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Discussion: Would 'Public Health Care Action' Be a Real Solution?
Min Yeo-jin & Jeon Eun-jin  |  themyj19@hanyang.ac.kr & mglory19@hanyang.ac.kr
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[348호] 승인 2020.12.01  
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People have realized the importance of public health through the COVID-19 pandemic. Unexpected infectious diseases began to spread everywhere. People raised questions on whether the state had the basic medical system required to cope with emergencies properly. As the need for public health care increased, the government announced a new policy addressing this issue. The government’s plan to expand the number of medical students by 4,000 over the next ten years and open a new public medical school sparked tensions within the medical sector. For this issue, it is necessary to understand the public health care and the Korean medical system.

What is Public Health Care?

Publicly funded health care (Public Health Care) refers to medical services or activities provided by public hospitals operated by the government to solve all citizens’ health problems. Public Health Centers are one of the representative institutions that provide ‘Public Health Care.’ They also include national and local medical centers.

Hwang Jeong-hae, Professor in the Health Administration at Hanyang-Cyber University, said that Public Health Care is hard to explain: “The public understands it as a governmentled, affordable, accessible medical service for all citizens. However, this explanation is not enough to understand the various situations and conflicts in Korea. Medical health care is a concept that includes the public in it. The health care management system depends on whether the government is taking the initiative to establish people’s rights or industry classification. In Europe, where health care exists within a stateled social security system, health care’s public nature is often seen as an essential factor. However, in the United States, where services are delivered through the healthcare industry, the advantage of a rapid application of state-led healthcare (except for the state-led Medicare) is at odds with the disadvantage of being privatelyled which is very expensive and economically inaccessible. Considering these examples, South Korea is close to privately led. The government is intervening in the form of managing private resources by their policy.”

 

 Is the Korean Health Care System Enough?

Park Kyoung-don, Professor from the Department of Public Policy & Management at Pusan National University, expressed his ideas on the Korean medical system. “In the case of South Korea, the government is responsible for policy decision making, and the private medical sector is in charge of policy implementation. The government delegates medical delivery to private medical institutions and provides financial support through medical fees and health insurance benefits during policy monitoring. Excessive competition among private medical institutions has created a nationwide imbalance in medical care. Therefore, public medical care and related policies led by the government result from calls for strengthening publicness in areas where private medical care is insufficient.”

South Korea has a reputation as a medically advanced country; still, some problems need to be improved—especially in public health care. The demand for public resources in the management of infected people has increased due to COVID-19. In light of this, there are limitations in public resources that prevent South Korea from moving in multiple directions. These include facilities, people, and equipment. Such limitations are not a problem only in South Korea. However, South Korea’s medical care, especially in the public sector, is in a state that falls short of other countries.

There are insufficient public hospitals. Public hospitals account for 5.8 percent (2016) among domestic hospitals, which is very low, considering that the average of 26 OECD member countries is 52.6 percent. Out of total beds, public hospitals account for only 10.3 percent. The number of doctors is also insufficient: When asked, “Do you want to work on the public side?” most of the medical students answered “No.” The reason is that the working environment is poor. For example, in a local medical center, there is a doctor who works in surgery or neurosurgery. Additionally, this is directly related to the “medical fee,” said Park Ga-hyun, a student at Kyung-hee University’s medical school. She said medical fees were set too low for some departments, and such departments were avoided. 

 

Why Not Integrate Public Medical Systems to Private Hospitals?

The government attempted to integrate public medical systems into private hospitals, but there were lots of difficulties. A representative example is a conflict between Professor Lee Kook-jong and Ajou University Hospital. The interests of private hospitals and Professor Lee conflicted with the operation in the Trauma Center. From the viewpoint of a private hospital, it is important to make profits. However, when operating a trauma center, the hospital suffers more damage (a 1.45 million won loss per person), making it difficult to manage for profit. 

As mentioned earlier, it will be challenging to maintain facilities and human resources because profitability is not guaranteed. Trauma center services require multiple medical teams to perform surgery with the best technology for urgent conditions. The level of facilities and equipment involved must have a certain amount of resources. The government is still supporting these areas, but hospitals have no motive for having such a center. Therefore, it is designed to move according to the regional area in the present system. 

Professor Park of Pusan National University said, “First the imbalance between cities and rural areas of medical personnel and medical facilities, which are medical resources, is increasing. It is unlikely that private hospitals intervene in medical care for areas or classes with low profits in a competitive relationship. Second, hospitals with fewer wards of 100 or less and small and medium-sized hospitals continue to go bankrupt or shut down. On the other hand, the efficiency of medical resources decreases as large-scale general hospitals’ concentration increase. Third, large-scale hospitals induce management to preserve income, increasing supply-induced demand such as over-treatment, redundant treatment, and unfair claims.” Integrating public health services into private hospitals is a challenging issue. 

 

The Government Policy for Public Health Care

Park Neung-hoo, the Minister of Health and Welfare (MOHW), explained a plan to develop public health care that would strengthen national responsibility and bridge the regional gap in medical services. The policy’s introduction discusses how medical resources are concentrated in metropolitan areas, creating gaps in medical services between urban and rural regions. This plan comprises four areas. First, strengthening public health infrastructure and networks to establish a regionally responsible medical system. Second, reinforcing response competencies in essential medical care is directly connected to life, medical services for the underprivileged, and infection and patient safety. Third, fostering professionals in public health care with a sense of mission and expertise. Fourth, expanding the role of local governments and the cooperation system between ministries to establish public health governance.

Under this plan, the government announced an additional plan to increase student numbers in medical schools by 400 starting in 2022. It plans to recruit an additional 4,000 students over the next ten years. Of the 400 students, 300 will be selected for the “Special Admission for local doctors” criteria. Instead of receiving a scholarship, they must engage in essential medical care at a local hospital for ten years (including the training period for the major) after obtaining a doctor’s license.

Other Countries’ Public Health Care Systems

The COVID-19 pandemic has also turned people’s attention to health systems in other countries. There are policies used in the distribution of health care. In the United States, there is a law to prevent the excessive expenditure of services and the expansion of unnecessary medical facilities within the medical area by requiring the state government to approve a Certificate of Need for high-quality small community hospitals. In Japan, their medical plan automatically reduces the number of medical beds in prefectures that exceed the standard.

It is worth noting examples from other countries and considering introducing them to Korea, but this is also not an easy task. Adjunct Professor Kim Ki-ok, from the Graduate School of Public Policy at Hanyang University, said, “The most beneficial welfare is to overcome the limitations of modern medicine through an integrated medical system and to manage the health of people in a way that has a good costperformance ratio. It seems that the service that people want is not working well as it is subordinated to Western medical manuals due to neglecting people’s needs.”

 

Conflicts over the new Public Health Care Policy

Among the new health care systems that the government suggested, two policies are especially controversial these days: increasing the number of students in medical school and establishing a public medical school in Korea. 

Government

According to the government, the appearance of such policies can mainly be explained by the lack of doctors in particular situations. First, the number of medical school students in Korea has been fixed to 3,058 since 2006. However, due to COVID-19, the current global pandemic, the problem of doctor deficiencies in certain regions stood out. The number of doctors per 1,000 people in Korea is only 2.4 while the OECD average number is 3.5. This gap becomes much larger when it comes to certain regions. For example, unlike the 3.1 doctors per 1,000 in Seoul, the number is only 1.4 per 1,000 in the Gyeongbuk area. This phenomenon is caused by doctors who mostly leave for the metropolitan area after graduating medical school. The deficiency of doctors is also problematic across specific medical fields in comparison to general fields. For instance, fields such as the division of infectious diseases or the division of biomedical lack doctors because they are much harder and tougher than other fields. Considering that all doctors earn the same amount of money, except the private medical field, it seems natural that so many choose to work in an easier field. 

The government’s new plans for the medical system were announced to overcome such doctor deficiency problems. First, as mentioned above, the government is planning to increase the number of students in medical school by 400 students each year, which will be 4,000 more students over ten years. To be more specific, the 300 students selected for the “Special Admission for local doctors” criteria are required to work in a severe medical field of a local medical institution for 10 years. If they do not complete their service, their doctor’s licenses will be cancelled. Moreover, the remaining 100 students will be divided into two fields: a specialized field and the medical scientist field. In the specialized field, students will become either an epidemiological survey specialist or a severe trauma doctor. In the medical scientist field, students will have the option to become a medical scientist in basic science, medicine manufacture, or biomedical field. 

Another policy to establish a public medical school is also being promoted. This has to do with 49 empty places for medical students when Seo-Nam medical school was closed. Aside from increasing the number of students in medical school, these empty seats will be taken to build a new public medical school. Since Jeonnam is the only region without a medical school in Korea, it seems highly likely that a public medical school will be established there. 

Doctors & Medical Students

However, when proposals of establishing a public medical school came out, doctors and medical school students strongly resisted. According to the bill establishing public medical schools, doctors who completed 10 years of mandatory duty can be prioritized in joining the MOHW, or public health and medical institutions. Not only the local medical centers, but also big national medical centers, like Seoul National University Hospital, are included in public health and medical institutions. Furthermore, civil society organizations plan to participate in recommending student applicants for public medical school. Considering these disputable points, doctors and medical students argued that these rules could be misused to illegally select students to their own tastes. Moreover, as mentioned earlier, the medical fee is the actual cause for doctor deficiency in some regions. For example, in cardiothoracic surgery, only 70% of the operation fee is arranged for the medical fee. That means that private hospital doctors in cardiothoracic surgery cannot manage a hospital alone. In other words, popular fields with enough medical fees become increasingly popular, while tougher fields with low medical fees fall short. Such realities cause the medical community to ask for higher medical fees rather than recklessly increasing the number of doctors. There is strong criticism from the public that doctors have an underlying intention where they are concerned about losing their profit, as the number of doctors increase. Finally, with all the complaints, Korean Medical Association (KMA) went on their first strike on August 14, against the government’s new policies for Public Health Care. They continued with a second strike on August 26. This decision was devastating to society because there was a lack of doctors during COVID-19. However, doctors still strongly insisted on going on strike from September 9 again. Although the ruling party, MOHW, and KMA made a document of agreement, it was medical school students who decided to reject the Korean Medical Licensing Examination (KMLE). This is a mandatory exam for medical school graduates to be employed in a famous university hospital or a general hospital. Such action was also a part of their strict resistance to government’s policies. However, the government strongly confronted medical school students by continuing the KMLE as it is, leaving those cancelled applications behind. In other words, a tense conflict between the government and doctors remained, as nobody conceded their point. Meanwhile, rejecting the KMLE was problematic for medical school students because it meant that seniors would have to wait another year to apply for the exam again. Therefore, KMA requested another chance for senior students to re-apply for the KMLE. However, the government disagreed, arguing that it would be unfair to provide a second chance for the national exam. Now, the conflict of the new public health care system is extended by another conflict – the KMLE. As one new conflict rises after another, it seems clear that these conflicts may last for a long time. 

Lee Ji-hyuk, a Sophomore at Hanyang University College of Medicine, also disagrees with the government’s new policy on Public Health Care, as it cannot be a fundamental solution to overcome the doctor deficiency problem. Moreover, considering public opinions on the issue, he thinks that the appeal from the medical community did not reach others effectively because of the social atmosphere, where the public tends to regard the medical community as people who only care for their own benefit. Although he understands their feelings to some extent, he asserts that excessive criticism should be restrained. Instead of criticizing the medical community, he thinks that it is important to listen to others first, fully understand the situation, and then decide whether to criticize or not. He also explained the reactions of other medical school students around him. Many students could not understand why such medical related policies were announced without opinions from the medical community. They were also under pressure because of the negative viewpoints about them. In fact, as some students applied for a leave of absence, they had many concerns related to the situation, which made the navigation of administration systems in medical school confusing. As a medical school student, Lee thinks that it is of the utmost importance to spend time fighting against the COVID-19 first, rather than wasting time on producing more conflicts. Since the COVID-19 has highlighted problems of Public Health Care, the government and the medical community should work together to overcome this global pandemic first. 

Desirable Solutions for a Better Public Health Care System

As explained above, the ongoing tension between the government and the medical profession is controversial. In order to step back from a particular viewpoint, it is necessary to evaluate these topics in a neutral way. Chung Woo-jin, Head Professor of the Division of Health Policy in the Graduate School of Public Health at Yonsei University, objectively pointed out the status of Public Health Care in Korea. Even though Korea has the lowest number of doctors among OECD nations, the number of medical education institutions is not that small. For example, there are nine national institutions among 40 medical related schools, which is not less than other national institutions in different departments, like Humanity Science Colleges or Engineering Colleges. Considering the above, the outcome efficiency of the health care system in Korea seems to be extremely high. This is because the health expenditure against the Gross Domestic Product (GDP) stays relatively low, even though the overall level of health is quite high. Furthermore, for a desirable solution, he added that it is of the utmost importance to find the best solution that is appropriate for our reality and to try to publicize this issue. To do so, a rational decision-making process, like an expert discussion on the policy problem and policy alternatives, is highly necessary. If not, Public Health Care policy may be recognized as something that was unilaterally forced by the government. Worse, it can be seen as an output of an unclear compromise between the government and the medical community. Eventually, people may consider it as an unnecessary policy or even a policy failure. Additionally, Professor Kim Ki-ok pointed out that Western medicine technology and Oriental medicine technology should be adequately applied in harmony, so that it becomes a necessary service for the public. Medical education in Taiwan is an ideal example for this, where doctors can acquire dual medical licenses. Like this, doctors who can introduce a medical service with one or dual medical licenses should also be nurtured in Korea. It would be desirable if such doctors could provide the public with diverse, objective medical services. However, for such solution to work, the climate must come first, where modern medicine and traditional medicine smoothly communicate, and acknowledge one another. Therefore, the process of alternative medicine specialist and education on integrative medicine should fully begin. 

According to Professor Chung, Korea maintains a private-public mixed health care system, where private medical facilities provide the public with private provisions and receive public funding through the national health insurance service. This shows a high level of outcome efficiency in the health care system. Therefore, when increasing Public Health Care in the current health care system, the problem should be precisely identified and improved CONTRIBUTED BY CHUNG WOO-JIN through clear and careful discussions.

 

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