same time, in 1963, the government enacted a law against environmental pollution and prepared to preserve the environment.
However, this law was ignored until 1976, because of the primacy of economic development that focused on quantitative growth. In 1977, laws regarding environmental preservation established systematic devices such as an establishment of environmental standards and the evaluation of environmental effects. In 1980, a governmental body, the Office of Environment, was established and subsequently became the Department of Environment. The laws regarding the preservation of the environment were changed completely to include laws regarding principles of environmental policy. These laws provided the foundation on which policies could be established regarding broad environmental control whilst taking into account both the ecology and the economy.
Since 1996, six pollutants (dust, sulphuric acid gas, carbon monoxide, carbon nitrogen, ozone, and lead) have been measured at 111 air pollution monitoring stations located in 47 cities all over Korea. Air pollution due to sulphuric acid gas and minute dust particles has decreased in the larger cities, but ozone levels have increased. Smog is a serious problem, and the solution has yet to be found. Owing to the increasing number of vehicles, increasing industrialization, and urbanization, noise has become a problem and the environmental standard for noise is exceeded in most geographical districts. In the future, noise pollution may become much more serious. Recently, noise pollution has increased due to the increase in air traffic.
In 1995, the Department of the Environment began enforcing an alarm system to reduce the damage by ozone gas. More important has been the effort to reduce the quantity of discharged ozone.
The distribution of sources of air pollution in 1994 was as follows: traffic, 47.5 per cent; industry, 29.5 per cent; electricity generation, 14.2 per cent; heating generation, 8.8 per cent. The main sources of water pollution are domestic sewage (12 638 000 m3/day in 1994) and factory waste water (7259 000m3/day in 1994). Any increase in sewage results in a further reduction in the water quality of rivers flowing through the larger cities (Ministry of Environment 1996). In addition, the increase in livestock industries and their waste accelerates the pollution of rivers in agricultural districts. Waste increases with economic development and improvements in the quality of life, but it has not been treated properly. Waste disposal is one of the most serious environmental problems requiring solution. Pollutants originating on land cause 80 per cent of the eutrophication of the sea. Wreckage of oil tankers and other large ships also damages fishing grounds.
The first water supply facilities in Korea, whose source was located at the Pummo Temple, were built by the Japanese in 1905 for the purpose of supplying water to ships. The first water supply facilities for the Korean population were built at Tuksom by American engineers in 1908. They used a slow-filtration method with a capacity of 12 000 t/day. As a result of the renovations in the 1950s after the Korean War and a population increase and rapid industrial development in the 1960s, water supply facilities have improved.
By the end of 1996, 83.6 per cent of the Korean population (about 38 820 000 people) were supplied with tapwater. The capacity of water supply facilities in Korea is 22 910 000 t/day. The distribution of water supply facilities by geographical districts is as follows: 98.1 per cent to the six large cities, and 1.9 per cent to small or medium-sized cities and to fishing and agrarian village districts. Most of the residents in the fishing and agrarian villages take drinking water from provisional water supply facilities and wells. The central or local government needs to exert more effort on expanding the water supply system.
In 1996 only 53 per cent of sewage in Korea was treated in disposal facilities. The government is planning to build 180 sewage disposal facilities in order to increase this figure to 70 per cent. Because of the high population density in Korea, the water from the upper reaches of rivers, with various types of sewage discharged into it, is collected as drinking water lower down. To improve this situation, 15 filtration plants on the four major rivers are changing their purification systems to an advanced disposal system using ozone or granular-activated carbon.
Health behaviours may be divided into those that can threaten health and those that can promote health and prevent diseases. Behaviours that can threaten health include unhealthy eating, smoking, and drinking (S.S. Choi 1996; National Statistical Office 1998b).
Eating is the basic element of all health-promoting behaviours. In Korea, 60.7 per cent of the population have regular eating habits, but this proportion is decreasing amongst young people; 71.9 per cent regularly eat breakfast, but more and more young people generally skip breakfast. Eating between meals is known to be harmful to health, but 59.6 per cent of the Korean population enjoy between-meal snacks. This is much lower than in the West (70 per cent), but the proportion is increasing in the younger generation. While sweets are a serious problem for Westerners, spicy and salty food are a problem for Koreans; 52.7 per cent of the population enjoy spicy and salty food. Many Koreans consume supplementary nutrients such as high-calorie food or tonics: vitamins and minerals (22.6 per cent), oriental herbs (20.5 per cent), honey (18.6 per cent), black goat meat (7.2 per cent), Korean traditional mushrooms (5.7 per cent), and others (5.3 per cent). Males show a higher preference for supplementary nutrients than females. In addition, the elderly consume more supplements than young people.
National surveys show that the proportion of male smokers has remained steady at 73.2 per cent in 1992 and 73 per cent in 1995. In terms of smoking quantity, the proportion of male smokers who consume 10 to 20 cigarettes a day has decreased from 59 to 57.7 per cent, and the proportion of female smokers who consume less than 10 cigarettes or less a day has increased from 61.3 to 62 per cent.
Generally, smoking begins in the late teens or early twenties. Therefore antismoking education would be most effective during this period. Smokers who wish to quit smoking constitute 53.5 per cent of all smokers, and the number of non-smokers has been increasing in recent years. The number of male non-smokers is increasing rapidly.
Alcohol is known to be helpful in reducing the risk of myocardial infarction, improving the quality of life, and relieving stress. However, excessive alcohol use causes social, psychological, and physical problems. Social problems include low work productivity, divorce, and family conflicts. Psychological problems include insomnia, depression, suicide, amnesia, senile dementia, etc. Excessive drinking is also associated with hepatitis, gastrointestinal disorders, diabetes, obesity, hypertension, and other diseases (WHO 1990). Male adult drinkers decreased from 84.7 per cent in 1992 to 83 per cent in 1995, while female adult drinkers increased from 33 to 44.6 per cent during the same period. From the age of 20 onwards, the number of drinkers is similar to that of smokers, irrespective of age above the twenties. Non-drinkers who do not smoke make up 50.7 per cent of the population, while 75.6 per cent of drinkers also smoke. Furthermore, the more one drinks, the more one smokes.
The most effective health behaviours are regular physical exercise and regular eating habits. However, few Koreans take proper exercise. Koreans who exercise regularly made up 14.3 per cent of the population in 1992 and 18.1 per cent in 1995 (National Statistical Office 1998b). In urban areas, the proportion taking regular exercise was highest among young people. Most people who take physical exercise do so frequently and for long periods. The most common exercise activities are running, skipping, mountain climbing, walking, light gymnastics, swimming, and tennis.
Self-assessment of health is generally categorized as excellent, good, fair, poor, and very poor. In the national survey of the Korean population in 1992, 85.8 per cent of the respondents believed that they were healthy (excellent, 5.8 per cent; good, 40.7 per cent; fair, 35.3 per cent). In a subsequent survey in 1995, 80.6 per cent of the respondents believed they were healthy. The proportion of respondents who believed that they were unhealthy increased from 18.2 per cent in 1992 to 19.5 per cent in 1995.
Health care is an essential element in improving health. According to the 1995 survey, methods of improving health care included exercise (18.1 per cent), diet (17.4 per cent), moderation in smoking and drinking (5.3 per cent), and other activities (8.8 per cent); however, 42.7 per cent of the respondents did nothing. Compared with 1992, more people were interested in taking care of their health via exercise, diet, and bath or sauna treatments, which are seen as a form of exercise in Korea by promoting blood circulation and metabolism, and increasing the excretion of excess hormones and other waste materials.
Average weekly working hours
The average length of the working week in manufacturing industries was 49.8 h in 1990, 49.2 h in 1995, and 48.4 h in 1996. These figures shows that working hours have been decreasing in recent years, but are still longer than those in developed countries.
The population of Korea
The combined population of North and South Korea in 1925 was 19.5 million in 1925; in 1949, the population of South Korea alone was approximately 20 million (Hong 1979). Between 1944 and 1950 the population increased by about 4 million. This increase of over 40 per cent is based not only on simple natural increase, but also on social phenomena such as the return of Korean nationals from abroad (e.g. Japan and Manchuria) and defections from North Korea.
The Korean War resulted in a population decrease and displacement, and restricted the population growth rate to about 10 per 1000 between 1949 and 1955. Since 1953, the mortality rate has rapidly reduced, and Korea experienced an annual population growth rate as high as 28.8 per 1000 between 1955 and 1960.
During the last 50 years, rapid economic development and an increasing quality of life have resulted in a variety of population shifts. With a rapid decrease in death and birth rates, Korea experienced a demographic turnaround in 25 years similar to that undergone in a century in Western countries. Korea’s population was 31 435 000 in 1970, 36 790 000 in 1975, 37 400 000 in 1980, 44 480 000 in 1985, and 44 609 000 in 1995. The respective mortality rate per 1000 during these periods was 9.8, 7.3, 6, and 5.4, the birth rate was 29.5, 24.6, 22.7, 16.2, and 15.8 respectively, and the natural increase was 19.7, 17.3, 15.4, 10.2, and 10.4 per cent respectively. Korea now has a similar population structure to that of developed countries.
The Korean government introduced a family planning programme as part of its Economic Development Plan in the early 1960s because of the high population density and Korea’s limited territory and natural resources. In the early 1960s, Korea’s fertility reached 6 per 1000 and the average life expectancy was 52.6 years. The structure of Korea’s population was a typical pyramid shape, based on a high fertility rate and a high mortality rate. However, through social and economic development, together with the government’s strong family planning programme, the fertility rate has been decreasing rapidly. The total fertility rate reached 2.1 in the mid-1980s, which is the substitution level for the population. Since then, Korea has maintained a low birth rate. Despite the fact that the government has made substantial cutbacks in the family planning programme, the total fertility rate in 1997 was 1.56 (Table 1) (National Statistical Office 1998c).
Table 1 Total annual national fertility in Korea (1960–1997)
According to the National Statistical Office (National Statistical Office 1996), the fertility rate will remain below the substitution level of the population in the twenty-first century. The annual population growth rate is predicted to fall from 0.98 per cent, which was maintained between 1990 and 2000, to 0.68 per cent between 2000 and 2010, and to 0.34 per cent between 2010 and 2020. It will eventually reach zero by 2028. After that, the mortality rate will exceed the birth rate, resulting in a negative growth rate which will result in an absolute decrease in the population. The population will exceed 50 000 000 for the first time in 2008, and it will reach a maximum of 52 776 000 in 2028. The population shift was predicted to increase by 46.6 per cent between 1970 and 2000, and by 11.6 per cent between 2000 and 2030. It can be foreseen that the scale of the population shift will not be as large in the twenty-first century as before.
People aged 60 and over formed 3.9 per cent of the whole population in 1980, 5.0 per cent in 1990, and 6.6 per cent in 1998. This proportion can be expected to increase in the future to 9.9 per cent in 2010, 13.2 per cent in 2020, and 19.3 per cent in 2030. The more older people there are in a society, the more money is required for social security provision such as pensions or medical care. The high cost of national medical services, and a critical demand for medical services for the aged, calls for the implementation of a new medical and welfare system for the elderly (E.Y. Choi et al. 1998).
Spectrum of diseases in Korea
The recent downward trend of acute infectious diseases showed that 3.7 people per 100 000 were affected in 1996. This trend has been continuing at this level during recent years. However, a particularly noteworthy phenomenon is that malaria has been increasing since 1994 (Ministry of Health and Welfare 1997).
Sixty-eight individuals were infected with cholera in 1995, and two were infected in 1996. The periods during which cholera was prevalent were short and there were no cholera-related deaths. Cholera in Korea typically occurs first along coastal areas and then spreads inland through the exchange of food, such as occurs in mourning houses, marriage ceremonies, etc. It is thought that cholera occurs in unclean coastal areas where sewage accumulates.
In the late 1960s there were over 4000 cases of typhoid fever, with a fatality rate of 1.48 per cent. However, the increase in Korea’s gross national product and improvements in sanitation, together with the development of public health care, have resulted in a continuous reduction in the incidence and fatality rate of typhoid over the last 40 years. The annual incidence rate has decreased to 0.5 per 100 000 people since 1980. However, a report shows that there are still tens of thousands of patients annually, and thus the disease is still endemic.
In the 1950s, the average annual incidence of Japanese encephalitis was 2000, with a fatality rate of about 40 per cent. Since then, the incidence and fatality rate have continued to fall. Since 1985, only one of 25 patients has died from Japanese encephalitis.
In the 1990s, new infectious diseases have appeared or reappeared. Bacterial dysentery (in 1993), type A hepatitis (in 1994), and mumps (in the spring of 1998) are examples of reappearances. Since 1994, the number of cases of malaria has rapidly increased near the 38th Parallel (the border between North and South Korea). The reason for the reappearance of such infectious diseases is the continuous mutation of pathogenic micro-organisms, changes in population and social conditions, and the modification of the Earth’s environment (B.Y. Choi 1999) (Table 2).
Table 2 Number of cases of critically acute infectious diseases in Korea (1985–1996)
In 1996, there were five cases of cholera and 35 cases of tropical malaria in Koreans who had visited Southeast Asia or Africa; the first Escherichia coli 0157 patient appeared in 1988. Furthermore, increasing numbers of foreign infectious diseases are entering Korea.
Since the first HIV-positive patients were identified in Korea in 1985, the number has been growing annually, and reached 811 by June 1999, according to a report by the Ministry of Health and Welfare. Of the total cases reported, 133 resulted in death and 115 resulted in AIDS (Table 3). Seventy-six of the 811 cases were under epidemiological investigation or classified as of unknown cause. Of the remaining 735 cases, 696 were infected by sexual contact (95 per cent), 21 by blood transfusions (including transfusions received overseas), 17 by blood products, and one by vertical infection. Of the 696 patients infected by sexual contact, 230 had sexual relationships with foreigners, 292 had domestic heterosexual relationships, and 174 had homosexual relationships. HIV first appeared in Korea amongst foreigners, but the infection has now spread to domestic heterosexuals. It should be noted that a relatively high number of homosexual males are infected. No cases have been linked to blood transfusions or blood products in the last 2 years. This improvement is thought to have been achieved through the screening of blood donations, and an increase in the safety of blood transfusions and blood products. Fortunately, no cases of infection by intravenous injection have yet been reported. The best way to control infectious diseases is to establish a surveillance system and to improve the information network.
Table 3 Cases of HIV infection and patients with AIDS in Korea
The mortality rate of infectious diseases has reduced significantly with improvements in housing conditions, nutrition, and medical care. However, the mortality rate of chronic degenerative diseases has been increasing rapidly. This trend will have a significant impact in the future, with the ageing of the population, changes in eating habits, an increase in the number of smokers, and a decrease in the amount of physical exercise.
Before 1970, infectious diseases were the greatest cause of death. However, the widespread use of antibiotics since the 1970s has resulted in a significant decrease in the number of deaths caused by infectious diseases.
In the early 1960s, the three major causes of death were diseases of the digestive system, such as diarrhoea and gastroenteritis, diseases of the respiratory system, such as pneumonia and influenza, and infectious and parasitic diseases. Malignant cancers were the fifth most significant cause of death. In 1970, the chief causes of death were diseases of the circulatory system. Malignant cancers were the fourth most significant cause of death while injury and poisoning were the fifth. In 1980, the most serious cause of death remained diseases of the circulatory system, cancer was the second, and injury and poisoning were the third. The order has remained unchanged until the present. However, recently, when the diseases of the circulatory system were divided into two categories (heart disease and cerebrovascular disease), the main cause of death became cancer. These three types of disease caused 61.9 per cent of all deaths in 1995 (Park 1998).
The number of Koreans who suffer from mental disorders is increasing due to rapid changes in living conditions and a more complicated social structure. At the end of 1996, the total number of people who suffered from mental disorders was estimated to be 993 000, or 2.16 per cent of the total population. Of all patients with mental illness, 115 000 (11.6 per cent) needed to be admitted to hospital. The prevalence rate of mental illness over a lifetime is 31.8 per cent in large cities, and 32 per cent in rural areas. The causes of mental illness in large cities and rural areas are alcohol misuse (21.7 per cent and 26.8 per cent), anxiety and somatoform disorders (7.4 per cent and 8 per cent), mood disorders (5.52 per cent and 3.07 per cent), and schizophrenia (0.12 per cent and 0.65 per cent) (Lee and Han 1986).
Trends in health policy in Korea
Between the end of the Second World War and the Korean War, the government was unable to increase investment in health care. Therefore most of the medical care was provided by non-governmental doctors who established the infrastructure of a health-care system through self-investment. The government had no policy for a desirable medical delivery system, but only developed policies for establishing a primary health care organization, disinfection, and medical aid.
The American Army Administration, which controlled the government of Korea after the Japanese occupation, judged that the prevention of illnesses was more effective than cure when supporting a country with limited resources for a public health system. Therefore the Administration declared the implementation of health care with a focus on the prevention of illnesses (American Army Administration Order No. 1, September 1945). A model health centre was established which began operation in October 1946. In 1958 the centre became the National Central Health Center but in 1959 it was dismantled. During its operation, this institution was a model for health-care programmes. It trained 330 health personnel, doctors, sanitary leadership members, and institution members, in addition to operating administrative training courses. After its dismantlement, the institution evolved into the National Health Research Institution (Kim 1984).
The National Health Care Law was enacted in 1951. More than 500 primary health care centres were built and operated. In 1953, 15 public health centres were established, and 471 primary health care centres were refurbished. As a result, health centres and primary health care offices were established in rural areas, but the government was unable to provide them with adequate support. After the enactment of the Health Centre Law in 1956, public health centres, governed by cities and provinces, were established and thus an infrastructure for country-wide preventive health care was put in place. However, because of political instability and financial limitations, the government allotted less than 1 per cent of the total government budget for health care, and this budget was only allocated to the control of acute infectious diseases, such as epidemic typhus, typhoid fever, smallpox, etc. (Yoo and Yang 1989).
The First Five-Year Economic Development Plan for the purpose of economic development began in 1962, but there was no investment in health-care development. However, although the governmental policies focused on economic development, a family planning policy was instituted.
The family planning programme as a health policy, which also helped to maximize economic development, formed the basis of governmental health programmes such as maternal and child health care and tuberculosis control. The Korean Family Planning Institute was established in 1961 as a non-governmental group. It organized the National Mothers’ Meeting and allowed this organization to develop family planning. This was very successful, and became the basis on which non-governmental organizations participated in health-care programmes. Originally, the maternal and child health-care programme was only a part of the family planning policy whose primary purpose was population control. However, it was found that the family planning programme could be organized better as part of the maternal and child health-care programme, which steadily became more active from 1980 onwards as maternal and child health-care centres began to be established all over the country.
Control of tuberculosis was mainly in the form of tuberculosis prevention. In 1952 the government organized the BCG Vaccine Action Team, which toured cities and provinces in order to vaccinate elementary and preschool children. In 1965, in co-operation with the Tuberculosis Institute which was established in 1953, the team also began to survey the national tuberculosis situation.
At the time that the Health Center Law was revised in 1962, there was approximately one health centre per 100 000 people in cities, and one health centre per county (kun) in rural areas. From 1969, health subcentres were set up in towns (eup) and ‘subcounties’ (myon). However, the health centres and the health subcentres could not be fully activated because of a shortage of labour and facilities. In particular, the health centres followed the American model, focusing on preventive care and not providing clinical care. As a result, the health centres and the health subcentres were largely disregarded by patients. Also, because the main health programmes at the health centres were top-down programmes, these did not reflect regional characteristics. The American style of public health care relied on private sector investment, which was small, and the public perceived itself to have little input in administrative policies.
During the Second Five-Year Economic Development Plan (1969–1971), the government tried to increase production from industry, agriculture, and fisheries. The health-care policy during this period focused on eliminating or reducing factors disadvantageous for a rapidly growing economy. These factors included the prevention of acute infectious diseases, tuberculosis control, the enlargement of health-care services in rural areas, the qualitative improvement of food and medicine, training of health personnel, and family planning, including maternal and child health care.
The Third and Fourth Five-Year Economic Development Plans (1972–1976 and 1977–1981) focused on the social development of rural areas, and included social as well as economic development in an effort to reduce the income gap between urban and rural areas.
Under the banner of ‘Self-Support, Diligence, and Co-operation’, the nationwide Saemael (New Town) Movement, strongly supported by the government, was divided into four elements: production-based businesses (electrical, roads, irrigation, etc.), ‘mental reformation’ (morality and education), increasing income, and the improvement of environmental welfare. Rural residents were urged to participate in the movement actively and voluntarily, thus leading to improvements in their own society. Although the business priorities were different in each locality, the main objectives of this movement were to provide safe water and sanitary housing, including kitchens and bathrooms, and the management of child-care centres for agricultural regions (Yoo and Yang 1989).
Between 1962 and 1979 the annual income per household increased from US$147 to US$4840 in rural areas, and from US$190 to US$5460 in urban areas.
The primary developmental aims of the health system in the Fourth Five-Year Economic Development Plan were dissemination of medical services, reduction of infectious diseases, maintenance of maternal and child health care, improvement of national nutritional status, and the general improvement of living conditions.
From the late 1970s, health policies were implemented through medical insurance. In the mid-1970s, unequal sharing of medical benefits was a serious social problem related to the unequal distribution of the benefits of economic growth. From a political viewpoint, it was necessary to establish a policy to solve this problem. However, the execution of the policy was accompanied by problems of financial investment and a limitation of financial resources. Furthermore, the policy only applied to the employees of the conglomerates that could afford this expenditure. During this process, a set price for medical insurance was developed to secure affordable insurance.
As medical insurance gradually spread and came into effect nationwide in 1989, its cost became one of the most important issues in medical policy. The financial investment for public medical care, corresponding to the nation’s economic power, grew continuously, and investment for creating facilities also steadily changed from the old privately controlled system to a government lending system. Governmental investment was also instituted as one of the most important policy measures.
Based on the new national medical insurance, a medical delivery system was also created. As a result, primary medical care began at clinics and health centres, as well as in secondary and tertiary general hospitals. This system was slowly put in place nationwide. From 1977, the government began to provide medical care for the poor.
From the end of the 1970s to the end of the 1980s, the government and some colleges tried to implement a model plan of primary health care. Family planning measures helped to realize this goal.
Rapid socio-economic development in the 1990s changed the trend of disease, and thus a new form of health policy was required. The recent trends in the causes of death differ from that of the past. Causes of death now resemble those in the West, i.e. a shift from respiratory and cerebrovascular disease to cancer and heart disease. To meet this changing trend in diseases, a health-care policy that was previously only focused on the treatment of diseases and which had a passive attitude to health care was forced to change by the late 1980s (Kim 1997).
To improve the recent patterns of harmful living, such as excessive drinking and smoking, the National Health Promotion Act was enacted in January 1995. This Act strengthened the health promotion programmes in such areas as health education, prevention service, and creating healthier living through improving individual health behaviours.
The Local Health Law was enacted in December 1996 to support the public health centres that were in charge of infectious disease control and family planning. The local public health centres became the central institutions for local people’s health. In addition, the law added a national health promotion programme and a programme for chronic degenerative disease control, preparing the way for the introduction of autonomous local health programmes by clarifying national and local judicial responsibilities.
A law for elderly welfare was enacted in June 1981 for the prevention, early detection, and treatment of diseases, and for rehabilitation in the elderly. Korea is becoming an ageing society; 6.3 per cent of the total population were over 65 years old in 1997 (National Statistical Office 1998b). The law was reformed in August 1997 to address the issue of financial security for elderly people.
The government enacted and promulgated a pollution prevention law in 1963, but it did not become effective until 1976, when the Five-Year Economic Development Plan ended, because it centred on economic development. In 1977, the enactment and promulgation of the Environment Preservation Law established and controlled environmental standards and developed institutional equipment for the assessment of environmental effects. In 1990, the Environment Preservation Law was wholly revised as a basic environmental policy law, and it brought about a new phase of environmental control and laid the foundations for reasonable and comprehensive control measures of the environment.
Transition of non-governmental medical facilities
At the end of the Second World War, the Korean government was established through the American Army Administration. However, the Korean War destroyed Korea’s economy and industry. As a result, health and medical care were neglected. Accordingly, health conditions were very poor, and even the existing facilities were not fully used because of the weak economy. Korean medical science, which had depended on Japan until the end of the Second World War, was introduced to American medical science, medical care system, and medical education after the Second World War. Thus the Korean medical establishment developed a health-care system which combined elements of both the Japanese and American approaches. Public medical institutions, which formed the core of the service during the Japanese colonial period, could not perform to their full capacity because of a shortage of doctors and obsolete facilities. Such limitations were caused by the government’s lack of financial resources and management skills. Missionary hospitals were also in financial difficulties but, with the decline of public hospitals, they began to play a central role. The Pusan Gospel Hospital, the Seoul Sanitation Hospital, the Baptist Hospital, the Inchon Christian Hospital, and the Wonju Christian Hospital were built in the 1950s. They also served a public function, and some of them became attached to universities. The Catholic Church established 15 small and large hospitals in a 20-year period beginning in the 1950s. The Red Cross developed smaller hospitals with less than 100 beds in eight areas including Seoul, and they took charge of medical care for the poor. Private medical institutions underwent large-scale growth and supported hospital care for the poor qualitatively and quantitatively until the end of the 1960s.
From the early 1960s, with the economy developing well, social insurance began to be introduced. The introduction of this insurance increased medical demand and led to an expansion of medical institutions. To solve the shortage of hospitals, the government provided financial aid and, in 1980, supported the building of private hospitals by establishing local private hospital programmes. Thus the structure of medical provision changed from public and missionary hospitals to private hospitals, and the scale and quantity of hospitals increased. Also, the purchase of expensive medical equipment increased rapidly.
However, many problems followed, such as an unbalanced distribution of health-care services in the regions, a rapid increase of health-care expenditure, and a shortage of doctors. Therefore, from 1984 onwards, the government tried to attract private hospitals to agricultural and fishing regions, which were experiencing the most severe shortage of hospitals, by restricting the number of hospitals that could be built in each region.
In the future, medical care services should be broadened to include poorer people and to ensure that a proper level of local health resources can be maintained.
Organization of public health in Korea
The Korean Public Health Administration system is composed of central and local health organizations. There is no direct link between them. Therefore all administrative systems that are composed of local autonomous groups constitute an artificial administrative system (S.S. Choi 1999b).
The Ministry of Health and Welfare is the central organization for the administration of health care at the national level, and it presides over such issues as the prevention of epidemics, regulation of medication, social welfare, medical security, pensions, domestic welfare, and others. It has no power over personnel or budgeting; as an administrative organization, it only provides technical support. Local health administration organizations are composed of the health departments of cities and provinces. In turn, each province is composed of bureaus under the health or social department and its health centres in administrative units: si (small city), kun (county), and ku (district, administrative unit of a large city). As units within the department, there are umbrella offices in each eup (town, administrative unit of a county with a large population), myon (subcounty, administrative unit of a county with a small population), and remote areas. The local health administrative organization has a dual system that is under the direct control of the Interior Ministry as part of the general administration. Under this system, the unique characteristics of health administration cannot be considered fully.
The national university hospitals that are directly or indirectly related to national health are administered by the Ministry of Education, police hospitals are administered by the Police Office, and medical centres of local corporations of cities or provinces are administered by the Interior Ministry. Because the central health administrative system is composed of various bodies, the functions and roles of the Ministry of Welfare and Health are restrained in the course of executing policies and therefore health and medical programmes have many problems with ineffectiveness and inefficiency.
The Central Health Administrative System
The Ministry of Health and Welfare is the central health administrative system of the government. The primary goal of the ministry is to improve the health of Korean citizens through the enactment of laws. The ministry is organized into two offices (planning and management, and social welfare policy), four departments (health policy, health promotion, health resource management, and pension insurance), three deliberation bureaus (social welfare deliberation, domestic welfare deliberation, and disability welfare deliberation), five centres (public information, inspection, technology co-operation, oriental medicine policy, and emergency planning), 27 divisions (including medical and medication policy, food policy, health promotion, prevention of epidemics, mental health, food and medication promotion, insurance policy, welfare of the elderly, child care, women’s welfare, disability leadership), and nine bureaus with special responsibilities (including international co-operation, oriental medicine, and women’s health).
The following institutions are attached to the Ministry of Health and Welfare: National Medical Center, National Health Center, National Health Safety Research Institute, National Social Welfare Training Center, five national psychiatric hospitals, National Sorok-Island Hospital, National Rehabilitation Center, two national tuberculosis centres, National Homesickness Management Office, 13 national quarantine offices, Food and Medicine Safety Agency, and six food and medicine agencies.
There are also 32 related groups, including the Korean Medical Association, the Korean Pharmacy Association, the Korea Red Cross, the Korea Association of the Elderly, the Korea Medical Insurance Union, the National Pension Management Corporation, the Korea Research Institute for Health and Society, and the Korea Health Management Association.
Local health organizations
Health administration organizations at the level of cities and provinces exist in Seoul, other metropolitan areas, and all provinces. The Ministry of Health and Welfare, as the central health administration organization, connects all public health centres for each city, county, and district.
Public health centres operating in cities, counties, and districts form the core national health organizations in Korea. The public health centres were established as local autonomous governments by an ordinance based on the public health centres. According to the ordinance, Seoul and all other metropolitan areas should have a centre in each district, and all other cities should have a centre in each town and county. In October 1997, there were a total of 245 centres—228 public health centres and 17 health medical centres. The business of public health centres is managed and controlled by the head of the local government, and the internal organizations and divisions are managed by the Direct Rules and Affairs Division of the public health centres. Decisions made at this level are based on local government policy, and the contents may differ amongst cities, counties, or districts.
Health and medical organizations in towns and subcounties are as follows. The town and subcounty should aim to establish one public health subcentre, based on a publicly decided law at each town and subcounty. As of October 1997, there were 1314 public health subcentres. The chief of the public health centre should be a qualified doctor. He or she is in charge of the area’s business and directs its programmes, supervises personnel, and guides the health and medical business of the subcentre.
Villager’s health centres are established in agricultural and fishing villages to care for the health of people living in those areas. These areas either do not have doctors, or they may have one for short periods of time. The public health centres in these areas are the lowest level of care and, as of 1997, there were a total of 2034 such centres. The public health practitioners in these centres are nurses and midwives whose qualifications are regulated by the Ministry of Health and Welfare based on the governor’s ordinance. They have a 24-week period of on-the-job training, during which they can perform minor medical services.
Korea’s medical policy
Korea’s medical security system is composed of medical insurance, worker’s compensation insurance, and medical aid.
In 1963, Korea’s medical insurance was enhanced by the enactment of a medical insurance law. However, its effects were generally insignificant, except for serving as a useful model for private businesses, because the national average annual income per household was only about US$100 at that time. A practical role was played by the second amendment, which was enacted at the end of December 1976.
Compulsory medical insurance began in 1977 for workers in companies with over 500 employees and in public corporation complexes. This was also the first year of the Fourth Five-Year Economic Development Plan, which centred on social development. Although it was mandatory, it was the beginning of social insurance.
The Insurance Law for Government Employees and Private School Teachers was promulgated in December 1977, and insurance businesses catering for government employees and private school teachers began to be established from January 1979. The coverage of insurance for employees in the private sector was extended from companies with more than 300 workers, to those more than 100 workers, and finally to those more than five workers.
While employees who had a regular cash income joined the medical insurance programme, self-employed workers or villagers living in agricultural or fishing areas could not join. This resulted in further social problems in the 1980s.
The government operated a pilot programme for regional medical insurance in 1981 and 1982, and, as a result, regional medical insurance for the self-employed in urban areas was etablished in 1988. In 1989, the programme was extended to city dwellers. By a series of such processes, national medical insurance was initiated.
When the national medical insurance law was passed in 1997, regional medical insurance and insurance for government employees and private school teachers were also established starting in October 1998.
The benefits of medical insurance are twofold:
benefits in kind (medical care benefits, maternity benefits)
cash benefits (medical care expenses, maternity expenses, funeral expenses).
The medical care benefit is given for the diagnosis, medication, provision of care materials, treatment, hospital admission, nursing care, transportation, and for sickness and injuries. Originally sickness benefits for diseases other than pulmonary tuberculosis were given for 330 days a year, but this was increased to 365 days a year in 2000. The benefit in kind for delivery is given for childbirth in medical institutions. The benefit in cash for delivery and care is paid only when the allowance in kind cannot be given because of unavoidable circumstances. The funeral benefit is paid in cash to the person who is responsible for the funeral service when an insured person or one of his supportees dies.
The medical insurance fee is between 3 and 3.2 per cent of the standard monthly income of government employees, private school teachers, and employees in the private sector. Employers and employees each pay 50 per cent of the fee. For private school teachers, the owner of the private school pays 30 per cent and the government pays 20 per cent of the medical insurance fee, while the teachers pay 50 per cent. The self-employed in rural and urban areas pay the fee by grade (from 1 to 50 classifications according to their income and assets).
Reimbursement of doctors’ and hospital fees are largely based on a fee-for-services schedule, which is determined by the government.
An experimental project using diagnosis-related groups was tried in 1997. The system is being partly introduced into medical services in 2000. Under this system an insured individual will pay a part of the medical fee when an actual medical service is received (patient co-payment), in addition to a medical insurance fee.
Medical claims review and payment of medical care fees is a third-party payment system in which medical services for the medical practitioner or medical facilities are not owned by the insurer. The medical service providers are reimbursed by the insurer on the basis of a fee-for-services through the insurance medical care institution.
Before 1976, the Medical Aid Project in Korea provided free medical services on the basis of the National Assistance Act. However, the practical results were not satisfactory. In order to spread medical benefits to people of low income, the Medical Aid Act was promulgated in 1977 and medical aid was begun. The Medical Aid Law was promulgated in December 1977, and the enforcement ordinance of the law was established in May 1978. The previous regulations of medical aid were abrogated while the enforcement regulations of the medical insurance law were put into effect in September 1978.
The purposes of the Medical Aid Law are to provide medical services to those who cannot support themselves or who have a low income, and to improve national health and social welfare. This law mandates medical aid institutions to provide medical services to people who need livelihood assistance under the National Assistance Act. This includes those aged 60 years and above, the infirm, those below 18 years of age, expectant and nursing mothers, men disabled by incurable diseases, the mentally or physically handicapped, and others who cannot support themselves.
The people who need medical aid are divided into two classes.
Class I: people in nursing or welfare facilities, victims of disasters, national heroes, human cultural assets, North Korean defectors, and patients with sexually transmitted diseases.
Class II: self-support recipients with livelihood assistance.
The range of medical aid includes diagnosis, medical treatment, surgical treatment for all kinds of illnesses and injury, childbirth, other treatments, supply of medicine or medical material, hospital admission, nursing, transfer, and other medical measures.
The method of imposing medical charges depends on the class of medical aid. All class I medical charges, including both outpatient and hospital admission treatments, are paid by the government. In class II, all medical charges for outpatient treatments are paid by the government. Charges below 100 000 won (Korean currency) for treatment during hospital admission are paid for by the patient. If charges exceed 100 000 won, the government provides an interest-free loan which is repaid by instalments within 1 to 3 years.
City and provincial governments have established medical aid foundations, which are supported by government aid, surpluses, proceeds from the foundation, and other sources.
Occupational accident compensation insurance
The Korean Constitution guarantees workers three primary rights: the right to work, an equal right to share profits, and protection for the unemployed. However, the laws underpinning these rights have not been established. Occupational accident compensation is provided to the workers by a collective contract, not by the law.
The Labour Standard Law for the health and safety of workers was enacted in May 1953. This law prescribed a system of no-fault compensation for workers’ occupational accidents. However, mismanagement by employers and a heavy burden of compensation for serious accidents drove the insurance companies into bankruptcy. The law could not achieve effective results and was unhelpful.
The Occupational Accident Compensation Insurance Law was enacted in 1963, when economic development through industrialization was a primary aim of Korea, and was enforced in 1964. This law was enacted to compensate occupational accidents fairly and quickly, and to reduce the burden on employers who could not provide accident compensation for large numbers of victims at the same time.
When the law was initially enforced, the insurance was managed by the government. Mine companies and manufacturing companies, which employ more than 500 workers, are legally required to buy the insurance policy.
An allowance for medical care was provided for hospital stays of longer than 11 days, and compensation for absence from work was 60 per cent of the average wage. Since then, the benefit has increased, and since 1982 the length of hospital stay qualifying for the medical care allowance has been reduced to 4 days. In 1989, compensation for absence from work was increased to 70 per cent of average wages. In 1992, workplaces employing more than four workers were required to buy the policy. Since 1995, the Korean Industrial Safety Complex has taken over management of the insurance.
The insurance premium depends on the total wage bill of the company which the policy holder manages and the type of company. Occupational accident compensation is provided for injuries and death, the causes and results of which are directly related to work. As of 1998 this insurance covers six kinds of allowance: medical care, absence from work, mental or physical handicap, survivor’s pension, pension for injuries and diseases, and funeral expenses.
Medical care services in Korea
Personnel expenses constitute 40 to 60 per cent of hospital budgets in Korea. The management of human resources is vital to the success of the promotion of health within Korea. Satisfactory health and medical services require a full supply and proper and effective management of well-trained health and medical human resources. This will help the national health and medical project to be executed satisfactorily with proper expenditure.
Health and medical human resources licensed by the Medical Service Act include medical doctors, dentists, oriental medical doctors, midwives, and nurses. Those who are licensed by the pharmacy laws include pharmacists and oriental medical pharmacists. The Medical Service Act prescribes 26 types of medical specialists and four types of special nurses, with additional nursing assistants, paramedics, massagers, and so on. Emergency service workers are licensed by the Emergency Service Law, nutritionists and cooks by the Food Sanitation Law, sanitarians and sanitary engineers by the Sanitarian Law, and veterinarians by the Veterinary Law.
As of 1997, on average there is one medical doctor for 735 people, one herbal doctor for 4951 people, one dentist for 2990 people, one pharmacist for 1004 people, and one nurse for 135 people.
All health and medical human resources, including medical doctors, have been increasing rapidly, but poor management of these resources will become a serious problem in the future. The increase in medical facilities is slower than that of human resources, so that there is unsatisfactory employment of medical personnel.
As of 1996, medical institutions employed 74.6 per cent of licensed medical doctors, 75 per cent of licensed dentists, 75.9 per cent of oriental medical doctors, 38.7 per cent of nurses, 13.6 per cent of midwives, 40.6 per cent of medical technicians, 26.8 per cent of medical records officers, and 31.5 per cent of nursing assistants.
The number of people served by one medical doctor or one dentist in Korea is larger than in developed countries. However, the present supply of medical human resources is considered to be sufficient to meet future demands. The supply of nurses, including nursing assistants, is close to the level in developed countries.
Specialists are defined as those who take a training course in internship and residency at a hospital or medical institution designated by the government after obtaining a medical licence according to the Medical Service Act, and who subsequently pass the qualifying examination of the Korean Medical Association.
The purpose of the medical specialty system is to encourage doctors to receive intensive and complete training in clinical specialities, and to continue to acquire new medical knowledge in order to upgrade the quality of medical care services and improve health care. There were 26 specialties and 34 726 specialists in 1996. This represents a 4.1-fold increase in the number of specialties compared with that of 1980. The number of specialists has increased, and the proportion of specialists amongst doctors has also increased since 1993. In 1996, 58.2 per cent of licensed doctors were specialists. The distribution of specialties is as follows: 14.2 per cent of specialties in internal medicine, 10.6 per cent of specialties in general surgery, 10.1 per cent of specialties in obstetrics and gynaecology, 8.4 per cent of specialties in paediatrics, and 8.3 per cent of specialties in family medicine.
Compared with medical doctors, pharmacists are outdated. According to the Medicinal Service Law, the specialization of dispensary and medical practice began to be implemented in 2000. Pharmacists will be in charge of dispensing medicine and will not be permitted to do so without a medical doctor’s prescription. The number of pharmacies will decrease, and a considerable number of pharmacists will become unemployed.
Almost all kinds of medical technicians and assistants are becoming outdated. Medical assistant services will have to be specialized, and continuous training is needed for them to meet the needs of specialized assistant services.
Medical facilities are places where health and medical services are provided, and are a substructure of the national health and medical system. They include medical institutions under the Medical Service Law, rural health and medical centres, health centres, health subcentres under the Health Service Center Law, and health clinics under the Temporary Law for Promotion of Agricultural and Fishing Villages.
Medical institutions are classified into general hospitals, other hospitals, and clinics. This classification is also applied to dental institutions and oriental medical institutions.
The third class of medical institutions has 262 general hospitals, which provide hospital admission, and diagnosis and treatment of more serious diseases. The second class of medical institutions has 456 hospitals, and the first class of medical institutions has 15 876 clinics. There are 49 sanitoriums, 9243 dental hospitals or clinics, 6446 oriental medical hospitals, 220 dispensaries or clinics, and 148 midwifery clinics in Korea (National Statistical Office 1998b).
The medical facilities have several problems. Firstly, the expansion in their number was achieved by non-governmental health insurance funds and therefore was dependent on private citizens. This interferes with the formulation and execution of a national health policy. A second problem is the regional difference in the increase of the number of institutions. A third problem is that unclear distinctions of services and functions between medical facilities creates wasteful expenditure. Fourthly, improvement in the quality and efficiency is slower than the expansion in the quantity of medical facilities.
Medical delivery system
The national health and medical system has always been considered as the core of primary policy in every establishment of long-term health projects. The establishment of a medical delivery system has been interrupted by disparate elements of public medical care, a lack of regional health planning, the unclear role of larger hospitals and clinics, and the lack of an economic transfer system.
The introduction of medical insurance resulted in a rapid increase in the demand for medical care, and in patient preference for large hospitals. The era of the national medical insurance system began with the medical insurance of the urban self-employed.
A patient-referral system was also introduced. Under this system, the country was divided into eight large and 142 middle-sized areas of medical care. Medical institutions were classified into the primary, secondary, and tertiary classes for the allocation of roles. The patients could choose primary or secondary medical institution care. The tertiary institution admitted patients with medical requests issued by the doctors of the primary or secondary institutions. If a patient chose any other primary or secondary institution outside his own geographical area without special permission from the insurer, he could not claim the allowance for the medical care. However, this restriction did not apply to emergency care and delivery. Any tertiary institution could provide primary medical services in six specialist fields, such as family medicine, ophthalmology, dermatology, rehabilitation medicine, and dentistry. The ultimate aim of this policy was to make the most of medical resources and to reduce medical costs.
The division of medical care areas was abolished in October 1998, and anyone can now receive medical services at any time in any area. Role allocation was not well established amongst the primary, secondary, and tertiary medical institutions, which led to excess competition and excessive preference of patients for larger hospitals. This problem is expected to be solved in the future. Medical-related systems should be improved to control human resources and facilities, and to meet the demands of health and medical care. The efficient use of human resources, health facilities, and medical care requires various plans, including the proper allocation of their functions and roles.
Public health services in Korea
The Korean family planning project was started by Christian missionaries and medical doctors in Wonsan and Wonju in the 1920s, and in Inchon in the 1930s. They initiated a birth control and contraception campaign for peasant women, but it did not attract much interest. Meanwhile, the Korean Mothers Association, which was established in 1958, adopted and developed education about family planning as one of its own projects. This was the first systematic campaign of family planning in Korea.
The overpopulation of developing countries was one of the main causes of the vicious circle of poverty. Beginning in 1960, the government adopted a population policy as part of its economic development. The development of family planning achieved remarkable success in curbing population growth. Korea has become one of the countries with a very low birth rate. Its fertility rate has been below the population replacement level since the mid-1980s. The composition of the population is similar to that of developed countries which has made a great contribution to Korean’s economic development.
In 1962, all the health centres throughout the country set up family planning consultation offices, and employed licensed nurses or midwives. At the same time, the Health Centre Law was revised to add consultation and education of family planning to the services of health centres. In 1963, the Law of Maternal and Child Health was established and provided the legal foundation of the Family Planning Project. This provided for legal abortion. In 1964, the section of family health was established under the city or provincial governments which took charge of the family planning project of the regional area. The association of family planning organized its branches with more than 30 members in city and county areas, and in individual workplaces.
The campaign for family planning spread rapidly all over the country, financed and supported by the government and other institutions.
When the Family Planning Project was adopted as a governmental policy, Korea had a rate of contraception of 4 to 9 per cent and was suffering an increasing crisis of population growth rates of 30 per cent. However, the contraception rate increased to 20 per cent in 1966, 25 per cent in 1971, 55 per cent in 1979, and 79 per cent in 1991. Contraception by intra-uterine device, condoms, vasectomy, and oral contraceptive pills increased in the early 1970s. Contraception by fallopian tube ligation increased to 4.1 per cent in 1976, 31.6 per cent in 1985, and 35.5 per cent in 1991. It is one of the most common forms of contraception (National Statistical Office 1992b). Vasectomies increased to 11 per cent in 1988, but were still less than a third of the fallopian tube ligations. At the same time, oral contraception decreased from the high point of 9 per cent in 1974 to 3 per cent in 1991 and 1.8 per cent in 1997. The change in contraceptive methods was brought about by the government’s efforts to encourage permanent sterilization.
The high rate of contraception decreased the total birth rate rapidly to 6 per cent in 1960, 4.7 per cent in 1971, 2.7 per cent in 1982, and 1.7 per cent in 1997. The nationwide survey of birth rate and family health in 1988 shows that 91 per cent of all children who were born in 1987 were the first or second child (Cho et al. 1997). The age distribution of parturient mothers also changed. In 1960, 3.1 per cent of parturient mothers were below 19 years old and 24.2 per cent were over 35 years of age, whereas in 1987 these figures decreased to 0.9 per cent and 2.8 per cent respectively. However, parturient mothers aged between 20 and 34 years old increased from 72.7 per cent in 1960 to 96.35 per cent in 1987.
The interval between deliveries has shortened. A woman born in 1945 delivered her first baby on average 16.8 months after marriage, and the interval between the deliveries of her first and second child was 29.5 months on average.
Maternal and child health
The Maternal and Child Health Project of the Ministry of Health and Welfare covers a wide range of child-health-related issues at all stages of growth from birth, including pregnancy. The coverage of the project is dependent on medical resources and finances. The potentially dangerous areas of antenatal care, perinatal care, and neonatal care are the main work of the project.
The health of both mother and child is closely related to the environment of the household, such as living or financial conditions, familial relationships, and lifestyle. Especially important is the father’s health, educational background, and job as regards his financial condition; also closely related to the family’s living conditions are his diet and the degree of interest in health. Recently, the Maternal and Child Health Project has included all family members.
Financial support for the Maternal and Child Health Project was very small in Korea. The administrative support of the government was also very small; the Administration Office for Maternal and Child Health was established at the Ministry of Health and Social Affairs in 1972. It was composed of two sections: maternal and child health, and family planning. However, it was abolished in 1981 and replaced by the smaller division of family health. Subsequently, the section of maternal and child health was abolished, and was replaced by the division of life and health. At the time of restructuring of the government system in 1998, the Division of Health of Regional Areas was established under the Department of Health Resources Management, and it took charge of maternal and child health.
Maternal mortality rate and causes of death
According to the statistics of the Ministry of Health and Social Affairs, the maternal mortality rate was 4.2 per 10 000 people in 1980, 3.4 per 10 000 in 1985, and 3 per 10 000 between 1988 and 1992 (Ministry of Health and Social Affairs 1994b). The national survey in 1997 showed that it was 2 per 10 000 between 1995 and 1996 (Han et al. 1997). According to a national survey of the birth rate and the maternal mortality rate, the maternal mortality rate was 1.82 per 10 000 neonates at 219 general hospitals throughout the country (Park and Hwang 1993). This mortality rate is twice as high as that of developed countries, and one-fifteenth that of developing countries.
According to the 1993 death statistics, the causes of maternal death that were direct, as opposed to indirect, made up 85.7 per cent (National Statistical Office 1994). Analysis of maternal death between 1980 and 1988, using data collected at 22 university hospitals and seven general hospitals, revealed that direct causes of maternal death made up 79 per cent, while indirect causes were 15.4 per cent, and unknown causes 5.6 per cent. Hypertensive disorders made up 42.4 per cent, most of which were eclampsia and pre-eclampsia. Haemorrhagic disorders were 42.2 per cent, and infectious diseases 15.6 per cent (Han et al. 1997)
A national survey (Moon et al. 1985) has shown that 80.9 per cent of maternal deaths were direct, and 19.1 per cent were indirect. The direct causes were haemorrhagic disorders (25.7 per cent), hypertension (16.3 per cent), embolism (15.6 per cent), and infection 1.4 per cent. This reveals differences from past experience.
Most of the deaths caused by pregnancy-induced hypertension can easily be prevented with early detection and treatment of the disease through antenatal care. Most of the deaths caused by haemorrhagic and infectious diseases can be prevented with a well-established system of first aid. The maternal death rate could be reduced to that in developed countries because almost all deliveries are performed at medical institutions.
Antenatal care is a preventive service in which the health of a pregnant woman and her fetus is periodically checked. It promotes the safe delivery of a healthy baby by providing health-care education and risk assessment to the expectant mother.
In 1985, 56.2 per cent of pregnant women received antenatal care within the first trimester (Moon et al. 1985), and this increased rapidly to 65.6 per cent in 1988 (Moon et al. 1989) and 89.4 per cent in 1994 (Hong et al. 1994). The average frequency of antenatal care was four visits in 1983 and 10 visits in 1994 (Hong et al. 1994).
The rate and frequency of antenatal care, and the time to the first antenatal visit, have improved. However, 18.6 per cent of pregnant women did not receive antenatal care within the first trimester of the third pregnancy and 32.7 per cent had an educational background below elementary school (National Economic Planning Board 1983). This must to be improved.
The Maternal and Child Health Law prescribes that a city or county official must issue a document of maternal and child health to those who inform them of their pregnancy. Few inform officials of their pregnancy in accordance with the provision; instead, most of the medical institutions issue the document at the time of antenatal care. In the national sampling survey, 86.9 per cent of pregnant women were document holders and 74.7 per cent carried the documents at every antenatal treatment (Hong et al. 1994).
Parturition is a physiological phenomenon which causes danger to both the pregnant woman and the fetus. Well-trained specialists and a hygienic environment are required to care for and deliver babies safely. The recent rate of delivery at medical institutions with specialists and facilities increased dramatically from 35.8 per cent in 1975 to 75.2 per cent in 1985 and 99.7 per cent in 1997, reaching the level of developed countries (Cho et al. 1997).
The rate of antenatal care has reached almost 100 per cent, but that of postnatal care remains low. In the 1988 national sampling survey, the rate of postnatal care was 52.3 per cent, while that of antenatal care was 88.5 per cent. There was a large gap between those living in urban areas and those in rural districts; the rate of postdelivery diagnoses was 57.5 per cent in urban districts, but only 37.3 per cent in rural districts. In the 1997 survey, these rates improved to 81 per cent throughout the country, with 81.7 per cent in urban districts and 77.8 per cent in rural districts (Cho et al. 1997; Moon et al. 1989). The government should continue to issue the maternal and child health document, and do its best to encourage deliveries at medical institutions and the provision of antenatal and postnatal care.
Health of infants
The infant mortality rate and causes of death
The infant mortality rate in Korea was 61.8 per 1000 in 1965, 53 per 1000 in 1970, 41.4 per 1000 in 1975, 13.3 per 1000 in 1985, and 12.8 per 1000 in 1990 (Ministry of Health and Social Affairs 1994b). The mortality rate of infants who were born in 1993 and died within a year was 9.9 per 1000 (Han et al. 1996).
The infant mortality rate in developed countries is on average below 10 per 1000, while that of developing countries is 102 per 1000 (Han et al. 1996). The rate in Korea is higher than that in developed countries but lower than that of developing countries, which means that more effort must be made to reduce it.
The Maternal and Child Health Law requires that medical institutions report neonatal deaths and stillbirths. According to the report, premature birth and low birth weight babies were 23.4 per cent in 1990 and 41.8 per cent in 1992, and are on the increase. Congenital anomaly caused 20.1 per cent of the deaths in 1990 which declined to 19 per cent in 1992, but it is now increasing again (Park and Hwang 1993).
Congenital anomaly caused 36 per cent of infant deaths after the neonatal period, and perinatal problems, such as fetal growth retardation, prematurity, hypoxia, and delivery asphyxia, caused 14 per cent of the deaths in 1993 (UNICEF 1995). Another survey showed that intra-uterine fetal growth retardation occurred in 25.3 per cent of deaths, neonatal breathing difficulty in 16.4 per cent, and congenital anomaly in 15.9 per cent (Han et al. 1996).
In developed countries, about two-thirds of infant deaths occur during the neonatal period, and half of all infant deaths happen within a week of birth. The deaths were caused by premature birth, intra-uterine fetal growth retardation, and congenital anomaly.
Fetal body weight at the time of birth is an important factor upon which survival probability depends. It is closely related to the health of the mother before and during pregnancy. It is known that in developed countries, such as the United States and the United Kingdom, the infant mortality rate is 1 per cent for those of normal weight, 3 to 5 per cent for those weighing less than 2500 g, and 45 to 55 per cent for those weighing less than 1500 g (Park and Hwang 1993).
Reports from 64 general hospitals throughout the country in 1966 revealed that the birth rate of infants who weighed less than 2500 g was 9.8 per cent (Han et al. 1996) and a little higher than 6 to 6.5 per cent in another survey (Bae and Kim 1997). This difference suggests that most pregnant women in critical condition are treated at general hospitals.
The mortality rate of infants in 1993 was 8 per 1000 babies and that of children below 5 years old was 9 per 1000, while that of 1 to 4 year olds was 1 per 1000 (Han et al. 1996).
According to the statistics of formal death notices, 2023 children aged 1 to 4 years old are reported to have died in 1993, and their death rate was 77 per 100 000 in their age group (National Statistical Office 1994). This is equivalent to a rate of 3 per 1000, excluding neonatal deaths, but is higher than that reported by UNICEF (1995). Considering these statistics, the mortality rate of Korean children (10 per 1000) is lower than that of 30 developed countries.
The causes of 1966 of 2023 deaths reported in 1993 were clearly revealed. The causes of 1012 cases (51.5 per cent) were injuries and poisoning, of which 458 were traffic accidents, 246 (12.5 per cent) were due to congenital anomaly, 143 (7.3 per cent) were due to malignant cancer, and 134 (6.8 per cent) were due to non-inflammatory diseases of the central nervous system (National Statistical Office 1994).
The national sample survey shows that the rate of maternal breast feeding was 68.9 per cent in 1982, 59 per cent in 1985, and 48.1 per cent in 1988. It decreased sharply to 11.4 per cent in 1994, and increased slightly to 14.1 per cent in 1997. The rate of artificial feeding increased from 15.6 per cent in 1985 to 18 per cent in 1988, and from 27.9 per cent in 1994 to 33.4 per cent in 1997 (Cho et al. 1997).
Various factors caused the rate of maternal feeding to be low, including urban dwelling, high educational background, high income, young age, the first baby, employed mothers, delivery at medical institutions above the class of hospitals, delivery by Caesarean section, care of babies in a nursery room in which the mother and her baby are kept apart, and low birth weight (Kim and Park 1988; Park et al. 1990; Shin and Park 1992).
Mental health services
Psychiatric diseases are difficult to cure in the short term, and their complete cure rate is also low. They cause both economic and emotional problems for the patient and the family. More special clinics are needed for psychiatric diseases, to provide better medical services for patients, and to establish an effective system for early detection, treatment, and after-care of psychotic diseases.
The Mental Health Law, which was established in 1995 and implemented in December 1996, is intended to help patients with psychiatric diseases to access medical services and to return to society. It also aims to remove infringement of the patient’s human rights during long-term hospital admission, and to lay the legal and institutional foundation of the mental health services (Ministry of Health and Welfare 1997).
The government has so far only aimed to provide mental health services by treating patients in psychiatric clinics which were to be expanded, not as a part of the regional mental health service. The expansion of mental health facilities was developed in three directions. Firstly, the zones of mental health service were established around psychiatric hospitals, and exisitng psychiatric hospitals were extended and new ones were built. Also, the number of beds in private psychiatric hospitals increased greatly. Secondly, general hospitals in 1989 were placed under an obligation to establish psychiatric departments, and the psychiatric departments of general hospitals were greatly expanded. Thirdly, unlicensed psychiatric asylums which were already in existence were upgraded to legal asylums, and new asylums were built.
In 1993, the Ministry of Health and Social Affairs began to focus on developing regional mental health services. Considering the universal trend and theoretical results of community psychiatry, the Korean policy of mental health should be provided on a regional basis. Without a strong policy, the mental health service cannot meet the social demands of confining psychotic patients to psychiatric hospitals.
The statistics from the data of medical insurance and medical aid allowances reveal that the annual prevalence rate of the treatment of psychiatric diseases was estimated to be 2.73 per 100 000 people in 1993. The prevalence rate of schizophrenia was 22.8 per 100 000, while that of mood disorder was 78.4 per 100 000. The rate of neurosis and other non-psychotic disorders was higher, but their symptoms and functional problems are not as serious and so they are not on the immediate agenda of the regional project of mental health.
The prevalence rate of psychiatric diseases of medical aid beneficiaries is twice as high as that of those with medical insurance. Specifically, the prevalence rate of psychoses such as schizophrenia, mood disorder, organic brain syndromes, alcoholism, or drug abuse among people receiving medical aid is much higher than that among those with medical insurance (S.S. Choi 1999c).
Facilities for the return of psychotic patients to society should be established to provide appropriate rehabilitation training programmes, such as occupational therapy and activities of daily living, and to help the patients adapt themselves to society and live independently. The activation of a mental health service project in a community needs specialists in mental health at regional health centres, who will be in charge of the prevention of psychiatric diseases and rehabilitation training for patients returning to society. With these efforts, a gradual deinstitutionalization of the patients could be accomplished.
Occupational health services
The Korean occupational health services were developed on the basis of the Labour Standard Law (1953) and the Occupational Accidents Compensation Insurance Law (1963). Later, the Occupational Safety and Health (1981) and the Prevention of Pneumoconiosis and Protection of Workers Diseased by Pneumoconiosis Law (1984) provided an institutional framework and made a great contribution to the stabilization of the occupational health project.
Health examination is divided into two types: general health examination and special health examination. Each has a primary (screening) and secondary (precise) function in the examination of health. In particular, in a special health examination, the list of topics covered was selected on the basis of hazardous factors in the workplace.
A regional allocation of special health examinations was adopted, with the medical institutions in the region taking responsibility for them. Health service providers, such as medical doctors, nurses, and industrial hygienists, were appointed according to the type and size of the work place. Mining and manufacturing companies with more than 1000 workers should appoint a doctor, a nurse, or an industrial hygienist. Other types of companies with more than 2000 workers should employ a full-time health manager. Small companies with between five and 49 workers comprised 85.8 per cent of all workplaces, and their workers made up 34.3 per cent of the total workforce.
The Occupational Safety and Health Law underwent major revision in 1989. It now requires that a proxy agent of occupational health services should be in charge of the occupational health service at workplaces with 50 to 300 workers, and that a medical doctor, two nurses, and two industrial hygienists are provided for every 1500 workers at 150 workplaces. The agent is responsible for all occupational health services, including environmental evaluation of workplaces, prevention planning against occupation-related diseases, and health education. Meanwhile, occupational health services at workplaces with between five and 50 workers are supported by government subsidy, as in 1993.
Special health examinations are carried out periodically every year according to the Occupational Safety and Health Law. The results show that the prevalence rate of observed occupational diseases is 1 to 2 per cent, and that the rate of pneumoconiosis is 43 to 76 per cent of all workers with observed occupational diseases. The rate of those afflicted by pneumoconiosis is 2.2 to 3.8 per cent of all workers at dusty workplaces, and pneumoconiosis and occupational hearing problems constitute 97 to 98 per cent of all occupational diseases.
The Korean occupational health service project should be converted gradually from prevention of occupational diseases to health promotion for all workers. The working conditions in smaller companies are much worse than those in larger companies, and it is difficult for their workers to be provided with health services by occupational health specialists. Health services for workers in smaller companies should be supported financially by a government subsidy and effective development of occupational health services should be accomplished nationwide.
Changes in the risk factors affecting human health, the epidemiology of disease, and the demands and use of health and medical care services have accompanied the changes in the population and the economic and social structure in Korea. Improvements have been occurring over the past 40 years in socio-economic conditions, nutrition, living conditions, and lifestyle, together with a beneficial reduction in population growth. As a result, Korea is now experiencing a variety of new problems related to health services.
In order to deal with the risk factors affecting health and the epidemiology of disease, health policies should aim to improve the management and control of unhealthy eating habits and lifestyles. They should also aim to address such diverse health problems as accidents, poisoning, psychiatric disorders, environmental pollution, and natural disasters, rather than concentrating on diseases of a single aetiology, such as the infectious diseases.
In the present system of health services, the structure of medical human resources, the functions of medical institutions, and the allowance systems of medical insurance are centred around the treatment of disease. However, resources should be allocated to the effective prevention of disease and to services for health promotion. Medical care systems should pursue these policies at low cost whilst maintaining high levels of effectiveness. Systems should be improved with regard to human resource and facilities management, and controlled to meet increasing demands. Policies to raise the efficiency of health services, which make clear the allocation of functions between the various institutions and people working in health facilities, should be outlined.
The system of information and statistics should be improved to establish a scientific and reasonable policy of health and medical care. Local governments lack the ability and the special knowledge required to deliver and control health services.
A system of information management should be established at every level of local government, and local governments should themselves have the ability to establish and implement reasonable plans concerning local health.
The success of the Korean family planning project contributed to changing the population pattern into a structure more like that of developed countries, and this project should continue. The maternal and child health project should be transferred to the family health project, which deals with the health of all family members. The system of issuing documents pertaining to maternal and child ealth will still be useful. In addition, a project to encourage hospital delivery and antenatal and postnatal care should be developed further. The project of mental health services should be changed to a regional basis. A powerful policy of mental health can change the social demand to isolate psychotic patients. Local government needs to support efforts to help their return to society and to active independent living in order to promote deinstitutionalization. The project of occupational health services should transfer its emphasis from prevention of occupational diseases to promotion of health for workers. The project of occupational health services for workers at smaller companies still needs a government subsidy.
Today, the whole world is interested in developing the quality of life. The national demand for improvement in quality of life is growing stronger together with a general rise in household incomes. The government has the responsibility of creating conditions under which people recognize that they are responsible for their own health, and that they can and should take care of themselves.
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