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A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine
G Model EUJIM 550 No. of Pages 6
European Journal of Integrative Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Integrative Medicine journal homepage: www.elsevier.com/eujim
Review article
A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine Kyeong Han Kima,1, Ju Ah Leeb,1, Ho-Yeon Goc , Jiae Choid , Sunju Parke, Myeong Soo Leed, Seong-Gyu Koa,* a
Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Republic of Korea KM Fundamental Research Division, Korea Institute of Oriental Medicine, Republic of Korea Internal Medicine College of Korean Medicine, Semyung University, Republic of Korea d Clinical Research Division, Korea Institute of Oriental Medicine, Republic of Korea e Department of Preventive Medicine, College of Korean Medicine, Daejeon University, Republic of Korea b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 April 2016 Received in revised form 25 May 2016 Accepted 26 May 2016 Available online xxx
Introduction: Korea has a unique health system that includes two independent systems: Western medicine and traditional Korean medicine (TKM). This review aimed to explore the impact and role of doctors practising TKM on the Korean public healthcare system. Methods: A search was conducted of official government agency websites, doctors’ associations and 3 Korean databases using the key words: ‘public doctor’, ‘public TKM doctor’ and ‘public health system’. The search was conducted on September 15, 2015. Neither the publication language nor the publication date were restricted. Results: The TKM public health system commenced in 1998 and after a two-year pilot project was expanded nationwide in 2002. In 2001, there were only 38 public health TKM doctors, this had increased to 1026 by 2015. Most of these practitioners work in public health centres (23.38%) and branch offices of community health centres (68.12%). Conclusions: This review has considered the public health doctor system with a focus on TKM doctors including assignment status of public health TKM doctors, the development of the TKM public health doctor system. Roles of public health TKM doctors. Although the public health doctor system has contributed to the improvement of Korean public health for 30 years, continuous development is required to improve the working conditions, provide reasonable regulation for the medical system, and strengthen the medical information and management. ã 2016 Elsevier GmbH. All rights reserved.
Keywords: Public health Traditional Korean medicine Review Integrated health system
Contents 1. 2.
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4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . 2.1.1. Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The development of the TKM public health doctor 3.1. Assignment status of public health TKM doctors . 3.2. Roles of public health TKM doctors . . . . . . . . . . . . 3.3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improving the work environment . . . . . . . . . . . . . 4.1.
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* Corresponding author at: Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea. E-mail address: [email protected] (S.-G. Ko). 1 These authors contributed equally to this work. http://dx.doi.org/10.1016/j.eujim.2016.05.009 1876-3820/ã 2016 Elsevier GmbH. All rights reserved.
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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4.2. Rational assignment . . Training and enhancing 4.3. Conflicts of interest . . . . . . . . Author contributions . . . . . . . Acknowledgements . . . . . . . . References . . . . . . . . . . . . . . .
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1. Introduction Public health system has changed as a result of changes in the epidemiology of the population. Recently, public health concepts have emphasized systematic planning and effective performance to identify and solve health problems in Korea [1]. In this study, the public health doctor system refers to a system in which doctors, dentists and traditional Korean Medicine (TKM) doctors are assigned to work in public health by the Minister of Health and Welfare to provide healthcare in underserved rural areas for three years in lieu of military service [2]. Public health doctors are selected from among those facing military duty, with the exception of Army doctors who are assigned to provide care to active duty soldiers and doctors and TKM doctors or dentists who are classified for replacement as a result of a physical examination. As planners and executors of community health services, public health doctors improve the quality of public healthcare services, contribute to improving the health of community residents, and provide primary care for the community [3]. In 1953, as the foundations of the Korean nation were being established after the Korean War, medical personnel were concentrated in major cities, which resulted in shortages of medical care in rural areas. For the entire nation to benefit equally, it was necessary to provide healthcare to underserved areas [4]. Therefore, the government instituted several programs over time, including the public physician system in 1959, which temporarily assigned currently practising physicians to underserved areas. In 1972, a programme that dispatched medical residents to work in health institutions in rural areas for six months during their residency training was launched. The specific duty designation system was started in 1976 and offered conditional medical licenses to those who failed the national medical licensing examination if they worked in an area selected by the government for two years. Finally, the public health scholarship system, in which the government provided tuition and fees for six years of medical college and scholarships for candidates who agreed to work at a public health institution for five years after graduation, was established in 1977. However, these initiatives did not achieve significant results [5]. In 1978, the government created the public health doctor system, in which physicians and dentists could be exempt from military service by practising in rural areas. Since then, heightened awareness of TKM has helped improve its status within the public healthcare system by making it more than a mere complement to western medicine. As part of the initiative to integrate TKM into the public healthcare system, doctors who practise TKM have gradually been incorporated into the public health system since 1998 [5,6]. In Korea the role of public health has been expanded rapidly and also has a unique system that includes two independent systems: Western medicine and TKM. However, the roles of medical doctors and dentists in public health centers are suitable to prevention business and health promotion. Medical doctors are charge of vaccination, basic medical check-up, and dentists are charge of tooth sealant, scaling, oral health check-up. Also in case of treatment, medical doctors mainly care chronic diseases and dentists are only involved in tooth extraction, so as to be different
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with private clinics. However, there are not obvious roles of Korean medical doctors for health promotion and prevention and there are not much different in treatment compared to private clinics.This review aimed to explore the impact and role of doctors practising TKM on the Korean public healthcare system. 2. Method 2.1. Data sources The data was obtained from the official reports the government agency websites, and each medical association websites. The government agency websites used for the study were the Ministry of Health and Welfare (http://www.mohw.go.kr/), the Ministry of National Defence (http://www.mnd.go.kr/), the Korea Health Promotion Foundation (http://www.khealth.or.kr/), and the Korea Health Industry Development Institute (https://www. khidi.or.kr/). Each medical association websites were the Association of Korean Medicine (www.akom.org/), Korean doctors association (https://www.kma.org/), and Korean dental association (www.kda.or.kr/). Laws and policies for public health doctors were searched from the Ministry of Government Legislation (www.law.go.kr). Additional data of the published papers were obtained from OASIS (Korean Medicine Information System, https://oasis.kiom.re.kr/), RISS (Research Information Service System, www.riss.kr/), KISS (Korean Studies Information Service, http://kiss.kstudy.com/), and national digital science library (http://www.ndsl.kr). 2.1.1. Search strategy To identify related studies, the basic used search terms were “public health doctor”, and “Traditional Korean Medicine”. Additional searches were performed using the combinations of terms such as “public health system”, “public doctor”, “public health doctor”, “public health TKM doctor”, and “public health dentist”. The reports and articles explaining public health doctors were all included. It were excluded reports that not contained traditional Korean medicine program or integrated medicine without TKM. Neither the publication language nor the publication date were restricted. The search was conducted on September15, 2015. 2.2. Data analysis Two authors (KHK and JAL) searched the databases and selected the reports. Also KHK and JAL categorized all collected data into the process, statutes and roles of the public health doctor system for systematic consideration, the development of the TKM public health doctor system. The third author MSL resolved the disagreements. SP, JC, and HYG extracted the data according to the predefined criteria. Eventually all data; age distribution, service region, arranging organization, training, specialty, each public health practitioner’s assigned task were arranged, analysed, compared, and developed strategy by all authors. The data extracted were as follows: numbers of each doctors per year, numbers of TKM doctors per service year from 2010 to 2015.
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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3. Results Total eleven reports were included [3,5–13]. The included reports were published between 1998 and 2015. 3.1. The development of the TKM public health doctor system To meet increasing demand for TKM services, doctors specializing in this field were assigned to public health services starting in 1998. In 1990, a two-year pilot project designed to include TKM in the public health system was launched. Based on high patient satisfaction, an expansion of the project was planned [7]. In 1995, with the beginning of the local self-government era, healthcare policies that could now be determined by local governments provided momentum to the expansion of outpatient clinics specializing in TKM within public health centres. In 1996, the “Regulation for Training Korean Medical Residents” was established, and beginning in 1998, medical residents who were trained at TKM hospitals that met certain standards were assigned to public health centres in rural areas as public health TKM doctors [8]. When the military service law was amended in 2000, TKM doctors were allowed to apply to become Army doctors after obtaining their traditional Korean medical doctor licenses [9]. Since 2002, opportunities for employment in the public health system have expanded for these TKM doctors [6]. In 2001, only 38 TKM doctors were assigned to the public health service. This number increased to 274 such doctors in 2002, 333 in 2003, 252 in 2006, and 1026 in 2015. Furthermore, the institutions to which they can potentially be assigned have been expanded to include public health centres in both major cities and rural areas, and today, TKM doctors are appointed to various national public hospitals, national public health institutions, and welfare facilities (Table 1) [3]. Medical and dental graduate school systems were started in 2005 and have gradually expanded. Thus, since 2009, the number of graduates who had not yet completed their military service has declined every year. There was also a decrease in the number of TKM public health doctors in 2012 because only one TKM graduate school was established in 2008. Furthermore, although the number of students who had not yet completed their military service increased in TKM colleges, there was no significant change in the overall supply of TKM public health doctors [3].
3
was found to have the highest percentage of assigned TKM doctors, at 19.94%, and Busan Province had the lowest, at 0.30%. For assigned facilities, most TKM doctors work in public health centres and branch offices of community health centres, with such branch offices accounting for 68.12% of assignments and public health centres for 23.38%. The majority of TKM doctors are general practitioners (88.16%), whereas rehabilitation medicine specialists account for 33.33% and paediatricians 0.85% of practitioners (Table 2). Compare to assignment statue of public health doctor who were members of the Association of Public Health Medical Doctors, it was also assigned in the most Jeonnam Province but the ratio was a lower (16.69%) than TKM doctors. For assigned facilities, most of doctors work in public health sub-centres (34.06%) and public health centres (10.70%) but lower than TKM doctors. More than half of doctors (58.08%) were specialists [10]. 3.3. Roles of public health TKM doctors Although the roles of public health TKM doctors have not been clearly defined, they can be roughly divided into two groups based on the goals of the public health system. As planners and executors of public health services in the community, they primarily improve the quality of public healthcare services and contribute to community residents’ practical health improvement through TKM. They play a secondary role as primary providers of TKM in the community [11]. There are differences of the work scope and treatments between TKM doctors and Medical doctors. The types of the work are presented in Table 3 By examining the areas of practise of public health TKM doctors, we determined that the majority (99.2%) [12] provide medical treatment, with public health services comprising half of those treatments. This is a very high percentage compared to public health doctors and public health dentists, who provide medical treatments at 90.4% [3] [14] and 65.6% [13], respectively. In particular, visits to public health centres and anti-smoking programmes account for a high percentage of the projects in which public health TKM doctors are involved [12]. However, because they often provide medical treatments on the spot, the rate at which they perform public health services might be much lower (Table 3). 4. Discussion
3.2. Assignment status of public health TKM doctors Of the 1026 public health TKM doctors in 2015 [5], assignments were identified for the 988 doctors who were members of the Association of Public Health Korean Medical Doctors [3]. When classified by the number of years worked, the number of first-, second-, and third-year practitioners were similar. The average age of a public health TKM doctor was 27.85 1.90. Jeonnam Province Table 1 Number of Public Health Doctors. Year
Total
TKM Doctors
Medical Doctors
Dentists
N
%
N
%
N
%
2010 2011 2012 2013 2014 2015
5179 4543 4046 3876 3793 3632
1053 1029 949 980 1002 1026
20.3 22.7 23.5 25.3 26.4 28.2
3363 2901 2528 2411 2379 2245
64.9 63.9 62.5 62.2 62.7 61.8
763 613 569 485 412 361
14.7 13.5 14.1 12.5 10.9 9.9
3) Operation guideline for public health doctor system, Ministry of Health & Welfare, Sejong, 2015. 7) Yearbook Publication Commission. 2013 Year Book of Traditional Korean Medicine; 2014.
Traditional Korean medicine has a deep trust and high public satisfaction with the intervention as traditional medicine as national characteristics medicine in Korea [15]. In particular, it is reported that residents in rural areas and elderly with traditional values have high satisfaction [16]. Meanwhile, 5 of entire 11 Korean Medicine college were established from late 1980s to early 1990s, so the number of new Korean medical doctors rapidly increased in late 1990s. Following these background, it seems to have increased assigning TKM public health doctors and begun systematical development since late 1990s. To address health equity issues, Korea provides public health services to underserved rural areas and other communities with low access to healthcare, including through the implementation of the public health doctor system [5]. The public health doctor system is an optional military path for Korean medical care providers, including medical doctors, TKM doctors and dentists, who are required to serve in the military. Those who wish to provide healthcare in rural, underserved areas can volunteer for three years of service in lieu of military service. Public health doctors are selected every year from among the volunteers. They receive military training and are subsequently
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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K.H. Kim et al. / European Journal of Integrative Medicine xxx (2016) xxx–xxx Table 2 Characteristics of Traditional Korean Medicine Public Health Doctors. Variables
General characteristics
No.
(%)
Length of service (yrs.)
1 2 3
326 324 338
33.00 32.79 34.21
Age(yrs., 28.86 1.89)
25-29 30-34 over 35
647 339 2
65.49 34.31 0.20
Region
Incheon Daegu Busan Ulsan Sejong Gangwon-do Gyeonggi-do Chungcheongbuk-do Chungcheongnam-do Gyeongsangbuk-do Gyeongsangnam-do Jeollabuk-do Jeollanam-do Jeju-do Other
26 7 3 6 6 82 94 81 115 139 111 100 197 17 4
2.63 0.71 0.30 0.61 0.61 8.30 9.51 8.20 11.64 14.07 11.23 10.12 19.94 1.72 0.40
Arranging organization
Public Health Centre Health Medical Centre Health Promotion Centre Public Health Sub-centre Geriatric Hospital National Hospital Hospital Ship Mobile Clinic Health Promotion Foundation Homeless Care Centre Sakhalin Returnee Support Centre
231 27 2 673 43 2 5 2 1 1 1
23.38 2.73 0.20 68.12 4.35 0.20 0.51 0.20 0.10 0.10 0.10
Training
General Practitioner Specialized Practitioner
871 117
88.16 11.84
Specialty
Acupuncture & Moxibustion Rehabilitation Medicine in Korean Medicine Neuropsychiatry in Korean Medicine Ophthalmology, Otorhinolaryngology & Dermatology in Korean Medicine Gynaecology in Korean Medicine Paediatrics in Korean Medicine Sasang Constitutional Medicine Internal Medicine in Korean Medicine Other
11 39 16 5 5 1 10 28 2
9.40 33.33 13.68 4.27 4.27 0.85 8.55 23.93 1.71
10) Membership list of public health Korean Medicine Doctors, Association of Public Health Korean Medical Doctors, Seoul, 2015.
assigned to healthcare facilities or organizations in rural areas, where they serve as governmental medical officers for a three-year term [17]. Thirty years after the implementation of the public health doctor system, Korea has not only resolved the problem of healthcare in underserved areas but has also made remarkable advances in the public healthcare sector, such as the implementation of a national health insurance system. Changes in the medical environment include gradually improved access to healthcare due to improved transportation and communication, diversified demand for healthcare services, and a shift in the healthcare paradigm from a focus on treatment to prevention and an overall improvement in health due to changes such as the epidemiological transition [18,19]. Therefore, the role of public health TKM doctors has expanded and evolved along with changes in the social and political medical environment [20]. Regardless of the social atmosphere, this survey of public health TKM doctors, to which 59.5%of those surveyed responded, indicated that the majority (99.2%) provide medical treatments and that the public health aspects of TKM are not well conducted. This weakness was attributed to a lack of incentives and motivation for public
healthcare services (34.2%), followed by a lack of experience in and access to available technology for public healthcare services (26.6%), and a lack of cooperation amongst the relevant institutions (20.7%) [12]. For the public health TKM doctor system to operate consistently in the future to improve medical equity and extend the lifespan of individuals, we propose the following policy changes. 4.1. Improving the work environment Public health TKM doctors are paid differentially, depending on where they are in their career at the time of appointment and their years of service. Based on 2015 data, the base salaries range from a minimum of KRW 1,306,800/month (1155 USD/month) to a maximum of KRW 2,557,700/month (2260 USD/month), plus incentives that can be paid from the budget of the affiliated agency. Furthermore, for the three years during which these doctors serve in the public health system, they have to perform public health services faithfully, and they cannot open medical practises or engage in any for-profit businesses. In particular, they cannot practise at any medical institution other than the institution to
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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Table 3 Public Health Doctors’ Current Work*. Responses* N (%)
Classification
Detail works
TKM Doctors
Total 1 2 3 4 5 6 7 8 9
TKM medical treatment Visiting home health care service for the elderly or disabled Anti-smoking activities using TKM Education for stroke prevention Education for health life practise using TKM Qigong exercise Sasang constitution diagnosis Obesity prevention using TKM Education of Korean-style pre-& postnatal care
494(100.0) 490(99.2) 269(54.5) 269(54.5) 190(38.5) 100(20.2) 60(12.1) 56(11.3) 53(10.7) 49(9.9)
Total 1 2 3 4 5 6 7 8 9
Simple medical treatment Vaccination Health consultation and education Home health care service visit Basic medical check-up Emergency medical service Administrative service Research activities Other
778(100.0) 696(89.5) 524(67.4) 482(62.0) 366(47.0) 284(36.5) 219(28.1) 167(21.5) 50(6.4) 14(1.8)
Total 1 2 3 4 5 6 7 8 9 10 11
Sealants Simple service, such as extraction Simple periodontal treatment, such as scaling Oral health education Oral health survey and investigation Prosthetics and related treatments Fluoride rinse Supply of dentures for the elderly or disabled Planning and implement of anti-smoking activities Anti-smoking activities Water fluoridation
212(100.0) 187(88.2) 139(65.6) 129(60.8) 91(42.9) 89(42.0) 63(29.7) 60(28.3) 37(17.5) 26(12.3) 12(5.7) 7(3.3)
Medical Doctors
Dentists
11) K.H. Seo, S.M. Lim, K.S. Park, D.H. Key, Y.H. Park, A study on the current state of public health doctors, Journal of Korean Medicine Association 55(1) 2012 56–73. 12) S.J. Kim, A Study on the Working Practice and Satisfaction of Public Health Oriental Medical Doctors, Seoul, 2007. 13) H.Y. Kim, S.K. Lee, Y.D. Park, Conditions and performance of public health dentists for public oral health activities, Public Health Dentistry 32(1) 86–95. * Multiple responses were allowed; TKM: Traditional Korea Medicine.
which they are assigned as public health doctors and can be punished for such actions, regardless of whether they receive payment [14]. As a solution to the problem of underserved areas, members of the Organisation for Economic Co-operation and Development (OECD) select students from rural areas and establish additional medical colleges and/or training programmes that provide education in rural areas. In addition, they assign specific professionals, such as nurses and pharmacists, to take partial charge of the medical practises or establish remote medical systems. Finally, they have established systems to subsidize medical treatments in rural areas. However, Korea provides an insufficient number of public healthcare professionals through the public health doctor system. It is apparent that the country has been operating an effective medical system in terms of cost efficiency by using high-quality healthcare professionals at a low cost in place of military duty [21]. Although the Korean GDP in 2014 was $1435.1 billion and has grown by approximately 26.8% since 1978when the public health doctor system was introduced [22,23], the percentage invested in public healthcare remains low. Furthermore, incentives for business activities that are paid by affiliated agencies are paid uniformly rather than following an objective evaluation of the business practises. As a result, this creates a situation that reduces the working efficiency of public health doctors and does not encourage active participation in public healthcare service [3]. In our survey of public health doctors, personal satisfaction was rated as low [24]. If the wages of public health doctors were updated and incentives for business activities were paid based one valuations of
the business, these doctors might be able to more actively participate in public healthcare service. 4.2. Rational assignment Each year, new public health TKM doctors receive four weeks of basic military training in Army training centres in the month of March. They are then transferred to the Ministry of Health and Welfare to receive their orders for public health service. They are randomly assigned to designated cities and provinces, with competition rates of more than 1:1. Based on the Ministry of Health and Welfare guidelines, mayors and governors determine the distribution and assign doctors to work in each city, county and district, depending on the local status. For existing assignees, unless there are special circumstances, such as serving on islands and isolated areas, they must work in the area to which they were first assigned before they are allowed to change their place of duty [5,14]. This assignment process does not consider doctors’ specialties or aptitudes, although public health TKM doctors are professional personnel. Although the specialist system was implemented in 2000 and covers eight specialty fields, TKM doctors are simply classified in the Department of Korean Medicine for their assignments. In addition, assignments are made in accordance with the criteria provided by the Ministry of Health and Welfare, so it is difficult to satisfy the demands for public healthcare in each community. Finally, 94.43% of all public health TKM doctors are assigned to branches of public health centres [3]. This is an exceptionally high figure, considering that 84.0% of public health
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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doctors, TKM doctors and dentists are assigned to all branches of public health centres. Therefore, public health TKM doctors should also be assigned to various public health institutions, such as national and public hospitals, national health institutions, public health organizations, and welfare facilities.
through the Korea Health Industry Development Institute (HI12C1889) and JAL, JC, and MSL were supported by a grant from the Korea Institute of Oriental Medicine (K 16111).
4.3. Training and enhancing control
[1] S.S. Bae, The function of health center in the new public health age, Korean J. Health Policy Adm. 11 (1) (2001) 131–152. [2] S.J. Yoon, A study on the branch of public health center’s status and approaches for reorganization, The 20th Anniversary Symposium of Korean Association for Public Health Doctor, Korean Association for Public Health Doctor, Seoul, 1998. [3] Ministry of Health & Welfare, Operation Guideline for Public Health Doctor System, Ministry of Health & Welfare, Sejong, 2015. [4] I.S. Yeo, H.S. Lee, S.S. Kim, K.H. Shin, Y.H. Park, Y.J. Park, History of Medicine in Korea, Research Institute for Healthcare Policy, Seoul, 2012. [5] Korea Health Industry Development Institute, A Study on Development of Assessment Tool and Strategies to Improve the Arrange System for Public Health Doctors, Korea Health Industry Development Institute, Seoul, 2005. [6] Ministry of Health & Welfare, Promotion Plan for Public Health Programs using Traditional Korean Medicine, Ministry of Health & Welfare, Seoul, 2006. [7] Committee for year book of traditional Korean medicine, 2013. Year Book of Traditional Korean Medicine, Kumkang, Daejeon, 2014. [8] Ministry of Health & Welfare, Integrative Health Promotion Business: Health Promotion Program with Traditional Medicine, Ministry of Health & Welfare, Sejong, 2015. [9] Comittee for preventive Korean medicine and public health, Preventive Korean Medicine and Public Health, Gyechuk, Seoul, 2015. [10] Association of Public Health Korean Medical Doctors, Membership List of Public Health Korean Medicine Doctors, Association of Public Health Korean Medical Doctors, Seoul, 2015. [11] K.H. Seo, S.M. Lim, K.S. Park, D.H. Key, Y.H. Park, A study on the current state of public health doctors, J. Korean Med. Assoc. 55 (1) (2012) 56–73. [12] S.J. Kim, A Study on the Working Practice and Satisfaction of Public Health Oriental Medical Doctors, CHA University, Pochon, 2007. [13] H.Y. Kim, S.K. Lee, Y.D. Park, Conditions and performance of public health dentists for public oral health activities, Public Health Dent. 32 (1) (2008) 86– 95. [14] Ministry of Health & Welfare, Operation Guideline for Public Health Doctor System, Ministry of Health & Welfare, Sejong, 2014. [15] O.R. Moon, J.S. Park, K.H. Kim, J.C. Lee, B.G. Jeong, D.M. Chang, Job analysis and strategies for utilizing oriental public health doctors working at health center, J. Health Med. Sociol. 11 (2002) 67–84. [16] S.S. Kwon, C.D. Oh, S.R. Yang, H.H. Lee, H.C. Kang, E.S. Chung, A baseline study on satisfaction rate and cognition rate on oriental medical card and occidental medical care III, J. Korean Acad. Fam. Med. 13 (11) (1992) 891–900. [17] Ministry of Health & Welfare, White Paper on Health and Welfare, Ministry of Health & Welfare, Sejong, 2013. [18] J.C. Lee, Y.M. Park, S.V. Ahn, H.Y. Lee, J.W. Hwang, A study on public health doctors’ participation in district public health program of health sub-centers in Korea, Korean J. Rural Med. 28 (1) (2003) 53–66. [19] J.R. Yi, Study on Public Health Doctors: Job Satisfaction Rate and Demand for Changes, Yonsei University, Seoul, 2000. [20] H.J. Jeong, H.S. Jo, S.S. Bae, A study on job satisfaction and strategies to improve the system of public health doctors in charge of community health programmes, Korean J. Health Policy Adm. 14 (2004) 1–23. [21] Seoul National University, Institutionalization of Supporting Public Healthcare Human Resources in National University Hospitals, Seoul National University, Seoul, 2013. [22] Statistics Korea, Economic Statistics Yearbook, Statistics Korea, Daejeon, 2015. [23] Statistics Korea, National income in Korea, Statistics Korea, Daejeon, 1978. [24] H.S. Kang, A Study on Improvement Methods of Public Doctor System in Public Health Institution, Hankyong National University, Anseong, 2004.
After assignments are made, public health TKM doctors should receive both centralized on-the-job training prior to reporting for their assignment and additional on-the-job training in the assigned area. One to two months after starting the assignment, they should receive circulating on-the-job training in cities and counties and then additional training through academic conferences and other venues. However, current on-the-job training is inefficiently conducted in a large group setting, and many studies have noted that such training does not address regional characteristics. In addition, the quality of on-the-job training is not consistent, and assessments of comprehension are not conducted after training is completed, so there is no choice but to do it formally. Therefore, it is necessary to develop a customized training process based on trainees’ demands. This study has considered the public health doctor system with a focus on TKM doctors. However, to identify an exact real-life condition, problem, or method to improve the system would require considering the overall public health doctor system as well as TKM’s role within that system. Furthermore, because only the assignment and job status of public health TKM doctors were assessed in this study, additional research evaluating the heads of public health centres, public health TKM doctors, and public health administrative staff, among others, should be conducted. For the Korean public health system to continuously improve medical equity and extend lifespans, more thorough exploration is necessary. Conflicts of interest The authors have declared no conflicts of interest. Author contributions KHK and JAL designed the study. KHK, JAL, SP and HYG participated in the design of the study and performed the statistical analysis. MSL and JC conceived of the study, and SKG participated in its design and coordination and helped draft the manuscript. All authors read and approved the final manuscript. Acknowledgements
References
This work was supported by the Traditional Korean Medicine R&D programme funded by the Ministry of Health and Welfare
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
European Journal of Integrative Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
European Journal of Integrative Medicine journal homepage: www.elsevier.com/eujim
Review article
A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine Kyeong Han Kima,1, Ju Ah Leeb,1, Ho-Yeon Goc , Jiae Choid , Sunju Parke, Myeong Soo Leed, Seong-Gyu Koa,* a
Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Republic of Korea KM Fundamental Research Division, Korea Institute of Oriental Medicine, Republic of Korea Internal Medicine College of Korean Medicine, Semyung University, Republic of Korea d Clinical Research Division, Korea Institute of Oriental Medicine, Republic of Korea e Department of Preventive Medicine, College of Korean Medicine, Daejeon University, Republic of Korea b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 April 2016 Received in revised form 25 May 2016 Accepted 26 May 2016 Available online xxx
Introduction: Korea has a unique health system that includes two independent systems: Western medicine and traditional Korean medicine (TKM). This review aimed to explore the impact and role of doctors practising TKM on the Korean public healthcare system. Methods: A search was conducted of official government agency websites, doctors’ associations and 3 Korean databases using the key words: ‘public doctor’, ‘public TKM doctor’ and ‘public health system’. The search was conducted on September 15, 2015. Neither the publication language nor the publication date were restricted. Results: The TKM public health system commenced in 1998 and after a two-year pilot project was expanded nationwide in 2002. In 2001, there were only 38 public health TKM doctors, this had increased to 1026 by 2015. Most of these practitioners work in public health centres (23.38%) and branch offices of community health centres (68.12%). Conclusions: This review has considered the public health doctor system with a focus on TKM doctors including assignment status of public health TKM doctors, the development of the TKM public health doctor system. Roles of public health TKM doctors. Although the public health doctor system has contributed to the improvement of Korean public health for 30 years, continuous development is required to improve the working conditions, provide reasonable regulation for the medical system, and strengthen the medical information and management. ã 2016 Elsevier GmbH. All rights reserved.
Keywords: Public health Traditional Korean medicine Review Integrated health system
Contents 1. 2.
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Search strategy . . . . . . . . . . . . . . . . . . . . . 2.1.1. Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The development of the TKM public health doctor 3.1. Assignment status of public health TKM doctors . 3.2. Roles of public health TKM doctors . . . . . . . . . . . . 3.3. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improving the work environment . . . . . . . . . . . . . 4.1.
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* Corresponding author at: Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, 26, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Republic of Korea. E-mail address: [email protected] (S.-G. Ko). 1 These authors contributed equally to this work. http://dx.doi.org/10.1016/j.eujim.2016.05.009 1876-3820/ã 2016 Elsevier GmbH. All rights reserved.
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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4.2. Rational assignment . . Training and enhancing 4.3. Conflicts of interest . . . . . . . . Author contributions . . . . . . . Acknowledgements . . . . . . . . References . . . . . . . . . . . . . . .
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1. Introduction Public health system has changed as a result of changes in the epidemiology of the population. Recently, public health concepts have emphasized systematic planning and effective performance to identify and solve health problems in Korea [1]. In this study, the public health doctor system refers to a system in which doctors, dentists and traditional Korean Medicine (TKM) doctors are assigned to work in public health by the Minister of Health and Welfare to provide healthcare in underserved rural areas for three years in lieu of military service [2]. Public health doctors are selected from among those facing military duty, with the exception of Army doctors who are assigned to provide care to active duty soldiers and doctors and TKM doctors or dentists who are classified for replacement as a result of a physical examination. As planners and executors of community health services, public health doctors improve the quality of public healthcare services, contribute to improving the health of community residents, and provide primary care for the community [3]. In 1953, as the foundations of the Korean nation were being established after the Korean War, medical personnel were concentrated in major cities, which resulted in shortages of medical care in rural areas. For the entire nation to benefit equally, it was necessary to provide healthcare to underserved areas [4]. Therefore, the government instituted several programs over time, including the public physician system in 1959, which temporarily assigned currently practising physicians to underserved areas. In 1972, a programme that dispatched medical residents to work in health institutions in rural areas for six months during their residency training was launched. The specific duty designation system was started in 1976 and offered conditional medical licenses to those who failed the national medical licensing examination if they worked in an area selected by the government for two years. Finally, the public health scholarship system, in which the government provided tuition and fees for six years of medical college and scholarships for candidates who agreed to work at a public health institution for five years after graduation, was established in 1977. However, these initiatives did not achieve significant results [5]. In 1978, the government created the public health doctor system, in which physicians and dentists could be exempt from military service by practising in rural areas. Since then, heightened awareness of TKM has helped improve its status within the public healthcare system by making it more than a mere complement to western medicine. As part of the initiative to integrate TKM into the public healthcare system, doctors who practise TKM have gradually been incorporated into the public health system since 1998 [5,6]. In Korea the role of public health has been expanded rapidly and also has a unique system that includes two independent systems: Western medicine and TKM. However, the roles of medical doctors and dentists in public health centers are suitable to prevention business and health promotion. Medical doctors are charge of vaccination, basic medical check-up, and dentists are charge of tooth sealant, scaling, oral health check-up. Also in case of treatment, medical doctors mainly care chronic diseases and dentists are only involved in tooth extraction, so as to be different
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with private clinics. However, there are not obvious roles of Korean medical doctors for health promotion and prevention and there are not much different in treatment compared to private clinics.This review aimed to explore the impact and role of doctors practising TKM on the Korean public healthcare system. 2. Method 2.1. Data sources The data was obtained from the official reports the government agency websites, and each medical association websites. The government agency websites used for the study were the Ministry of Health and Welfare (http://www.mohw.go.kr/), the Ministry of National Defence (http://www.mnd.go.kr/), the Korea Health Promotion Foundation (http://www.khealth.or.kr/), and the Korea Health Industry Development Institute (https://www. khidi.or.kr/). Each medical association websites were the Association of Korean Medicine (www.akom.org/), Korean doctors association (https://www.kma.org/), and Korean dental association (www.kda.or.kr/). Laws and policies for public health doctors were searched from the Ministry of Government Legislation (www.law.go.kr). Additional data of the published papers were obtained from OASIS (Korean Medicine Information System, https://oasis.kiom.re.kr/), RISS (Research Information Service System, www.riss.kr/), KISS (Korean Studies Information Service, http://kiss.kstudy.com/), and national digital science library (http://www.ndsl.kr). 2.1.1. Search strategy To identify related studies, the basic used search terms were “public health doctor”, and “Traditional Korean Medicine”. Additional searches were performed using the combinations of terms such as “public health system”, “public doctor”, “public health doctor”, “public health TKM doctor”, and “public health dentist”. The reports and articles explaining public health doctors were all included. It were excluded reports that not contained traditional Korean medicine program or integrated medicine without TKM. Neither the publication language nor the publication date were restricted. The search was conducted on September15, 2015. 2.2. Data analysis Two authors (KHK and JAL) searched the databases and selected the reports. Also KHK and JAL categorized all collected data into the process, statutes and roles of the public health doctor system for systematic consideration, the development of the TKM public health doctor system. The third author MSL resolved the disagreements. SP, JC, and HYG extracted the data according to the predefined criteria. Eventually all data; age distribution, service region, arranging organization, training, specialty, each public health practitioner’s assigned task were arranged, analysed, compared, and developed strategy by all authors. The data extracted were as follows: numbers of each doctors per year, numbers of TKM doctors per service year from 2010 to 2015.
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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3. Results Total eleven reports were included [3,5–13]. The included reports were published between 1998 and 2015. 3.1. The development of the TKM public health doctor system To meet increasing demand for TKM services, doctors specializing in this field were assigned to public health services starting in 1998. In 1990, a two-year pilot project designed to include TKM in the public health system was launched. Based on high patient satisfaction, an expansion of the project was planned [7]. In 1995, with the beginning of the local self-government era, healthcare policies that could now be determined by local governments provided momentum to the expansion of outpatient clinics specializing in TKM within public health centres. In 1996, the “Regulation for Training Korean Medical Residents” was established, and beginning in 1998, medical residents who were trained at TKM hospitals that met certain standards were assigned to public health centres in rural areas as public health TKM doctors [8]. When the military service law was amended in 2000, TKM doctors were allowed to apply to become Army doctors after obtaining their traditional Korean medical doctor licenses [9]. Since 2002, opportunities for employment in the public health system have expanded for these TKM doctors [6]. In 2001, only 38 TKM doctors were assigned to the public health service. This number increased to 274 such doctors in 2002, 333 in 2003, 252 in 2006, and 1026 in 2015. Furthermore, the institutions to which they can potentially be assigned have been expanded to include public health centres in both major cities and rural areas, and today, TKM doctors are appointed to various national public hospitals, national public health institutions, and welfare facilities (Table 1) [3]. Medical and dental graduate school systems were started in 2005 and have gradually expanded. Thus, since 2009, the number of graduates who had not yet completed their military service has declined every year. There was also a decrease in the number of TKM public health doctors in 2012 because only one TKM graduate school was established in 2008. Furthermore, although the number of students who had not yet completed their military service increased in TKM colleges, there was no significant change in the overall supply of TKM public health doctors [3].
3
was found to have the highest percentage of assigned TKM doctors, at 19.94%, and Busan Province had the lowest, at 0.30%. For assigned facilities, most TKM doctors work in public health centres and branch offices of community health centres, with such branch offices accounting for 68.12% of assignments and public health centres for 23.38%. The majority of TKM doctors are general practitioners (88.16%), whereas rehabilitation medicine specialists account for 33.33% and paediatricians 0.85% of practitioners (Table 2). Compare to assignment statue of public health doctor who were members of the Association of Public Health Medical Doctors, it was also assigned in the most Jeonnam Province but the ratio was a lower (16.69%) than TKM doctors. For assigned facilities, most of doctors work in public health sub-centres (34.06%) and public health centres (10.70%) but lower than TKM doctors. More than half of doctors (58.08%) were specialists [10]. 3.3. Roles of public health TKM doctors Although the roles of public health TKM doctors have not been clearly defined, they can be roughly divided into two groups based on the goals of the public health system. As planners and executors of public health services in the community, they primarily improve the quality of public healthcare services and contribute to community residents’ practical health improvement through TKM. They play a secondary role as primary providers of TKM in the community [11]. There are differences of the work scope and treatments between TKM doctors and Medical doctors. The types of the work are presented in Table 3 By examining the areas of practise of public health TKM doctors, we determined that the majority (99.2%) [12] provide medical treatment, with public health services comprising half of those treatments. This is a very high percentage compared to public health doctors and public health dentists, who provide medical treatments at 90.4% [3] [14] and 65.6% [13], respectively. In particular, visits to public health centres and anti-smoking programmes account for a high percentage of the projects in which public health TKM doctors are involved [12]. However, because they often provide medical treatments on the spot, the rate at which they perform public health services might be much lower (Table 3). 4. Discussion
3.2. Assignment status of public health TKM doctors Of the 1026 public health TKM doctors in 2015 [5], assignments were identified for the 988 doctors who were members of the Association of Public Health Korean Medical Doctors [3]. When classified by the number of years worked, the number of first-, second-, and third-year practitioners were similar. The average age of a public health TKM doctor was 27.85 1.90. Jeonnam Province Table 1 Number of Public Health Doctors. Year
Total
TKM Doctors
Medical Doctors
Dentists
N
%
N
%
N
%
2010 2011 2012 2013 2014 2015
5179 4543 4046 3876 3793 3632
1053 1029 949 980 1002 1026
20.3 22.7 23.5 25.3 26.4 28.2
3363 2901 2528 2411 2379 2245
64.9 63.9 62.5 62.2 62.7 61.8
763 613 569 485 412 361
14.7 13.5 14.1 12.5 10.9 9.9
3) Operation guideline for public health doctor system, Ministry of Health & Welfare, Sejong, 2015. 7) Yearbook Publication Commission. 2013 Year Book of Traditional Korean Medicine; 2014.
Traditional Korean medicine has a deep trust and high public satisfaction with the intervention as traditional medicine as national characteristics medicine in Korea [15]. In particular, it is reported that residents in rural areas and elderly with traditional values have high satisfaction [16]. Meanwhile, 5 of entire 11 Korean Medicine college were established from late 1980s to early 1990s, so the number of new Korean medical doctors rapidly increased in late 1990s. Following these background, it seems to have increased assigning TKM public health doctors and begun systematical development since late 1990s. To address health equity issues, Korea provides public health services to underserved rural areas and other communities with low access to healthcare, including through the implementation of the public health doctor system [5]. The public health doctor system is an optional military path for Korean medical care providers, including medical doctors, TKM doctors and dentists, who are required to serve in the military. Those who wish to provide healthcare in rural, underserved areas can volunteer for three years of service in lieu of military service. Public health doctors are selected every year from among the volunteers. They receive military training and are subsequently
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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K.H. Kim et al. / European Journal of Integrative Medicine xxx (2016) xxx–xxx Table 2 Characteristics of Traditional Korean Medicine Public Health Doctors. Variables
General characteristics
No.
(%)
Length of service (yrs.)
1 2 3
326 324 338
33.00 32.79 34.21
Age(yrs., 28.86 1.89)
25-29 30-34 over 35
647 339 2
65.49 34.31 0.20
Region
Incheon Daegu Busan Ulsan Sejong Gangwon-do Gyeonggi-do Chungcheongbuk-do Chungcheongnam-do Gyeongsangbuk-do Gyeongsangnam-do Jeollabuk-do Jeollanam-do Jeju-do Other
26 7 3 6 6 82 94 81 115 139 111 100 197 17 4
2.63 0.71 0.30 0.61 0.61 8.30 9.51 8.20 11.64 14.07 11.23 10.12 19.94 1.72 0.40
Arranging organization
Public Health Centre Health Medical Centre Health Promotion Centre Public Health Sub-centre Geriatric Hospital National Hospital Hospital Ship Mobile Clinic Health Promotion Foundation Homeless Care Centre Sakhalin Returnee Support Centre
231 27 2 673 43 2 5 2 1 1 1
23.38 2.73 0.20 68.12 4.35 0.20 0.51 0.20 0.10 0.10 0.10
Training
General Practitioner Specialized Practitioner
871 117
88.16 11.84
Specialty
Acupuncture & Moxibustion Rehabilitation Medicine in Korean Medicine Neuropsychiatry in Korean Medicine Ophthalmology, Otorhinolaryngology & Dermatology in Korean Medicine Gynaecology in Korean Medicine Paediatrics in Korean Medicine Sasang Constitutional Medicine Internal Medicine in Korean Medicine Other
11 39 16 5 5 1 10 28 2
9.40 33.33 13.68 4.27 4.27 0.85 8.55 23.93 1.71
10) Membership list of public health Korean Medicine Doctors, Association of Public Health Korean Medical Doctors, Seoul, 2015.
assigned to healthcare facilities or organizations in rural areas, where they serve as governmental medical officers for a three-year term [17]. Thirty years after the implementation of the public health doctor system, Korea has not only resolved the problem of healthcare in underserved areas but has also made remarkable advances in the public healthcare sector, such as the implementation of a national health insurance system. Changes in the medical environment include gradually improved access to healthcare due to improved transportation and communication, diversified demand for healthcare services, and a shift in the healthcare paradigm from a focus on treatment to prevention and an overall improvement in health due to changes such as the epidemiological transition [18,19]. Therefore, the role of public health TKM doctors has expanded and evolved along with changes in the social and political medical environment [20]. Regardless of the social atmosphere, this survey of public health TKM doctors, to which 59.5%of those surveyed responded, indicated that the majority (99.2%) provide medical treatments and that the public health aspects of TKM are not well conducted. This weakness was attributed to a lack of incentives and motivation for public
healthcare services (34.2%), followed by a lack of experience in and access to available technology for public healthcare services (26.6%), and a lack of cooperation amongst the relevant institutions (20.7%) [12]. For the public health TKM doctor system to operate consistently in the future to improve medical equity and extend the lifespan of individuals, we propose the following policy changes. 4.1. Improving the work environment Public health TKM doctors are paid differentially, depending on where they are in their career at the time of appointment and their years of service. Based on 2015 data, the base salaries range from a minimum of KRW 1,306,800/month (1155 USD/month) to a maximum of KRW 2,557,700/month (2260 USD/month), plus incentives that can be paid from the budget of the affiliated agency. Furthermore, for the three years during which these doctors serve in the public health system, they have to perform public health services faithfully, and they cannot open medical practises or engage in any for-profit businesses. In particular, they cannot practise at any medical institution other than the institution to
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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Table 3 Public Health Doctors’ Current Work*. Responses* N (%)
Classification
Detail works
TKM Doctors
Total 1 2 3 4 5 6 7 8 9
TKM medical treatment Visiting home health care service for the elderly or disabled Anti-smoking activities using TKM Education for stroke prevention Education for health life practise using TKM Qigong exercise Sasang constitution diagnosis Obesity prevention using TKM Education of Korean-style pre-& postnatal care
494(100.0) 490(99.2) 269(54.5) 269(54.5) 190(38.5) 100(20.2) 60(12.1) 56(11.3) 53(10.7) 49(9.9)
Total 1 2 3 4 5 6 7 8 9
Simple medical treatment Vaccination Health consultation and education Home health care service visit Basic medical check-up Emergency medical service Administrative service Research activities Other
778(100.0) 696(89.5) 524(67.4) 482(62.0) 366(47.0) 284(36.5) 219(28.1) 167(21.5) 50(6.4) 14(1.8)
Total 1 2 3 4 5 6 7 8 9 10 11
Sealants Simple service, such as extraction Simple periodontal treatment, such as scaling Oral health education Oral health survey and investigation Prosthetics and related treatments Fluoride rinse Supply of dentures for the elderly or disabled Planning and implement of anti-smoking activities Anti-smoking activities Water fluoridation
212(100.0) 187(88.2) 139(65.6) 129(60.8) 91(42.9) 89(42.0) 63(29.7) 60(28.3) 37(17.5) 26(12.3) 12(5.7) 7(3.3)
Medical Doctors
Dentists
11) K.H. Seo, S.M. Lim, K.S. Park, D.H. Key, Y.H. Park, A study on the current state of public health doctors, Journal of Korean Medicine Association 55(1) 2012 56–73. 12) S.J. Kim, A Study on the Working Practice and Satisfaction of Public Health Oriental Medical Doctors, Seoul, 2007. 13) H.Y. Kim, S.K. Lee, Y.D. Park, Conditions and performance of public health dentists for public oral health activities, Public Health Dentistry 32(1) 86–95. * Multiple responses were allowed; TKM: Traditional Korea Medicine.
which they are assigned as public health doctors and can be punished for such actions, regardless of whether they receive payment [14]. As a solution to the problem of underserved areas, members of the Organisation for Economic Co-operation and Development (OECD) select students from rural areas and establish additional medical colleges and/or training programmes that provide education in rural areas. In addition, they assign specific professionals, such as nurses and pharmacists, to take partial charge of the medical practises or establish remote medical systems. Finally, they have established systems to subsidize medical treatments in rural areas. However, Korea provides an insufficient number of public healthcare professionals through the public health doctor system. It is apparent that the country has been operating an effective medical system in terms of cost efficiency by using high-quality healthcare professionals at a low cost in place of military duty [21]. Although the Korean GDP in 2014 was $1435.1 billion and has grown by approximately 26.8% since 1978when the public health doctor system was introduced [22,23], the percentage invested in public healthcare remains low. Furthermore, incentives for business activities that are paid by affiliated agencies are paid uniformly rather than following an objective evaluation of the business practises. As a result, this creates a situation that reduces the working efficiency of public health doctors and does not encourage active participation in public healthcare service [3]. In our survey of public health doctors, personal satisfaction was rated as low [24]. If the wages of public health doctors were updated and incentives for business activities were paid based one valuations of
the business, these doctors might be able to more actively participate in public healthcare service. 4.2. Rational assignment Each year, new public health TKM doctors receive four weeks of basic military training in Army training centres in the month of March. They are then transferred to the Ministry of Health and Welfare to receive their orders for public health service. They are randomly assigned to designated cities and provinces, with competition rates of more than 1:1. Based on the Ministry of Health and Welfare guidelines, mayors and governors determine the distribution and assign doctors to work in each city, county and district, depending on the local status. For existing assignees, unless there are special circumstances, such as serving on islands and isolated areas, they must work in the area to which they were first assigned before they are allowed to change their place of duty [5,14]. This assignment process does not consider doctors’ specialties or aptitudes, although public health TKM doctors are professional personnel. Although the specialist system was implemented in 2000 and covers eight specialty fields, TKM doctors are simply classified in the Department of Korean Medicine for their assignments. In addition, assignments are made in accordance with the criteria provided by the Ministry of Health and Welfare, so it is difficult to satisfy the demands for public healthcare in each community. Finally, 94.43% of all public health TKM doctors are assigned to branches of public health centres [3]. This is an exceptionally high figure, considering that 84.0% of public health
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009
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doctors, TKM doctors and dentists are assigned to all branches of public health centres. Therefore, public health TKM doctors should also be assigned to various public health institutions, such as national and public hospitals, national health institutions, public health organizations, and welfare facilities.
through the Korea Health Industry Development Institute (HI12C1889) and JAL, JC, and MSL were supported by a grant from the Korea Institute of Oriental Medicine (K 16111).
4.3. Training and enhancing control
[1] S.S. Bae, The function of health center in the new public health age, Korean J. Health Policy Adm. 11 (1) (2001) 131–152. [2] S.J. Yoon, A study on the branch of public health center’s status and approaches for reorganization, The 20th Anniversary Symposium of Korean Association for Public Health Doctor, Korean Association for Public Health Doctor, Seoul, 1998. [3] Ministry of Health & Welfare, Operation Guideline for Public Health Doctor System, Ministry of Health & Welfare, Sejong, 2015. [4] I.S. Yeo, H.S. Lee, S.S. Kim, K.H. Shin, Y.H. Park, Y.J. Park, History of Medicine in Korea, Research Institute for Healthcare Policy, Seoul, 2012. [5] Korea Health Industry Development Institute, A Study on Development of Assessment Tool and Strategies to Improve the Arrange System for Public Health Doctors, Korea Health Industry Development Institute, Seoul, 2005. [6] Ministry of Health & Welfare, Promotion Plan for Public Health Programs using Traditional Korean Medicine, Ministry of Health & Welfare, Seoul, 2006. [7] Committee for year book of traditional Korean medicine, 2013. Year Book of Traditional Korean Medicine, Kumkang, Daejeon, 2014. [8] Ministry of Health & Welfare, Integrative Health Promotion Business: Health Promotion Program with Traditional Medicine, Ministry of Health & Welfare, Sejong, 2015. [9] Comittee for preventive Korean medicine and public health, Preventive Korean Medicine and Public Health, Gyechuk, Seoul, 2015. [10] Association of Public Health Korean Medical Doctors, Membership List of Public Health Korean Medicine Doctors, Association of Public Health Korean Medical Doctors, Seoul, 2015. [11] K.H. Seo, S.M. Lim, K.S. Park, D.H. Key, Y.H. Park, A study on the current state of public health doctors, J. Korean Med. Assoc. 55 (1) (2012) 56–73. [12] S.J. Kim, A Study on the Working Practice and Satisfaction of Public Health Oriental Medical Doctors, CHA University, Pochon, 2007. [13] H.Y. Kim, S.K. Lee, Y.D. Park, Conditions and performance of public health dentists for public oral health activities, Public Health Dent. 32 (1) (2008) 86– 95. [14] Ministry of Health & Welfare, Operation Guideline for Public Health Doctor System, Ministry of Health & Welfare, Sejong, 2014. [15] O.R. Moon, J.S. Park, K.H. Kim, J.C. Lee, B.G. Jeong, D.M. Chang, Job analysis and strategies for utilizing oriental public health doctors working at health center, J. Health Med. Sociol. 11 (2002) 67–84. [16] S.S. Kwon, C.D. Oh, S.R. Yang, H.H. Lee, H.C. Kang, E.S. Chung, A baseline study on satisfaction rate and cognition rate on oriental medical card and occidental medical care III, J. Korean Acad. Fam. Med. 13 (11) (1992) 891–900. [17] Ministry of Health & Welfare, White Paper on Health and Welfare, Ministry of Health & Welfare, Sejong, 2013. [18] J.C. Lee, Y.M. Park, S.V. Ahn, H.Y. Lee, J.W. Hwang, A study on public health doctors’ participation in district public health program of health sub-centers in Korea, Korean J. Rural Med. 28 (1) (2003) 53–66. [19] J.R. Yi, Study on Public Health Doctors: Job Satisfaction Rate and Demand for Changes, Yonsei University, Seoul, 2000. [20] H.J. Jeong, H.S. Jo, S.S. Bae, A study on job satisfaction and strategies to improve the system of public health doctors in charge of community health programmes, Korean J. Health Policy Adm. 14 (2004) 1–23. [21] Seoul National University, Institutionalization of Supporting Public Healthcare Human Resources in National University Hospitals, Seoul National University, Seoul, 2013. [22] Statistics Korea, Economic Statistics Yearbook, Statistics Korea, Daejeon, 2015. [23] Statistics Korea, National income in Korea, Statistics Korea, Daejeon, 1978. [24] H.S. Kang, A Study on Improvement Methods of Public Doctor System in Public Health Institution, Hankyong National University, Anseong, 2004.
After assignments are made, public health TKM doctors should receive both centralized on-the-job training prior to reporting for their assignment and additional on-the-job training in the assigned area. One to two months after starting the assignment, they should receive circulating on-the-job training in cities and counties and then additional training through academic conferences and other venues. However, current on-the-job training is inefficiently conducted in a large group setting, and many studies have noted that such training does not address regional characteristics. In addition, the quality of on-the-job training is not consistent, and assessments of comprehension are not conducted after training is completed, so there is no choice but to do it formally. Therefore, it is necessary to develop a customized training process based on trainees’ demands. This study has considered the public health doctor system with a focus on TKM doctors. However, to identify an exact real-life condition, problem, or method to improve the system would require considering the overall public health doctor system as well as TKM’s role within that system. Furthermore, because only the assignment and job status of public health TKM doctors were assessed in this study, additional research evaluating the heads of public health centres, public health TKM doctors, and public health administrative staff, among others, should be conducted. For the Korean public health system to continuously improve medical equity and extend lifespans, more thorough exploration is necessary. Conflicts of interest The authors have declared no conflicts of interest. Author contributions KHK and JAL designed the study. KHK, JAL, SP and HYG participated in the design of the study and performed the statistical analysis. MSL and JC conceived of the study, and SKG participated in its design and coordination and helped draft the manuscript. All authors read and approved the final manuscript. Acknowledgements
References
This work was supported by the Traditional Korean Medicine R&D programme funded by the Ministry of Health and Welfare
Please cite this article in press as: K.H. Kim, et al., A review of the development of the public health doctor system in Korea—The role of traditional Korean Medicine, Eur. J. Integr. Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.05.009