Successful in combating COVID-19, South Korea faces a heavy load of NCDs and lifestyle diseases

A series of sustained reforms after 2015 MERS outbreak to develop a robust health information system for pandemic response seems to be the backbone of South Korea’s response against COVID-19 pandemic. However, the country is still facing a heavy load of NCDs (Non-Communicable Diseases), lifestyle, and pollution-related diseases.

Rome was not built in a day. This age-old adage seems quite relevant to describe the successful response of South Korea against the COVID-19 pandemic which has brought its public healthcare system in global limelight. Despite being situated in the close neighborhood of China - the original epicenter of COVID-19, South Korea successfully limited the spread and casualties due to the pandemic. As per the situation board of WHO, South Korea had recorded 298 deaths and 13,979 confirmed cases till July 24.

The first confirmed case of COVID-19 in South Korea was reported on January 19, four days before an unprecedented lockdown was imposed in Wuhan. By the time WHO declared it a Public Health Emergency of International Concern (PHEIC) on January 30, South Korea had reported 4 confirmed cases. The first big jump of 20 cases was reported on February 19 and the peak period continued for about a month with the highest single-day jump of 813 cases on February 29. Thereafter, the cases went down which even followed a successful national election on April 15.

The success of the South Korea model is based on its big data approach wherein real-time geospatial data were collected by linking smartphones for real-time information dissemination. These individual datasets such as credit card history, GPS location of cell phones, test reports which amount to infringement of the right to privacy in several countries, were used on a real-time basis to create maximum awareness and alertness among the people. However, there was no voice of protest on the grounds of ‘right to privacy’ even during the general elections. This cooperation of citizens and political class was apparently because the agencies were not authoritarian but adopted a highly transparent and voluntary approach in their push for social distancing measures wherein lockdowns were not enforced by police. Except for schools, all other economic activities in the country continued despite the pandemic.

In a survey conducted by Seoul National University’s Graduate School of Public Health, 78% of 1,000 respondents agreed that human rights protections should be eased to strengthen virus containment efforts.

The need for legal backing to a robust health information system was felt in South Korea way back in 2015 during the MERS coronavirus outbreak which resulted in 186 cases and 38 deaths. In the immediate aftermath, the Infectious Diseases Control and Preventing Act 2015 was enacted which gives all the powers to government health agencies to avail individual data from credit cards, mobile data, and health records – and to release the mobility data in the form of ‘travel logs’. These travel logs, besides helping the patient to trace from where he might have been infected, also help others to stay alert and get tested for possible infections in case someone in their contact history tests positive. “WHO acknowledges that the Republic of Korea has sufficient capacity to cope with communicable diseases, considering its high awareness of suspect cases, a system in place to quickly isolate suspect cases, an adequate number of isolation beds, stockpiles of personal protective equipment and testing facilities that extend to the provincial level (24),” reads Country Cooperation Strategy (CCS) 2019-23 submitted by South Korea to WHO as part of International Health Regulation 2015.

Health Information System in South Korea

Healthy Lifestyles, Chronic Disease Management, Infectious Disease Management, Safe Environment, Population Health Care, and System Management are six national priorities for health in the National Health Plan 2020.

Korea Centers for Disease Control (KCDC) is an integrated umbrella body of South Korea's public healthcare system to strengthen emergency response capabilities, seek integrated research, standardize biomedical research data and build a relevant infrastructure, keep the nation safe from disease threats, and promote surveillance of diseases. KCDC is responsible for the formulation and implementation of public health policies. Besides, it has at least seven specialized centers to look after various aspects of public healthcare including the National Center for Medical Information and Knowledge which is responsible for all kinds of health data collection, research, and maintaining an e-library.

The country has a single-payer health insurance system that facilitates online collection and utilization of health data. Almost all the health facilities – public and private - in the country are linked with an online system to process health insurance claims. This entire data of health records including the consumables is updated and used by health authorities in formulating public healthcare policies and responses. The health information system in South Korea could be better understood as follows:

1. National Health Insurance (NHI): NHI program finances the health system of South Korea. NHI covers about 97% of the population, and the remaining 3% is covered by the Medical Aid Program, which is a taxpayer-funded program to ensure access to health care for the low-income population. NHI can utilize and produce databases of the entire population from the data collected by medical services that are covered under the program.
2. Health Insurance Review and Assessment Service (HIRA): It reviews and assesses healthcare costs and service quality, as well as supports the national health insurance policy in determining medical fee schedules and drug prices. HIRA possesses an IT-based automated Drug Utilization Review System which provides information on the drugs that a patient is taking and the contraindications (alerts/prohibitory orders for drugs due to their harmful effects) to prescribers and pharmacists. As of 2012, 96.8% of health facilities were using electronic medical claims, and 82% of them adopted the Medical Claims Portal Service, which is a free web-based claim system developed by HIRA.
3. Emergency Operations Center (EOC): Set up in 2015, the EOC with 40 seats is open 24x7. During normal days it acts as a 24x7 surveillance center for the infectious diseases while in the event of an infectious disease outbreak it is expanded into Central Epidemic Control Countermeasure Headquarters. The center carries out various activities including coordination with ministries, states, hospitals, specialists, dispatching Rapid Response Teams to the site, and carry out initial epidemiological investigations, etc.
4. KCDC Call Center: This call center (1339) provides 24x7 service to callers for guidance on infectious diseases with a call back service if all the lines were busy. Besides, South Korean citizens living abroad are also provided dedicated lines to contact the center
5. Laboratory Surveillance Service for Influenza and Respiratory Virus: Set up in 2001 and upgraded from time to time, the Center acts as a permanent laboratory surveillance service for influenza and respiration virus in the country. It gathers information from primary health centers and hospitals on the Influenza virus, parainfluenza virus, adenovirus, RS virus, rhinovirus, coronavirus, metapneumovirus, and bocavirus. Besides it also provides regular weekly data to KCDC.
6. Smart Quarantine Information System Project: Smart Quarantine Information System is based on advanced information and communication technology (ICT) system that gathers information on arrivals from various countries facing disease outbreaks and shares the information with Minister of Foreign Affairs, Health Insurance Review & Assessment Service, telecommunication companies and KCDC. Before the spread of COVID-19, a proposal to establish an Advanced National Quarantine System to utilize roaming data was also in the pipeline.

It’s because of such a robust health information system in place, South Korea has maintained a 95% vaccination rate and achieved the WHO certification of eliminating measles in 2014. It has also achieved significant success in controlling Hepatitis B, TB, and Malaria, which are now limited to the provinces adjacent to the demilitarized zone in the northern region of South Korea. The KCDC also publishes reports and guidelines on public healthcare for physicians.

Field Lessons of MERS Coronavirus 2015

The chaos most of the countries are facing today due to COVID-19 was experienced by South Korea in 2015 during MERS Coronavirus. In those days, although only 186 positive cases were found, more than 10,000 persons had to be isolated and about 2,000 schools were closed within a month.

After the outbreak was controlled, a joint commission of the Republic of Korea and WHO, concluded that the rapid spread was due to three main reasons:

1. Extremely crowded emergency rooms and multi-bed hospital rooms
2. Doctor shopping i.e. patients and their relatives visit multiple doctors
3. Patient visitors in hospitals

These lessons were properly used by the Korean authorities to enhance their pandemic response on the ground.

How South Korea is Handling COVID-19

South Korea followed a multi-pronged and integrated approach to handle the COVID-19 which includes testing suspects, contact tracing, surveillance testing, case management, utilizing public-private partnerships, protection of healthcare workers, financial support to COVID-19 patients and suspects, and large scale volunteerism for social distancing measures from day one. The existing public health information system provided an edge to the country in planning and implementing an integrated COVID-19 response plan to health authorities on the ground which is referred to as ‘joined-up response’ and involves optimum utilization of hospitalization facilities and healthcare workers between cities and regions. In addition, the private partners provided most of the technological and healthcare innovations such as testing kits, mobile apps, medical consumables, PPE kits, etc. to handle the pandemic. Followings are the key aspects of COVID-19 response plan of South Korea:

1. Geospatial Data for Contact Tracing: South Korea used real-time data from smartphones, banking records, and CCTV footage, etc. for efficient contact tracing. In addition to that, the data were also used for real-time updates on the movement of suspected cases and COVID-19 patients to make people aware of possible exposure to the infection.
2. Innovative testing methods: South Korea’s innovative ‘drive-in’ and ‘walk-in’ COVID-19 testing facilities proved decisive in quickly detecting the patients who could have been potential spreaders for the virus. These hundreds of small contactless facilities have been created in such a way that healthcare workers are not exposed to patients/suspects during the sample collection process. In case a fever patient calls KCDC Call Center, the attendant immediately guides him/her to wear a mask and follow social distancing. The patient is then referred to a testing center and provided the required healthcare assistance.
3. Quarantine Facilities: South Korea did not overburden its healthcare facilities and introduced home quarantine facilities from the initial days. With the help of private partners, it launched several mobile apps and interactive websites to guide the patients in home quarantine facilities and contactless healthcare besides extending institutional quarantine facilities for serious patients.
4. Protection of Healthcare Workers (HCWs): Protection of HCWs – doctors, nurses, and disinfection staff – has been a key priority in the COVID-19 response of South Korea. The measures such as proper segregation of suspected and infected patients, regular disinfection, temperature monitoring of healthcare workers, Personal Protective Equipment (PPE) kits, restriction on visitors in hospitals, etc., helped the authorities to achieve lower infection among the healthcare workers. According to an initial study, a total of 2.4% HCWs were infected while only 1.0% of HCWs were infected on duty. The percentage of HCWs infected during work was 21% during MERS 2015. Besides, the percentage of HCWs infected by COVID-19 in South Korea is reportedly lower in comparison to other countries.
5. Automated Awareness Campaign: With 95% smartphone penetration, South Korea is among the countries with the highest internet penetration. This has helped the health authorities plan an internet-based interactive, automated health information campaign on COVID-19. Through a public-private partnership, South Korea launched mobile apps for providing real-time location-based alerts and information on COVID-19 patients to people. It was due to these campaigns and strategies that the country did not require national lockdown to implement social distancing.
6. Financial Assistance: The government’s decision to provide paid leaves to infected employees and an assured sum to unemployed persons helped in allying fear from the minds of people and they voluntarily approached COVID-19 testing centers. Besides, transparency and decisive political leadership also played an important role in combating the pandemic. 

Public Healthcare Problems in South Korea 

Though South Korea has evolved its system to handle infectious disease outbreaks, it is struggling with non-communicable diseases (NCDs) and behavioral problems like many other countries. In the CCS submitted to WHO, it has enlisted the following challenges to its public healthcare system: 

1. Half of the population above 30 years is projected to be afflicted with abnormal conditions that may trigger the development of cardiovascular diseases or type 2 diabetes by 2030.
2. Regional health inequalities exist in South Korea. Health status is unequal between major cities, such as Seoul, and other areas, as well as between urban and rural areas in general.
3. Low birth rate, the decreasing tendency of breastfeeding, skincare, and Kangaroo care of mothers to their babies.
4. Aging: In 2011, the percentage of the population in South Korea aged over 65 years reached 11.4% and by 2017 it reached 14%. According to the categorization set by the Organization for Economic Co-operation and Development (OECD), South Korea has an aged population. The trend positions South Korea to be the second-most aged country after Japan by 2050.

Conclusion and Agenda for Discussion

In this age of globalization and climate change induced by the persistent threat to biodiversity, health security threats are increasing by the day and becoming more complicated. It is very difficult for any country to manage these disease outbreaks alone which necessitate the need for an integrated and holistic healthcare system. South Korea is a leading country in the cloud-based health information system as in 2013-14, the government, universities, and private companies of South Korea signed agreements with Saudi Arabia, UAE, Iraq, Philipines, Mongolia to develop their national level cloud-based public healthcare information systems. 

South Korea seems to have one of the best healthcare information systems but its heavy load of NCDs indicates major systematic loopholes.

The successful COVID-19 response of South Korea highlights the importance of a robust and integrated health management information system (HMIS) in the pandemic resilience healthcare system. However, the public healthcare system in South Korea seems heavily dependent on the clinical approach and pays less emphasis to the preventive healthcare and socio-psychological aspect of health. There is a need to review the public healthcare information system in the country with an aim to improve on the fronts of NCDs, socio-psychological, and behavioral health issues. Besides, it needs short, mid, and long term plans to reduce pollution-related disease load.

Centre of Excellence on Emerging Development Perspectives (COE-EDP) is an initiative of VisionRI and aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.