Public Health Nursing Vol. 32 No. 2, pp. 161–168 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12143
SPECIAL FEATURES: HEALTH POLICY
Historical Overview of Community Health Practitioners in Korea Changyeong Kwak, PhD, APRN,1 and Young Ko, PhD, RN,2 1
Department of Nursing, Hallym University, Chuncheon, Korea; and 2College of Nursing, Gachon University, Incheon, Korea
Correspondence to: Dr. Young Ko, College of Nursing, Gachon University, 191 Hambakmoeiro, Yeonsu-Gu, Incheon 406-799, Korea. E-mail: [email protected]
ABSTRACT The Korean government introduced CHPs (Community Health Practitioners) as front-line primary health care providers to address the health disparity between urban and rural areas. Through their dedicated contribution over last 30 years, the CHPs have improved Koreas public health through the successful control of high birth rates, a lowered maternal and infant mortality rate in the 1980s, eradication of parasitic infection, and containing many communicable diseases including hepatitis B. However, rapid changes in the health care environment and demands for health care among rural residents have required changes in the roles and functions of the CHPs. They are challenged by fundamental changes in the public health system addressing various health issues due to a rapidly aging society, pandemic of chronic disease, new infectious disease, and climate changes. CHPs should continuously transform their roles and functions to establish a lifelong health management system. This article presents a historical overview of the CHP system and their tasks and activities. Also, recent challenges that CHPs are facing and strategies to overcome those challenges will be discussed. This historical overview will be informative for other developing countries in resolving their own public health problems. Key words: community health nursing, nurse practitioner, primary care, public health systems, rural health.
Due to Korea’s rapid economic growth in the mid-1970s, urbanization led to a widening socioeconomic gap between the urban and rural areas. Private hospitals and health care providers were concentrated in metropolitan areas, which became one of the major causes of health disparities between urban and rural areas (Korea Institute for Health and Social Affairs [KIHASA], 1990; Moon, 1977). To address this regional inequality of health care services, the Korean government distributed Community Health Practitioners (CHPs) to rural and very remote areas to serve as front-line primary health care providers. They also managed community health problems and promoted residents’ well-being (Korean Nurses Association [KNA], 1997; Yi, 2009). Through the CHPs’ dedication and hard work, they became one of the main contributors to the successful control of high birth rates and lowered maternal mortality rates in the
1980s (Kim & Oh, 1985; Statistics Korea, 2010), as well as the eradication of parasite infections and communicable diseases such as polio in 2000, the measles in 2006, and hepatitis B in 2008 (Korea Center for Disease Control and Prevention [KCDC], 2012). Without their devotion, Korea would not have achieved such significantly improved health indicators in a short period of time. CHPs are unique among health care providers in the world because their program was launched to resolve health issues raised by rapid industrialization in Korea. The CHPs were experienced nurses who were trained to be primary health care providers and community health nurses. Therefore, as primary health care practitioners, their roles are similar to that of midlevel practitioners (MLP) in many countries, such as nurse practitioners (NPs) in United States, Canada, or Australia. However, CHPs and MLPs differ in that CHPs are not
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required to possess master’s degrees. Also, CHPs are restricted to working only with socio-economically isolated populations within designated areas. Yet, it may be safe to say that their roles are comparable because both systems have been adopted by primary health care services as substitutes for physicians to ensure a more efficient use of resources (Offredy & Townsend, 2000; Parker, Forrest, McCracken, MaRae, & Cox, in press). As a community health nurse, CHPs may also be similar to Public Health Nurses (PHNs) in Japan. CHPs and PHNs are the first line of public health administration in the community and are not required to have a master’s degree. However, PHNs differ from CHPs because of their dependency on doctors and lack of geographical limitation for their work, unlike CHPs in Korea (Yoshioka-Maeda et al., 2006). In the past, Canada used advanced practice nurses as primary care NPs, but the government allowed them to expand their roles to public health nursing in 2006. They got involved in public health areas because the government wanted to shift the emphasis of their roles from treatment to health promotion, disease prevention, and communitybased care (DiCenso et al., 2007). In this way, the roles and functions of CHPs are similar to that of the Primary NPs in Canada, yet the education and training requirements are completely different from each other. As discussed above, many countries use nurses to provide adequate access to primary health care and public health through advanced education or training. Although their roles and functions are not exactly same, it is evident that advanced practice nurses play an important role in resolving health problems in their countries. This article presents a historical overview of the CHP system in Korea. Some of challenges and strategies to overcome obstacles are also discussed. We hope this historical overview of the Korean CHP system is informative for other developing countries in resolving their own public health problems.
Research methods This study strives to historically capture the roles and functions of CHPs, and how they have been influencing the current health care services in Korea over time. Our research is mainly based on primary sources, such as published government
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documents and records, and unpublished official reports from ‘the Association of Community Health Practitioners’. We also obtained oral histories from interviews with pioneers and current leaders of CHP who provided us direct or indirect experiences with knowledge of the CHP system. The secondary resources that we used were newspapers, periodicals, journals, and other written documents. We performed our search in Korean by typing the phrases of “community health practitioners,” “primary care services,” and “public health nursing” into search engines and obtained written documents. After collecting all of the information, we organized them chronologically, and categorized each by primary care services and public health nursing. All materials were carefully reviewed and evaluated, grounded in facts and eye witnesses.
Results After reading the research material collected, 13 governmental records and documents, 4 citations, and 15 articles were chosen for the analysis. We included all governmental documents and records assuming they are objective and valid. Any confusing information or conflicted interests retrieved from newspapers or periodicals were not included in this study because they did not meet the test of internal criticism. Our narrative documents did not include any vague or uncertain opinions obtained from oral interviews. This result section categorized into background of CHP establishment, their roles and functions, and governmental programs participated. In addition, we present the legislative Chronology and governmental responses relating to the CHP system in Table 1.
Establishment of the CHP system In the early 1970s, rural residents in Korea had little access to health care services because most medical facilities were built in metropolitan areas (KIHASA, 1990). This led to an inequitable distribution of medical personnel and health care delivery system (Ministry of Health & Social Affairs [MOHS], 1981; Moon, 1977). To resolve this issue, the government announced the ‘Fourth Five-year Plan for Economic Development and Community Health Service’ by establishing a CHP-led primary health care delivery system in rural areas (Kim, Park, Jung, & Joo, 1976; KNA, 1997).
Kwak and Ko: Community Health Practitioners in Korea TABLE 1. Historical Record related to Community Health Practitioner Date 12/1956
1976 1977 1978 12/1980
6/1986
1/1988 7/1989 12/1995
Events Enactment of ‘Health Center Act’- describe the role and activities of public health nurse and public health center Pilot Project for Community Health Practitioner System Introduction of ‘Employees Medical Insurance System’ Alma Ata Declaration: primary health care approach Enactment of ‘Special Act for Healthcare in Rural Areas Act’—describe the role and activity of community health nurse practitioner as primary health care provider and public health center post Built Public Health Center Posts and arranged the Community Health Nurse Practitioners in all remote rural area Introduction of ‘Medical Insurance System for Rural Area’ Settlement of ‘National Medical Insurance System’ Enactment of ‘National Health Promotion Act’ Revocation of ‘Health Center Act and enactment of ‘Law for Community Health’—strengthen community-based health and activate health promotion
With funding from the government, the Korea Health Development Institute (KHDI) planned to train experienced nurses as primary care providers in rural areas and started a pilot project to evaluate the proposed CHP system. The initial pilot project was launched in 1976 by combining the primary health care providers’ roles with community health nursing to meet urgent health matters. The government provided additional funding to the KHDI to conduct research for further utilization of the CHP system. The required funding was supplied through a loan from the Agency for International Development. A total of 25 CHPs received the initial training program which consisted of theory education, hospital practicum, and community practicum (KHDI, 1979). After completing the training program, the CHPs were assigned to three remote mountain areas and provided primary health care for common health problems and health education. The midevaluation of the pilot project concluded
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that the CHPs efficiently carried out primary health care services (KHDI, 1979). With this positive evaluation, the Korean government decided to expand the CHP system nation-wide and enacted the legislation of the ‘Special Act for Healthcare in Rural Areas (SAHRA)’ in 1980. Also, five regulations were announced to implement SAHRA: (a) to abrogate a law for public health care aiming at giving equal medical benefits to doctor-less villages by sending doctors serving their mandatory military obligations, (b) to integrate primary health care into SAHRA for rural residents, (c) for the village head to set up and run the CHP system, (d) for the town leader to appoint a CHP among qualified nurses, (e) to allow CHPs to practice within their legal scopes (Kang, 2000; Yim, 1981).
Operating System of the CHP For the CHP workplace, the Public Health Center Posts (PHCPs) were built in convenient places for easy access and managed populations greater than 1,000 and less than 5,000. Each health center was required to have a floor space of a minimum of 66 m2 and have rooms for history taking and physical examination, medication, interventions, meetings, and other activities (MOHS, 1989). As shown in Figure 1, CHPs were to work closely with village leaders, which is one of the reasons for successful implementation. There are two resident organizations that oversee fiscal budgets and support the CHP system; the Community Steering Committee (CSC) and the Village Health Workers (VHW). The CSC consists of 20 board members including the director, associate director, and 18 steering committee members. The board members are elected by the city governor or the mayor of the town. Each elected board member monitors the fiscal budget and works collaboratively to establish comprehensive and effective community health services. The board is responsible for strategic directions and overseeing of the organization. They are also responsible for electing board members (MOHS, 1984). The VHW is a leader of the residents. One of the main roles of the VHW is mediating and connecting residents to the CHP for health-related matters. They report the number of residents, any problems of pregnant women or infants, nursing mothers to be followed up by the CHP, medical emergency situations, and any
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Figure 1. Operating System of Public Health Center Post (PHCP) environmental matters (Lee, Han, & Lee, 1993; MOHS, 1984).
CHPs’ Legal Scopes of Practice as a primary health care provider SAHRA and its amendments define the CHPs’ responsibilities, guidelines, and legal scopes (MOHS, 1981). Originally, in 1980, CHPs were permitted to prescribe 68 drugs, but the legal scopes of prescription were extended to meet residents’ needs over time. CHPs are now prescribing 104 drugs for primary medical services (Ministry of Health and Welfare [MOHW], 2002). The CHPs’ legal scopes of direct patient care are listed as follows: 1. Health history taking and physical examination 2. Basic blood tests 3. Management of common health problems and follow-up of chronic disease with dispensing of medications permitted by the law and regulations 4. Management of prenatal care, normal delivery and infant, postpartum care and women’s health, and administration of contraceptive devices (e.g., Intrauterine devices) 5. Immunizations and vaccinations 6. Environmental management and infection control 7. Emergency management and medical treatments including intravenous fluid and drugs to manage critical conditions.
CHP’s Participation in Public Health Programs Maternal and child health program The Maternal and Child Health Program (MCHP) started along with the economic development project. At the beginning stages of the program, the MCHP focused on decreasing the birth rate and improving maternal health for women of childbearing age (19–49 years) (Son, 2008). The contents of the MCHP included general health education including sex education and family planning, services for contraception, and delivery, including prenatal and postpartum care (Korea Institute for Population and Health [KIPH], 1986). The Family Planning (FP) project was administered as a socialwelfare benefit for socio-economically vulnerable populations (Son, 2008). With the government’s support, the FP project attained remarkable results, and the birth rate decreased from 6.0 in 1960 and 2.83 in 1980 to 1.08 in 2005 (Statistics Korea, 2010). The MCHP consisted of two types of health services: direct medical services and the promotion of maternal health and well-being (KIPH, 1986). For direct medical services, CHPs worked as midwives to manage normal deliveries. They also inserted intrauterine contraceptive devices at request or provided free birth control pills or condoms. To promote maternal health, they provided prenatal care, postpartum care, and health checkups for newborns. As we enter into the new decade, the CHPs’ functions in MCHP are redefined and reorganized to meet the current needs of health care services. Nowadays, many women and children in rural areas are from multicultural backgrounds (Kim, 2009; Statistics Korea, 2013). They may not be
Kwak and Ko: Community Health Practitioners in Korea accustomed to the Korean culture or experience difficulties receiving health services due to obstacles such as language barriers (Kim, Park, & Kim, 2011; Yang, 2010). To provide resident-sensitive health services, the CHPs provide customized health management services through home visits. Also CHPs connect ethnic minorities to the Multicultural-Family Support Center and Marriage Immigration Support Center. Infectious disease control project In the early 1970s to 1980s, controlling communicable diseases was one of the main concerns of health policymakers. To prevent communicable disease, CHPs conducted group education to improve the environmental hygiene status and control infectious disease. The CHPs educated the community leaders first, and encouraged the PHCP committee to start campaigns for improving environmental hygiene conditions. The education contents included drinking water management, waste disposal, removal of insect habitats, disinfection methods, and vaccinations (Kim, 2008; KIPH, 1982). If any resident was suspected of having a communicable disease, the CHP immediately reported the case to the Public Health Center. If the patient was confirmed, he/she was separated from other residents and both the patient and the people in contact with the patient were monitored. In addition, the CHP traced transmission routes to locate the source of infection (KCDC, 2006a; KIPH, 1982; Lee, 2006). One of the infectious diseases that CHPs played a key role in controlling was Tuberculosis (TB). The key component of ‘Directly Observed Treatment, Short-course (DOTs)’ may be early detection of the first case in the community. To detect a patient, CHPs informed residents in advance about the arrival of X-ray examination buses to attract more people to participate. During the free X-ray checkup, sputum samples were collected and sent to laboratories for testing. If a patient was confirmed with TB, antituberculosis medicine was dispensed with refill prescriptions obtained from the physician, followed by long periods of treatment. CHPs also provided education programs to control infection. Patients were encouraged to maintain diets that were high protein and vitamins, and family members were required to receive regular checkups (KCDC, 2006a; KIPH, 1982). With their dedicated efforts and governmental supports, the infection
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rate of Tb has decreased from 41.6% in 1980, and 27.3% in 1990 to 6.5% in 2010. Controlling Tb infection, however, should be under close attention once again because there were 39,545 new Tb cases developed in 2012 (KCDC, 2012). Nowadays, CHPs participate in the program as case managers and become part of the ‘Tb Net Working System’ which refers clients to medical providers and prevents further spreading of germs (KCDC, 2011). They also closely monitor for potential residents who are at high risk for infection. Interestingly, the treatment success rate in the public sector is much higher than that of the private sector (Kim, 2008). It is possible that CHPs have played a significant role in this as they are one of the key members of the public health system. For better and efficient management of Tb in Korea, a partnership between private and public sectors should be established, and we believe CHPs can play an important role in connecting the two parties. The Hepatitis B project was another infectious disease that has a much higher incidence rate in Korea than in any other developed country. To control Hepatitis B, CHPs performed antigen/antibody tests and liver function tests in collaboration with the Korean Association of Health Promotion (KAHP). After receiving test results, the CHPs educated carriers and infected patients to control transmission routes. The CHPs administered vaccinations to noninfected residents (Kim, 2008; KIPH, 1982). In 2008, Korea received a certification from the World Health Organization for successful Hepatitis B management (Cho, 2008). In the 1980s, the CHPs focused on controlling communicable diseases, environmental management, and administering immunizations for TB, Epidemic Hemorrhagic Fever, hepatitis B, and other water-borne diseases (Kim, 2008). After the successful management of these infectious diseases, CHPs now focus on the prevention of influenza or pneumonia in elderly citizens. The contents of health education have also been changed from prevention of spreading germs to promoting healthy lifestyles. Anti-parasite project The Anti-Parasite Project (APP) was one of the major government health projects in the 1970s which focused on improving living conditions and environment in Korea
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through a 5-year economic development plan. In the 1960s, Korea was considered an under-developed country. Many people could not afford shoes or laundry detergent. There were no established sewage systems, and people were using human feces for fertilization because there were no chemical fertilizers. Due to this low socio-economic environment, most people had at least one or more parasite infection. To control parasite infection, CHPs collaborated with a team from the Korean Association for Parasite Eradication. They also educated community residents to end the vicious cycle of transmission and provided antiparasite medications. By 1997, the APP was discontinued because the infection rate had decreased to less than 0.1%, and investigators were certain that there was no possibility for another breakout (Hong et al., 2006). Despite the evident progress, however, the Anti-Liver Fluke Project (ALFP) was established because there was a high risk of liver fluke infection around five river areas. Liver fluke is the most common food-borne parasitic disease in Korea which is transmitted through eating raw fresh-water fish. The ALFP was carried out centering on regional public health centers where liver fluke was rampant (KCDC, 2006b). CHPs advertised the project and provided group education to teach residents how to prevent infection and avoid eating raw fish caught from the river. CHPs also conducted screening tests and dispensed medication to egg-positive patients (Park, 2008). An epidemiologic study showed that the helminth egg-positive rate had decreased from 12.4% to 7.0% in 2009 (Hong et al., 2006), and the ALFP will continue until the infection rate is reduced to 1%. Hypertension management project Korea undertook the enactment of the National Health Promotion Act in 1995, which was a milestone for initiating a national and local health promotion program in Korea (Nam, 2011). Under this act, CHPs participated in various public health education programs for health promotion and Hypertension Management Program (HMP) may be the most successful program. The HMP was implemented at an individual and community level. At the individual level, they built individualized plans by taking into account residents’ characteristics of health-related factors, lifestyles, and environment.
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In other words, they became front-line health practitioners who developed and operated HMPs to fit individual health problems. The Saje program may be the most successful and comprehensive model that comprised of walking events, relaxation therapy, and education for lifestyle modification including eating and harmful social habits (Kang, 2008). With the CHPs’ participation, the evaluation of the HMP indicated the CHPs delivered an effective and efficient HMP (Kang, 2008) and improved rural residents’ bio-indicators significantly (Jeong et al., 2006). At the community level, CHPs focused on specific individual health problems by building collaborative relationships with physicians (Kwon, 2003). These partnerships with doctors enable CHPs to provide higher quality medical services in addition to the roles as a gatekeeper (Kang, 2008; Park, Bang, & Hyun, 2007). Currently, the HMP is an ongoing project and is one of the major chronic disease management projects in public health. Day-care program for the elderly The Daycare Program (DCP) was the result of a joint effort by primary health care services and welfare services (Son, Moon, Park, & Lee, 2008). It was established in 2001 as a volunteer program in collaboration with the village leader. Senior residents gather to the facility and work together or participate in recreational activities. They cook and share foods with people who are not able to manage daily activities independently. Currently, the DCP is only implemented in some rural areas because it is not an official government program. However, there will be an increased need for the program because residents are living longer in disabling conditions (Jung, 2008). In fact, health policymakers began to closely monitor this program in 2013 as a way of caring for elders who have difficulties performing daily activities. However, there is no government fund available because it was started as a voluntary program. If the DCP is to be implemented nationwide as an official government program, other auxiliary services (such as pick-up services, meal support, and devices for rehabilitation etc.) will be required to make it successful. Originally, the CHP system was established to reduce inequities in health care services for underserved populations in the early 1980s. The main services of CHPs were primary medical services,
Kwak and Ko: Community Health Practitioners in Korea mother-child care, family planning, and controlling infectious diseases. Between the late 1990s and 2000s, their roles expanded considerably to preventing chronic diseases and improve health promotion. Due to their continuous adaptation to changing health climates, it has been consistently evaluated positively and earned high levels of consumer satisfaction for the health care services they provide (Kim, Yoo, Kim, Koh, & Shin, 1991). However, another metamorphosis process is needed as the CHP system is facing several new challenges. The first challenge is that Korea faces one of the most rapid population aging and unequal distribution of health services (OECD Facebook statistics, 2013). Usually as the number of elderly increases, so the number of people with chronic disabling conditions that require long-term care (LTC) services. If the CHPs’ roles and functions can be expanded for community-based LTC services, they can play an important role in allocating social resources efficiently and effectively. Second, the Korean elderly population currently has the highest suicide rate among OECD countries (Kwon, Chun, & Cho, 2009). Although the government has actively addressed this problem through various public programs, decreasing suicide rates may be difficult to achieve unless they are managed at an individual level. Currently, CHPs participate in the program as the principal front-line gatekeepers for early detection and prevention. They work as supporters, educators, and monitors through home visits, providing group education, promoting mental health, and telephone calls (Lee, 2009). The CHP system is in a unique position for managing individual needs and we are certain that they will do an exemplary job in these private matters as they have with the Family Planning Project. Lastly, traditional collaboration with neighbors has become weaker resulting in weak social safety networking systems among rural residents. The facility where CHPs work may be used as spaces for socialization to promote the Korean traditional customs, such as looking after and helping fellow citizens. We believe the CHP system is one of the most effective and sustainable public health care delivery systems in Korea. It has and will continuously adapt to meet community needs as part of a regionally accepted health care delivery system.
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Acknowledgments This study was funded by the faculty research support grant at the Hallym University.
Conflict of interest No conflict of interest has been declared by the authors.
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SPECIAL FEATURES: HEALTH POLICY
Historical Overview of Community Health Practitioners in Korea Changyeong Kwak, PhD, APRN,1 and Young Ko, PhD, RN,2 1
Department of Nursing, Hallym University, Chuncheon, Korea; and 2College of Nursing, Gachon University, Incheon, Korea
Correspondence to: Dr. Young Ko, College of Nursing, Gachon University, 191 Hambakmoeiro, Yeonsu-Gu, Incheon 406-799, Korea. E-mail: [email protected]
ABSTRACT The Korean government introduced CHPs (Community Health Practitioners) as front-line primary health care providers to address the health disparity between urban and rural areas. Through their dedicated contribution over last 30 years, the CHPs have improved Koreas public health through the successful control of high birth rates, a lowered maternal and infant mortality rate in the 1980s, eradication of parasitic infection, and containing many communicable diseases including hepatitis B. However, rapid changes in the health care environment and demands for health care among rural residents have required changes in the roles and functions of the CHPs. They are challenged by fundamental changes in the public health system addressing various health issues due to a rapidly aging society, pandemic of chronic disease, new infectious disease, and climate changes. CHPs should continuously transform their roles and functions to establish a lifelong health management system. This article presents a historical overview of the CHP system and their tasks and activities. Also, recent challenges that CHPs are facing and strategies to overcome those challenges will be discussed. This historical overview will be informative for other developing countries in resolving their own public health problems. Key words: community health nursing, nurse practitioner, primary care, public health systems, rural health.
Due to Korea’s rapid economic growth in the mid-1970s, urbanization led to a widening socioeconomic gap between the urban and rural areas. Private hospitals and health care providers were concentrated in metropolitan areas, which became one of the major causes of health disparities between urban and rural areas (Korea Institute for Health and Social Affairs [KIHASA], 1990; Moon, 1977). To address this regional inequality of health care services, the Korean government distributed Community Health Practitioners (CHPs) to rural and very remote areas to serve as front-line primary health care providers. They also managed community health problems and promoted residents’ well-being (Korean Nurses Association [KNA], 1997; Yi, 2009). Through the CHPs’ dedication and hard work, they became one of the main contributors to the successful control of high birth rates and lowered maternal mortality rates in the
1980s (Kim & Oh, 1985; Statistics Korea, 2010), as well as the eradication of parasite infections and communicable diseases such as polio in 2000, the measles in 2006, and hepatitis B in 2008 (Korea Center for Disease Control and Prevention [KCDC], 2012). Without their devotion, Korea would not have achieved such significantly improved health indicators in a short period of time. CHPs are unique among health care providers in the world because their program was launched to resolve health issues raised by rapid industrialization in Korea. The CHPs were experienced nurses who were trained to be primary health care providers and community health nurses. Therefore, as primary health care practitioners, their roles are similar to that of midlevel practitioners (MLP) in many countries, such as nurse practitioners (NPs) in United States, Canada, or Australia. However, CHPs and MLPs differ in that CHPs are not
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required to possess master’s degrees. Also, CHPs are restricted to working only with socio-economically isolated populations within designated areas. Yet, it may be safe to say that their roles are comparable because both systems have been adopted by primary health care services as substitutes for physicians to ensure a more efficient use of resources (Offredy & Townsend, 2000; Parker, Forrest, McCracken, MaRae, & Cox, in press). As a community health nurse, CHPs may also be similar to Public Health Nurses (PHNs) in Japan. CHPs and PHNs are the first line of public health administration in the community and are not required to have a master’s degree. However, PHNs differ from CHPs because of their dependency on doctors and lack of geographical limitation for their work, unlike CHPs in Korea (Yoshioka-Maeda et al., 2006). In the past, Canada used advanced practice nurses as primary care NPs, but the government allowed them to expand their roles to public health nursing in 2006. They got involved in public health areas because the government wanted to shift the emphasis of their roles from treatment to health promotion, disease prevention, and communitybased care (DiCenso et al., 2007). In this way, the roles and functions of CHPs are similar to that of the Primary NPs in Canada, yet the education and training requirements are completely different from each other. As discussed above, many countries use nurses to provide adequate access to primary health care and public health through advanced education or training. Although their roles and functions are not exactly same, it is evident that advanced practice nurses play an important role in resolving health problems in their countries. This article presents a historical overview of the CHP system in Korea. Some of challenges and strategies to overcome obstacles are also discussed. We hope this historical overview of the Korean CHP system is informative for other developing countries in resolving their own public health problems.
Research methods This study strives to historically capture the roles and functions of CHPs, and how they have been influencing the current health care services in Korea over time. Our research is mainly based on primary sources, such as published government
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documents and records, and unpublished official reports from ‘the Association of Community Health Practitioners’. We also obtained oral histories from interviews with pioneers and current leaders of CHP who provided us direct or indirect experiences with knowledge of the CHP system. The secondary resources that we used were newspapers, periodicals, journals, and other written documents. We performed our search in Korean by typing the phrases of “community health practitioners,” “primary care services,” and “public health nursing” into search engines and obtained written documents. After collecting all of the information, we organized them chronologically, and categorized each by primary care services and public health nursing. All materials were carefully reviewed and evaluated, grounded in facts and eye witnesses.
Results After reading the research material collected, 13 governmental records and documents, 4 citations, and 15 articles were chosen for the analysis. We included all governmental documents and records assuming they are objective and valid. Any confusing information or conflicted interests retrieved from newspapers or periodicals were not included in this study because they did not meet the test of internal criticism. Our narrative documents did not include any vague or uncertain opinions obtained from oral interviews. This result section categorized into background of CHP establishment, their roles and functions, and governmental programs participated. In addition, we present the legislative Chronology and governmental responses relating to the CHP system in Table 1.
Establishment of the CHP system In the early 1970s, rural residents in Korea had little access to health care services because most medical facilities were built in metropolitan areas (KIHASA, 1990). This led to an inequitable distribution of medical personnel and health care delivery system (Ministry of Health & Social Affairs [MOHS], 1981; Moon, 1977). To resolve this issue, the government announced the ‘Fourth Five-year Plan for Economic Development and Community Health Service’ by establishing a CHP-led primary health care delivery system in rural areas (Kim, Park, Jung, & Joo, 1976; KNA, 1997).
Kwak and Ko: Community Health Practitioners in Korea TABLE 1. Historical Record related to Community Health Practitioner Date 12/1956
1976 1977 1978 12/1980
6/1986
1/1988 7/1989 12/1995
Events Enactment of ‘Health Center Act’- describe the role and activities of public health nurse and public health center Pilot Project for Community Health Practitioner System Introduction of ‘Employees Medical Insurance System’ Alma Ata Declaration: primary health care approach Enactment of ‘Special Act for Healthcare in Rural Areas Act’—describe the role and activity of community health nurse practitioner as primary health care provider and public health center post Built Public Health Center Posts and arranged the Community Health Nurse Practitioners in all remote rural area Introduction of ‘Medical Insurance System for Rural Area’ Settlement of ‘National Medical Insurance System’ Enactment of ‘National Health Promotion Act’ Revocation of ‘Health Center Act and enactment of ‘Law for Community Health’—strengthen community-based health and activate health promotion
With funding from the government, the Korea Health Development Institute (KHDI) planned to train experienced nurses as primary care providers in rural areas and started a pilot project to evaluate the proposed CHP system. The initial pilot project was launched in 1976 by combining the primary health care providers’ roles with community health nursing to meet urgent health matters. The government provided additional funding to the KHDI to conduct research for further utilization of the CHP system. The required funding was supplied through a loan from the Agency for International Development. A total of 25 CHPs received the initial training program which consisted of theory education, hospital practicum, and community practicum (KHDI, 1979). After completing the training program, the CHPs were assigned to three remote mountain areas and provided primary health care for common health problems and health education. The midevaluation of the pilot project concluded
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that the CHPs efficiently carried out primary health care services (KHDI, 1979). With this positive evaluation, the Korean government decided to expand the CHP system nation-wide and enacted the legislation of the ‘Special Act for Healthcare in Rural Areas (SAHRA)’ in 1980. Also, five regulations were announced to implement SAHRA: (a) to abrogate a law for public health care aiming at giving equal medical benefits to doctor-less villages by sending doctors serving their mandatory military obligations, (b) to integrate primary health care into SAHRA for rural residents, (c) for the village head to set up and run the CHP system, (d) for the town leader to appoint a CHP among qualified nurses, (e) to allow CHPs to practice within their legal scopes (Kang, 2000; Yim, 1981).
Operating System of the CHP For the CHP workplace, the Public Health Center Posts (PHCPs) were built in convenient places for easy access and managed populations greater than 1,000 and less than 5,000. Each health center was required to have a floor space of a minimum of 66 m2 and have rooms for history taking and physical examination, medication, interventions, meetings, and other activities (MOHS, 1989). As shown in Figure 1, CHPs were to work closely with village leaders, which is one of the reasons for successful implementation. There are two resident organizations that oversee fiscal budgets and support the CHP system; the Community Steering Committee (CSC) and the Village Health Workers (VHW). The CSC consists of 20 board members including the director, associate director, and 18 steering committee members. The board members are elected by the city governor or the mayor of the town. Each elected board member monitors the fiscal budget and works collaboratively to establish comprehensive and effective community health services. The board is responsible for strategic directions and overseeing of the organization. They are also responsible for electing board members (MOHS, 1984). The VHW is a leader of the residents. One of the main roles of the VHW is mediating and connecting residents to the CHP for health-related matters. They report the number of residents, any problems of pregnant women or infants, nursing mothers to be followed up by the CHP, medical emergency situations, and any
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Figure 1. Operating System of Public Health Center Post (PHCP) environmental matters (Lee, Han, & Lee, 1993; MOHS, 1984).
CHPs’ Legal Scopes of Practice as a primary health care provider SAHRA and its amendments define the CHPs’ responsibilities, guidelines, and legal scopes (MOHS, 1981). Originally, in 1980, CHPs were permitted to prescribe 68 drugs, but the legal scopes of prescription were extended to meet residents’ needs over time. CHPs are now prescribing 104 drugs for primary medical services (Ministry of Health and Welfare [MOHW], 2002). The CHPs’ legal scopes of direct patient care are listed as follows: 1. Health history taking and physical examination 2. Basic blood tests 3. Management of common health problems and follow-up of chronic disease with dispensing of medications permitted by the law and regulations 4. Management of prenatal care, normal delivery and infant, postpartum care and women’s health, and administration of contraceptive devices (e.g., Intrauterine devices) 5. Immunizations and vaccinations 6. Environmental management and infection control 7. Emergency management and medical treatments including intravenous fluid and drugs to manage critical conditions.
CHP’s Participation in Public Health Programs Maternal and child health program The Maternal and Child Health Program (MCHP) started along with the economic development project. At the beginning stages of the program, the MCHP focused on decreasing the birth rate and improving maternal health for women of childbearing age (19–49 years) (Son, 2008). The contents of the MCHP included general health education including sex education and family planning, services for contraception, and delivery, including prenatal and postpartum care (Korea Institute for Population and Health [KIPH], 1986). The Family Planning (FP) project was administered as a socialwelfare benefit for socio-economically vulnerable populations (Son, 2008). With the government’s support, the FP project attained remarkable results, and the birth rate decreased from 6.0 in 1960 and 2.83 in 1980 to 1.08 in 2005 (Statistics Korea, 2010). The MCHP consisted of two types of health services: direct medical services and the promotion of maternal health and well-being (KIPH, 1986). For direct medical services, CHPs worked as midwives to manage normal deliveries. They also inserted intrauterine contraceptive devices at request or provided free birth control pills or condoms. To promote maternal health, they provided prenatal care, postpartum care, and health checkups for newborns. As we enter into the new decade, the CHPs’ functions in MCHP are redefined and reorganized to meet the current needs of health care services. Nowadays, many women and children in rural areas are from multicultural backgrounds (Kim, 2009; Statistics Korea, 2013). They may not be
Kwak and Ko: Community Health Practitioners in Korea accustomed to the Korean culture or experience difficulties receiving health services due to obstacles such as language barriers (Kim, Park, & Kim, 2011; Yang, 2010). To provide resident-sensitive health services, the CHPs provide customized health management services through home visits. Also CHPs connect ethnic minorities to the Multicultural-Family Support Center and Marriage Immigration Support Center. Infectious disease control project In the early 1970s to 1980s, controlling communicable diseases was one of the main concerns of health policymakers. To prevent communicable disease, CHPs conducted group education to improve the environmental hygiene status and control infectious disease. The CHPs educated the community leaders first, and encouraged the PHCP committee to start campaigns for improving environmental hygiene conditions. The education contents included drinking water management, waste disposal, removal of insect habitats, disinfection methods, and vaccinations (Kim, 2008; KIPH, 1982). If any resident was suspected of having a communicable disease, the CHP immediately reported the case to the Public Health Center. If the patient was confirmed, he/she was separated from other residents and both the patient and the people in contact with the patient were monitored. In addition, the CHP traced transmission routes to locate the source of infection (KCDC, 2006a; KIPH, 1982; Lee, 2006). One of the infectious diseases that CHPs played a key role in controlling was Tuberculosis (TB). The key component of ‘Directly Observed Treatment, Short-course (DOTs)’ may be early detection of the first case in the community. To detect a patient, CHPs informed residents in advance about the arrival of X-ray examination buses to attract more people to participate. During the free X-ray checkup, sputum samples were collected and sent to laboratories for testing. If a patient was confirmed with TB, antituberculosis medicine was dispensed with refill prescriptions obtained from the physician, followed by long periods of treatment. CHPs also provided education programs to control infection. Patients were encouraged to maintain diets that were high protein and vitamins, and family members were required to receive regular checkups (KCDC, 2006a; KIPH, 1982). With their dedicated efforts and governmental supports, the infection
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rate of Tb has decreased from 41.6% in 1980, and 27.3% in 1990 to 6.5% in 2010. Controlling Tb infection, however, should be under close attention once again because there were 39,545 new Tb cases developed in 2012 (KCDC, 2012). Nowadays, CHPs participate in the program as case managers and become part of the ‘Tb Net Working System’ which refers clients to medical providers and prevents further spreading of germs (KCDC, 2011). They also closely monitor for potential residents who are at high risk for infection. Interestingly, the treatment success rate in the public sector is much higher than that of the private sector (Kim, 2008). It is possible that CHPs have played a significant role in this as they are one of the key members of the public health system. For better and efficient management of Tb in Korea, a partnership between private and public sectors should be established, and we believe CHPs can play an important role in connecting the two parties. The Hepatitis B project was another infectious disease that has a much higher incidence rate in Korea than in any other developed country. To control Hepatitis B, CHPs performed antigen/antibody tests and liver function tests in collaboration with the Korean Association of Health Promotion (KAHP). After receiving test results, the CHPs educated carriers and infected patients to control transmission routes. The CHPs administered vaccinations to noninfected residents (Kim, 2008; KIPH, 1982). In 2008, Korea received a certification from the World Health Organization for successful Hepatitis B management (Cho, 2008). In the 1980s, the CHPs focused on controlling communicable diseases, environmental management, and administering immunizations for TB, Epidemic Hemorrhagic Fever, hepatitis B, and other water-borne diseases (Kim, 2008). After the successful management of these infectious diseases, CHPs now focus on the prevention of influenza or pneumonia in elderly citizens. The contents of health education have also been changed from prevention of spreading germs to promoting healthy lifestyles. Anti-parasite project The Anti-Parasite Project (APP) was one of the major government health projects in the 1970s which focused on improving living conditions and environment in Korea
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through a 5-year economic development plan. In the 1960s, Korea was considered an under-developed country. Many people could not afford shoes or laundry detergent. There were no established sewage systems, and people were using human feces for fertilization because there were no chemical fertilizers. Due to this low socio-economic environment, most people had at least one or more parasite infection. To control parasite infection, CHPs collaborated with a team from the Korean Association for Parasite Eradication. They also educated community residents to end the vicious cycle of transmission and provided antiparasite medications. By 1997, the APP was discontinued because the infection rate had decreased to less than 0.1%, and investigators were certain that there was no possibility for another breakout (Hong et al., 2006). Despite the evident progress, however, the Anti-Liver Fluke Project (ALFP) was established because there was a high risk of liver fluke infection around five river areas. Liver fluke is the most common food-borne parasitic disease in Korea which is transmitted through eating raw fresh-water fish. The ALFP was carried out centering on regional public health centers where liver fluke was rampant (KCDC, 2006b). CHPs advertised the project and provided group education to teach residents how to prevent infection and avoid eating raw fish caught from the river. CHPs also conducted screening tests and dispensed medication to egg-positive patients (Park, 2008). An epidemiologic study showed that the helminth egg-positive rate had decreased from 12.4% to 7.0% in 2009 (Hong et al., 2006), and the ALFP will continue until the infection rate is reduced to 1%. Hypertension management project Korea undertook the enactment of the National Health Promotion Act in 1995, which was a milestone for initiating a national and local health promotion program in Korea (Nam, 2011). Under this act, CHPs participated in various public health education programs for health promotion and Hypertension Management Program (HMP) may be the most successful program. The HMP was implemented at an individual and community level. At the individual level, they built individualized plans by taking into account residents’ characteristics of health-related factors, lifestyles, and environment.
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In other words, they became front-line health practitioners who developed and operated HMPs to fit individual health problems. The Saje program may be the most successful and comprehensive model that comprised of walking events, relaxation therapy, and education for lifestyle modification including eating and harmful social habits (Kang, 2008). With the CHPs’ participation, the evaluation of the HMP indicated the CHPs delivered an effective and efficient HMP (Kang, 2008) and improved rural residents’ bio-indicators significantly (Jeong et al., 2006). At the community level, CHPs focused on specific individual health problems by building collaborative relationships with physicians (Kwon, 2003). These partnerships with doctors enable CHPs to provide higher quality medical services in addition to the roles as a gatekeeper (Kang, 2008; Park, Bang, & Hyun, 2007). Currently, the HMP is an ongoing project and is one of the major chronic disease management projects in public health. Day-care program for the elderly The Daycare Program (DCP) was the result of a joint effort by primary health care services and welfare services (Son, Moon, Park, & Lee, 2008). It was established in 2001 as a volunteer program in collaboration with the village leader. Senior residents gather to the facility and work together or participate in recreational activities. They cook and share foods with people who are not able to manage daily activities independently. Currently, the DCP is only implemented in some rural areas because it is not an official government program. However, there will be an increased need for the program because residents are living longer in disabling conditions (Jung, 2008). In fact, health policymakers began to closely monitor this program in 2013 as a way of caring for elders who have difficulties performing daily activities. However, there is no government fund available because it was started as a voluntary program. If the DCP is to be implemented nationwide as an official government program, other auxiliary services (such as pick-up services, meal support, and devices for rehabilitation etc.) will be required to make it successful. Originally, the CHP system was established to reduce inequities in health care services for underserved populations in the early 1980s. The main services of CHPs were primary medical services,
Kwak and Ko: Community Health Practitioners in Korea mother-child care, family planning, and controlling infectious diseases. Between the late 1990s and 2000s, their roles expanded considerably to preventing chronic diseases and improve health promotion. Due to their continuous adaptation to changing health climates, it has been consistently evaluated positively and earned high levels of consumer satisfaction for the health care services they provide (Kim, Yoo, Kim, Koh, & Shin, 1991). However, another metamorphosis process is needed as the CHP system is facing several new challenges. The first challenge is that Korea faces one of the most rapid population aging and unequal distribution of health services (OECD Facebook statistics, 2013). Usually as the number of elderly increases, so the number of people with chronic disabling conditions that require long-term care (LTC) services. If the CHPs’ roles and functions can be expanded for community-based LTC services, they can play an important role in allocating social resources efficiently and effectively. Second, the Korean elderly population currently has the highest suicide rate among OECD countries (Kwon, Chun, & Cho, 2009). Although the government has actively addressed this problem through various public programs, decreasing suicide rates may be difficult to achieve unless they are managed at an individual level. Currently, CHPs participate in the program as the principal front-line gatekeepers for early detection and prevention. They work as supporters, educators, and monitors through home visits, providing group education, promoting mental health, and telephone calls (Lee, 2009). The CHP system is in a unique position for managing individual needs and we are certain that they will do an exemplary job in these private matters as they have with the Family Planning Project. Lastly, traditional collaboration with neighbors has become weaker resulting in weak social safety networking systems among rural residents. The facility where CHPs work may be used as spaces for socialization to promote the Korean traditional customs, such as looking after and helping fellow citizens. We believe the CHP system is one of the most effective and sustainable public health care delivery systems in Korea. It has and will continuously adapt to meet community needs as part of a regionally accepted health care delivery system.
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Acknowledgments This study was funded by the faculty research support grant at the Hallym University.
Conflict of interest No conflict of interest has been declared by the authors.
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