Authors: Wan Ho Kim, MD, PhD Yoon Ghil Park, MD, PhD Hyung-Ik Shin, MD, PhD Sang Hee Im, MD, PhD

Health Policy

Affiliations: From the Department of Public Rehabilitation Service, National Rehabilitation Center, Seoul, South Korea (WHK); Department of Rehabilitation Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea (YGP); Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea (H-IS); and Department of Rehabilitation Medicine, Kwandong University College of Medicine, Gangneung, South Korea (SHI).

ANALYSIS

The World Report on Disability and Recent Developments in South Korea ABSTRACT

Correspondence: All correspondence and requests for reprints should be addressed to: Yoon Ghil Park, Department of Rehabilitation Medicine and the Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, 712 Enojuro, Ganam-gu, Seoul 135-720, South Korea.

Disclosures: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

0894-9115/14/9301(Suppl)-S58/0 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000024

Kim WH, Park YG, Shin H-I, Im SH: The World Report on Disability and recent developments in South Korea. Am J Phys Med Rehabil 2014;93:S58YS62. The latest National Survey on Persons with Disabilities estimated 2,683,400 persons with disabilities in South Korea, of whom 58% were men and 42% were women. People with physical disability represent approximately 50% of the entire population with disability. Disability-related policies and services to improve the participation of persons with disabilities have been expanded in the last decades, guided by 5-yr plans. The number of physiatrists has increased, although it still varies significantly by location. As part of the comprehensive measures to expand rehabilitation services, several regional rehabilitation centers have been established. In addition, a community-based rehabilitation program has been implemented that comprises Strong Point Public Health Centers, which provide local health promotion programs for persons with disabilities, family support programs, and community participation programs. As the aged population increases, it is predicted that the population of persons with disabilities in South Korea will also increase. A long-term and innovative financial model will be required to meet the corresponding needs. A recent milestone of evidence-based practice is the publication of Clinical Practice Guideline for Stroke Rehabilitation in Korea. Key Words:

Rehabilitation, Persons with Disability, Epidemiology, Policy

I

n South Korea, the most recent disability-related data are available from the latest National Survey on Persons with Disabilities conducted in 2011.1 The survey estimated 2,683,400 persons with disabilities nationwide. The prevalence of persons with disability was 5.6%, indicating an increase by 1 point in comparison with 2005, of whom 58% were men and 42% were women. The percentage of persons with disabilities residing in the community was 97.3%. Among 15 different disability types, 1,303,032 persons had physical disability, representing approximately 50% of the entire population with disability, followed by brain lesions, visual impairments, and hearing impairments. A total of 38.8% of the persons with disability were 65 yrs or older and 32.1% of those people were between the ages of 50 and 64 yrs. The high percentage of older people with disabilities also reflects that the society is gradually aging.

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Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1 (Suppl), January 2014 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

BURDEN OF DISABILITY A total of 55.1% of the disabilities are postnatal, and 35.4% are caused by accidents. A total of 72.4% of the persons with disabilities received regular medical examinations for the purpose of rehabilitation and health management within the past year, and 70.4% of them had received health examination within the last 2 yrs. Chronic diseases affected persons with disabilities; the highest prevalence was hypertension (33.5%), followed by arthritis (10.3%) and diabetes (8.9%). A total of 13.9% of the population with disability needed help from others. The people who provided such help for daily life were mostly family members (84.2%) such as the spouse or the parents. The utilization of personal assistants and caregivers had increased up to 10.8%; more than three times the utilization rate reported 3 yrs ago, probably as the result of the expanded implementation of the Personal Assistance Service for Persons with Disabilities since 2011. The monthly average income level of the household with persons with disabilities was approximately US $1,780 (2,000,000 Korean won), which was 53.4% of the national monthly average income level per household. The monthly average expenditure of the household with persons with disabilities was US $1,460 (1,620,000 Korean won), which was 54% of the national monthly average household expenditure. The rate of persons with disabilities who had spent additional disability-based expenses in the past year was 72%, and their monthly average additional expenditure was US $150 (167,000 Korean won). Thereby, medical expenses took up the highest proportion with US $51 (56,800 Korean won) per month. The rate of International Labour Organization (ILO) standardsYapplied economic activity used by the Korea National Statistical Office was 38.5%. The unemployment rate of 7.8% was twice higher than the total unemployment rate of 3.2%. The wage level of employed persons with disabilities was US $1,280 (1,420,000 Korean won), which was only 54.6% of the average national wage (US $2,340 or 2,600,000 Korean won).

WHAT HAS BEEN DONE? Policies and Legislation Policies concerning disabilities and rehabilitation in Korea have been developed and expanded in the last decades to improve the participation of persons with disabilities. This includes the expansion of convenient facilities for people with disability, the introduction of the Disability Support Pension, as www.ajpmr.com

well as the legislation and implementation of the personal assistance support program.2 For this purpose, a 5-yr plan program for the Promotion of the Welfare of Disabled People was established, which covers the welfare services for persons with disabilities. The first 5-yr plan was effective between 1998 and 2002. The second 5-yr plan was promoted from 2003 until 2007, aiming at the BRealization of an Inclusive Society with Participation of the People with Disabilities as Equal Citizens.[ The second 5-yr plan therefore stimulated, among others, the development and provision of life stageYspecialized welfare services, the expansion of inclusive education through sharing the accountabilities for general education and special education, and the employment of persons with disabilities. The third 5-yr plan was implemented from 2008 until 2012, and its objectives were, first, the implementation of an inclusive society; second, an active welfare policy promotion through job creation and proactive investment; and third, the establishment of a consumer-oriented welfare system and restructuring of the delivery system.3 Disability concepts and categories being applied in this country were changed into the direction of the international trend. In 2000, brain lesions; autism; as well as hearing, visual, and intellectual impairments were added to the existing concept of impairment that used to be restricted to physical, hearing, language, visual, and intellectual impairments. In 2003, facial deformations, ostomy, impairments of liver, epilepsy, and impairments of the respiratory system were included in the category of impairment. There are also services for elderly people needing assistance in everyday life. In 2012, caregivers offered assistance to approximately 320,000 beneficiaries. Persons with disabilities can also use the activity assistance services according to the Act on Welfare of Persons with Disabilities before the age of 65 yrs. After the age of 65 yrs, they can change to the assistance by the Act on Long Term Care Insurance for the Elderly.4

Funding Mechanisms in Rehabilitation The current status of medical security for persons with disabilities shows that the entire population of persons with disabilities either subscribes to the National Health Insurance or received the Medicaid benefits according to the National Disability Survey of 2011.5 The total expenditure by the National Health Insurance for physiotherapy and occupational therapy was approximately US $765 million (880 billion Recent Developments in South Korea

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Korean won) according to the 2010 data. Approximately US $340 million (390 billion Korean won) of the total was spent on heat therapies for pain and the use of percutaneous electrical treatment. Only approximately US $426 million (490 billion Korean won) was considered as expense for minimization of disability after the onset of acquired disability or specialized rehabilitation therapy for congenital disability.4 Assistive devices are indispensable for rehabilitative therapy for persons with disabilities. In the past, these were excluded from the health insurance benefits. However, those devices directly related to the medical care were included in the first 5-yr plan for the Promotion of the Welfare of Disabled People of 1999. The total expenditure of public funds for assistive devices as a rehabilitation benefit was estimated to be approximately US $46.7 million (51.7 billion Korean won) in 2011. Medical expenses are also paid for persons eligible for assistance from the National Basic Living Security Act, nearly US $8 million (9 billion Korean won) for approximately 230,000 cases as of 2007. To assist persons with hearing impairment, cochlear implants were included in the National Health Insurance benefits starting in 2005. This has reduced the burden of medical expenses not only for children younger than 10 yrs but also for patients with severe hearing loss and deafness. The Ministry of Employment and Labor directly operates 7 hospitals for rehabilitative therapy after industrial injuries and also selected 30 private rehabilitation hospitals in 2012, where return-to-work rehabilitation programs are being implemented.

therapists currently registered are 38,247 and 5,390, respectively.7 On the basis of the Act on Welfare of Persons with Disabilities of 2000, the qualification system of assistive devices (orthotics/prosthetics) technicians was established to prepare a systematic foundation for manufacture and supply of good-quality orthotics and prosthetics. At the end of 2009, a total of 800 technicians had been trained, and the training course had been established at five universities including the Korea National College of Welfare. On the other hand, speech-language therapists and audiologists were privately certified until 2012, when a certification system for the speech-language rehabilitation counselors was implemented on the basis of the same act. The number of speech-language therapists was 5288 at the end of June 2010, whereas the number of audiologists was approximately 600. In addition, as of the end of December 2010, the Korea Blind Union had presented the national certification of Braille translator/proofreader to 407 professionals. The sign language interpreters have been educated by organizations related to the persons with hearing disabilities and also certified by the national group starting in February 2006; as of the end of December 2010, a total of 913 sign language interpreters had been certified. The number of social workers in medical institutions was 1882 in 2009; 80% of them are working in hospitals or higher-level institutions. This means that many social workers are working in institutions providing rehabilitation medicine services.

Service Delivery Human Resources The Korean Board of Rehabilitation Medicine Examination was established in 1983. The number of physiatrists taking the examination has increased each year. In 2012, a total of 1520 specialists were practicing the specialty, representing 1.8% of the total number of medical specialists. The geographical distribution of physiatrists shows significant variability, and most of them are in the capital city.6 In addition to medical doctors, those associated with rehabilitation medicine include physiotherapists, occupational therapists, prosthetics/orthotics technicians, speech-language therapists, audiologists, Braille translators/proofreaders, and sign language interpreters. Among them, physiotherapists and occupational therapists are the only job types for which the state manages certifications and licenses. As of 2010, the numbers of physiotherapists and occupational

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The medical institutions providing rehabilitation medicine services include specialized medical institutions and general hospitals where the department of rehabilitation medicine is organized. Services are also provided in hospital-based clinics specialized in rehabilitation medicine. The number of medical institutions in which a department of rehabilitation medicine has been established is 1273, including 159 tertiary hospitals, 202 general hospitals, 257 hospitals, 250 nursing care hospitals, and 359 clinics where the specialists in rehabilitation medicine are on duty. These numbers represent less than 15% of all the medical institutions in the country.8 The National Rehabilitation Center, which is the only national central rehabilitation institute in South Korea, is specialized in the rehabilitation of spinal cord injury, musculoskeletal conditions, stroke, brain injury, children with disabilities, auditory rehabilitation, and low vision rehabilitation. The center

Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1 (Suppl), January 2014

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

operates 300 beds and includes the National Rehabilitation Research Institute, where research is conducted on topics such as assistive technology, motor and cognitive functional rehabilitation, and rehabilitation policy. The community rehabilitation hospital clinics are medical institutions supported by the government for expansion/renovation and the purchase of medical rehabilitation equipment. Currently, there are 17 medical rehabilitation facilities annexed to nonprofit foundations such as social welfare foundations in 13 cities. As a part of the comprehensive measures to expand public healthcare services suggested in 2005, regional rehabilitation hospitals were proposed for six areas nationwide. Three were opened as of 2012 and are providing comprehensive and sustainable good-quality rehabilitation medical care services. In addition, the Ministry of Health and Welfare began implementing a system to designate private rehabilitation medicine specialized hospitals when these have met certain evaluation standards. Since 2011, ten hospitals have been certified.9 Community-based rehabilitation has been promoted by private hospitals at first, but in 1993, the National Rehabilitation Center began its educational program for community-based rehabilitation administrators of the community and the communitybased rehabilitation administrators of the local selfgovernment. Since 2000, it has been promoting the program by designating the Strong Point Public Health Centers. As of 2012, a total of 60 localities are in the implementation phase, and the number of persons with disabilities supported by the Strong Point Public Health Centers corresponds to approximately 5% of the total number of persons with disabilities in the country. These Strong Point Public Health Centers are implementing rehabilitation programs such as the health promotion program for persons with disabilities, the family support program, and the community participation program.10,11 In South Korea, the number of institutions providing rehabilitation therapy and the number of beds needed have increased. However, the responsibilities of different medical institutions are not clear, and the standards of treatment are unsatisfactory, resulting in ineffective use of medical resources and unequal geographical distribution. Because of such issues, the length of stay and the medical expenses have increased. To correct such problems, the delivery system of rehabilitation medicine services should be constructed as a continuum that can refer the persons with disabilities and their families to the optimal service at the appropriate time. www.ajpmr.com

Research for the development of clinical practice guidelines for stroke rehabilitation has been implemented as collaboration between the Departments of Neurology, Neurosurgery, and Rehabilitation Medicine with the assistance of the Ministry of Health and Welfare. As a result, the Clinical Practice Guideline for Stroke Rehabilitation in Korea was published in 2009.

Affordable Technology To improve daily living capacity of low-income persons with disabilities, the government has provided assistive devices such as orthotics/prosthetics and wheelchairs since 1980. Moreover, in 1997, the government included assistive devices in the health insurance benefits and gradually expanded its implementation. The rehabilitation assistive devices provision project for persons with disabilities included household goods that promote the convenience of everyday life (television subtitle receivers, audio wristwatch) and prosthesis not covered by the insurance benefits (bedsore prevention mat, orthopedic shoes) since 1999. During the last few years, other devices have been added to the list including remote control for acoustic signals, audible desktop watches, portable wireless beacon, and adaptive seating devices. Regarding the types of assistive devices owned by persons with physical disabilities and brain lesions, the most frequent device was the cane (22.3%). Power wheelchairs, scooters, and orthopedic shoes were owned by 6.9%, 5.3%, and 2.9%, respectively. The use of these three items has increased. Regarding the types of assistive devices for the persons with visual disabilities, 50.2% owned eyeglasses, and of those with auditory disabilities, 74.3% owned hearing aids. Persons with linguistic disabilities were using the artificial larynx. Many with kidney disabilities were using a peritoneal dialysis system, those with respiratory disabilities use the oxygen generator, and those with stoma or urinary fistula disabilities were mainly using ostomy bags. The regulations concerning the Designation of Rehabilitation Assistive Devices for the Disabled were enacted in September 2002. The objectives of these regulations are to expand the diffusion of the rehabilitation assistive devices and to improve quality in accordance with the first 5-yr plan. The same regulations established a uniformed classification system for the types and the names of rehabilitation assistive devices by designating 231 types of rehabilitation assistive devices. In accordance with the second 5-yr plan, the regulations concerning the Designation of Recent Developments in South Korea

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Assistive Devices for the Disabled were revised to conform with the ISO 9999 system now establishing standards and specifications for 316 kinds of rehabilitation assistive devices. In 2009, the BRehabilitation Assistive Devices for the Disabled Infrastructure Construction Project[ was implemented to study the industrialization and legal system of rehabilitation assistive devices for persons with disabilities, and currently, the case management project is being promoted in six areas nationwide.12

tion institutions should develop and offer health examinations as well as health promotion programs for various types of disabilities. For more effective prevention programs, it will be necessary to establish comprehensive disability prevention programs or centers. Last but not least, because people with disabilities live their whole life with basic healthcare needs, the construction of a continuous and linked rehabilitation medicine delivery system is a primary goal for the maintenance of health and the rehabilitation of persons with disabilities.

CONCLUSIONS With the aging of the population, it is projected that the number of persons with disabilities in Korea will continue to increase. Accordingly, the cost of medical care will also increase. To be prepared for this challenge, a long-term innovative financing plan will be required. For an effective and efficient provision of rehabilitation medical services, a local-level consultation group shall be required that can coordinate several services concurrently for service transfer to the community after an acute period of rehabilitative therapy. In addition, it will be necessary to develop a network including the tertiary hospitals and general hospitals where the acute treatment is provided, the National Rehabilitation Center and Regional Rehabilitation Centers where comprehensive rehabilitation services are provided, private rehabilitation hospitals that provide inpatient rehabilitation services, and the community-based rehabilitation program of public health centers. Quality improvement should be promoted by introducing the certification system of rehabilitation hospitals. This will help avoid unnecessary readmissions and support the ultimate goal of returning the individuals to society and inclusiveness. In the long-term, the inclusion of general medicine services for persons with disabilities should be considered and a continuous follow-up system should be established through professional and continuous rehabilitation at the local level. The construction of a remote rehabilitation service system using advanced information technology will be beneficial for effective rehabilitation services for persons with disabilities with limited mobility. As the population of persons with disabilities will increase, it is anticipated that the need for health care in the community will also increase. Therefore, rehabilita-

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REFERENCES 1. Korea Institute for Health and Social Affairs: 2011 National Disability Survey. 2012, pp. 109Y279 2. Korea Ministry of Government Legislation: Pension for Persons with Disabilities Act. Available at: http:// www.law.go.kr/lsInfoP.do?lsiSeq=114802#0000. Accessed April 2012 3. Seoul, Korea Ministry of Health and Welfare: 3rd Five-Year Plan Program for the Promotion of the Welfare of Disabled People. 2012, pp 3Y72 4. Long Term Care Insurance: Available at: http://www. longtermcare.or.kr/portal/longtermcare/main.jsp. Accessed April 2012 5. National Health Insurance Service. Available at http:// www.nhis.or.kr/static/html/wbd/g/a/wbdga0302.html. Accessed April 2012 6. Seoul, Health Insurance Review and Assessment Service: Statistics of Healthcare Organization to National Health Insurance Program. 2012, pp. 13Y14 7. Seoul, Korea Ministry of Health and Welfare: 2010 White Paper of Health and Welfare. 2011, pp. 46Y117 8. Seoul, Korea Institute for Health and Social Affairs: 2011 National Medical Care Resources and Utilization Survey. 2011, pp. 77Y107 9. Seoul, Ministry of Health and Welfare: Year Book. 2011, pp. 146Y7 10. Seoul, National Rehabilitation Center: Community Based Rehabilitation Guideline. 2013, pp. 53Y68 11. Korea Ministry of Health and Welfare: 2013 Community Integrated Health Promotion Program Guideline. 2013, pp. 105Y6 12. Korea Assistive Technology Center: Rehabilitation Assistive Devices for the Disabled Infrastructure Construction Project. Available at: http://knat.go.kr/wordpress/ archives/163. Accessed April, 2012

Am. J. Phys. Med. Rehabil. & Vol. 93, No. 1 (Suppl), January 2014

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

The World Report on Disability and recent developments in South Korea.

The latest National Survey on Persons with Disabilities estimated 2,683,400 persons with disabilities in South Korea, of whom 58% were men and 42% wer...
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