By Soonman KWON, Seoul National University, and HSG board member
The world has been hit hard by the COVID-19 pandemic. South Korea experienced a surge of patients in mid-February largely due to a mass infection in a big church in the south-east region. Korea responded swiftly to the epidemic and has managed to slow the widespread COVID-19 infection. This blog reviews the crucial steps the South Korean Government took and key factors of its health care system that may provide fruitful lessons for other countries in responding to a pandemic.
Communication and transparency
Each day, the government provided a briefing on new cases, mortality, number of people treated, and regional distribution of cases. It was reported by the Deputy Minister of Health and Welfare and the Director of the Korean Center for Disease Control (KCDC). Mayors and governors of major cities and provinces have also provided frequent briefings on the new developments on the epidemic.
Transparent communication was essential as it helped the public fully trust the government and comply with government recommendations. Trust is an important element of social capital, and trust in government is particularly crucial in an emergency. Most people voluntarily followed government recommendations on social distancing, wearing masks and hand washing, even without major restrictive measures. There was no stockpiling by consumers.
Minimum level of restrictions
The government did not implement severe restrictive measures, such as lockdowns. There has been no ban on the entry of air travelers from specific countries or regions, except Hubei, China. Although the beginning of the spring semester has been postponed and face-to-face classes have moved to online classes nationwide, there is still no ban on public gatherings or religious meetings, and restaurants and shops are all open. The public was quick to comply with the government’s recommendation of social distancing, cancelling meetings, and by businesses encouraging employees to work from home.
Korea is an open economy, and the government was worried about the potentially negative impact that border closure can have on economy in the long run. Border closure and a ban on travelers from countries with many positive cases has been a controversial issue. Some experts and opposition party politicians have strongly pushed the government to implement stronger restrictions on inbound travelers.
Until recently, the government mandates testing for people entering Korea with symptoms, and recommends two weeks of self-quarantine at home for those without symptoms, who report to government through a mobile phone app. Now, with the surge of cases in Europe and the USA, travelers from those countries will be tested on arrival at Incheon airport and will have to self-quarantine for two weeks, even if they tested negative.
Instead of very restrictive measures, a policy of extensive tracing was adopted. When a person tests positive, all paths are traced to check where and when a patient visited. This includes checking visited restaurants or modes of transportation (including specific bus or subway routes and lines). The government uses all types of information, such as credit card payment, mobile phones, and closed channel cameras. Text messages are then sent by local and district government to all residents, encouraging those who were exposed to the contacts to self-isolate or get tested, contributing to the reduction of infection.
The extensive tracing of contacts can be controversial from a privacy perspective. Businesses may be negatively impacted when they lose customers due to reports that a positive COVID-19 patient has visited a local restaurant or shop. However, the contact tracing was, and still is, widely supported by the public. Contract tracing must be based on social consensus and may not be applied to other countries where personal privacy is a key concern.
Early and mass testing
The government adopted mass testing for early detection. At the end of January, the government met with test kit producers and agreed on the need to produce the kit rapidly. Test kits were made available in early February thanks to a fast-track approval. In about six weeks, more than 300,000 people were tested. Early action by the government and mass testing has led to early detection and self-isolation to prevent infection.
At an early stage, there were some cases where a patient visited health facilities for testing and the health personnel was infected and the facility was closed. Later, outdoor drive-through testing units were introduced nationwide for quick testing without the potential risk of infections. Now, outdoor walk-through testing stations have been introduced at Incheon airport. A single test costs about 150 USD but are free for those who have traveled abroad, exposed to the contacts of patients or with a physician’s recommendation. Even for those who are not ex-ante eligible for free testing, it becomes free for individuals who tested positive.
Flexible and rapid response
Mass testing resulted in many patients testing positive. Initially all those who tested positive for COVID-19 were hospitalized. However, it soon became obvious that the hospitalization of all patients would overload the entire health system with a shortage of beds for severe COVID-19 patients and impact on other severely ill patients. In order to avoid this crisis, patients were prioritized based on severity. Large suburban residential buildings, used by public enterprises or large private firms for education, training and short-term residence of their employees, were transformed to house patients with milder symptoms. As of 15 March, sixteen centers nationwide accommodated about 3,000 patients largely from the region where there was a mass infection related to a church. These patients are evaluated by a physician who checks their temperature and respiratory symptoms twice a day. Vulnerable patients, such as older patients or those with pre-existing conditions, along with patients with severe symptoms of COVID-19, are given higher priority and hospitalized.
Universal Health Coverage and health financing
Thanks to UHC, all patients have access to treatment, covered by the Korea National Health Insurance Service (NHI). For communicable diseases, such as COVID-19, copayment of NHI is exempt, and the financial burden of treatment is minimized for patients. Lost income in the case of self- or house-quarantine is compensated by the government according to a formula. As mentioned earlier, the cost of testing is free for most people. Although more than 90% of hospitals are private, they all participate in the NHI system with the same contract conditions for both public and private providers set by law. When masks are rationed, they are distributed by pharmacies using the NHI database. The COVID-19 experience highlights how UHC is an important foundation to cope with epidemic and health security crises.
Learning from the past
The painful experience of MERS (Middle East Respiratory Syndrome) with 186 cases and 38 deaths in 2015 has led to lessons learned and a quicker response from both the government and the public. The current administration invested more funds in the health sector compared to prior administrations. As the first early cases of COVID-19 were reported, the government was already on a fast-track to prepare mass production of test kits, a key step for early detection and swift containment of the virus. The public also were prepared to accept the extensive contact tracing for effective detection at the expense of privacy. As a result, the government and the public worked together in containing the disease as quickly as possible to prevent a repeat of the MERS crisis.
Although all private providers are part of the NHI system, they were less willing to establish special wards, e.g. with negative-pressure isolation rooms. The government designated some public hospitals for COVID-19 patients, and the existing (non-COVID-19) patients were transferred to other hospitals when there was a surge of COVID-19 patients. Dedication of hospitals for an epidemic and the quick mobilization of resources was easier for public providers than its private counterparts. Admissions and transfer of COVID-19 patients and coordination among providers could have been made more effectively if Korea had more public providers, which currently account for less than 10% of all hospitals.
Vulnerable populations (e.g. older people, patients in long-term care institutions) were hit harder by the epidemic. In a few long-term care (LTC) hospitals, a majority of patients were infected. LTC institutions have a smaller number of health personnel per patients by law. In addition, the self-employed, temporary workers or employees in small businesses and vulnerable industry cannot work from home and are at higher risk, as was the case of about 100 infection cases in a call center in Seoul.
The COVID-19 epidemic also struck the poor, the elderly living alone, and children in families supported by the welfare program. Social distancing can sometimes lead to feelings of isolation for them. These vulnerable groups are likely to experience more mental stress, which can have a long-term negative impact on health. The government proposes the exemption or discount of NHI contribution for these vulnerable populations. The government is also currently proposing a plan to implement rescue income support, voucher, and rescue loan programs for vulnerable populations.
Confirmed Cases and Fatality from COVID-19, South Korea