The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.     

Political Feasibility Analysis of the New Financing Scheme for the National Health Insurance Reform in Taiwan: An Application of Stakeholder Analysis

This study carries out in‐depth political feasibility analysis of the prospective health financing reform currently taking place in Taiwan. The National Health Insurance (NHI) Program, which was established in Taiwan in 1995, covers virtually all of the island's citizens. Between the years 2001 and 2004, the Taiwanese Government organized a taskforce to carry out the wholesale reform of the NHI program into the so‐called ‘Second Generation NHI Program’. This study is part of the comprehensive review, focusing on the preferences and positions of key policy stakeholders with regard to the financial reform proposals, as well as their network relationships. The approach of stakeholder analysis was employed to conduct this empirical study. The results reveal that the new financing scheme has a certain degree of support from the policy stakeholders participating in this study, and that in particular, the measures concerning equity and sustainability were most welcome. However, controversy remains with regard to the issue of the equitable sharing of contributions. It is clear that there is much strong support for the new scheme amongst the administrative and legislative elite, although the same level of support is not evident amongst the social elite affiliated with employees' associations and welfare groups.     

Familialisation Effects of the State Welfare: Focused on the National Health Insurances in S. Korea and Taiwan

The national health insurances in Korea and Taiwan have maintained the dependent system that includes the insureds and their families. These two cases explicitly exemplify the familialism in East Asian welfare regime. However, comparing the two systems in detail, we can easily note the variation in their familialisation effects despite similar family realities in the two societies. To explain why Korea and Taiwan adopted the NHI of different institutional arrangements, this article focuses on the historical combination of the state's political and fiscal concerns and families' rational choice, which led to the variation in family policy.     

Health Policy in the Asian NIEs

This paper compares the health policies of Hong Kong, South Korea, Singapore and Taiwan with the purpose of drawing policy lessons. The study finds two distinct policy clusters: Hong Kong and Singapore on the one hand, and Korea and Taiwan on the other. With respect to provision of health care, the former rely largely on public hospitals for delivering inpatient care while the latter rely on private hospitals. In matters of financing, they are similar in that out‐of‐pocket is a major source of financing in all four countries. However, they are also different because Korea and Taiwan have universal health insurance while the city states do not. The study concludes that public provision of hospital care, as in Hong Kong and Singapore, yields more favourable outcomes than many mainstream economists would have us believe. Conversely, private provision in combination with social insurance, as found in Korea and Taiwan, severely undermines efforts to contain health care costs.     

Social enterprise policy design: Constructing social enterprise in the UK and Korea

Taking the elusive definition of social enterprise as its starting point, this study seeks to understand the impact of government policies on the development of social enterprises in the national contexts of the UK and South Korea. The social construction of target populations is utilised as a theoretical framework in order to identify which factors influence government policy. A comparison of the two countries over a 14‐year period from 1997 to 2010 reveals that, despite very different contexts, governments in both countries have taken an instrumental approach to social enterprise. This tendency is more pronounced in Korea however, where government has limited the input of stakeholders and used an approval system to control access to the social enterprise name. The study concludes by recommending a more value‐oriented approach to social enterprise.     

Exploring the endogenous governance model for alleviating food insecurity: Comparative analysis of food bank systems in Korea and the USA

Food security is one of the dimensions in reducing poverty. Food bank governance is a key system for increasing food security. Even if thousands of food banks operate around the world by importing the standard US model, a universal standard of governance cannot always be applied to all countries, because actors, networks, and institutions embedded in unique social, economic, cultural, and political contexts retain endogenous properties. Hence, the governance model must reflect the endogeneity each society has. This article aims to theoretically suggest the endogenous governance model and to empirically demonstrate the validity of this model by comparing the governance of food banks in the USA and Korea. Although Korea introduced the US food bank model, the Korean model has been adapted and changed, evolving its own system. To find the difference in endogenous food bank governance between the two countries, we compared the variety of governance models, the institutional context, mode of network, actors' attributes, and time perspective.     

民国时期广州药物规管政策变迁(1921—1936)

药品规管是现代各国治理的核心问题。随着广州市政厅在1921年成立,药品问题也被列入当地卫生部门的一个政策议程。为什么具有现代思维的规管者要强加规范原来没有规制传统的广州药品市场,又如何规范?本文以一个历史研究者的角度从21世纪初回望国民政府的各种措施在多大程度上可算是失去的选项?并尝试追溯广州药品规管的政策过程,考察卫生部门试图建立官僚自主性的意志及其限制。     

Involvement of Ministries of Health in Health Service Coverage Decisions: Is England an Aberrant Case?

This article examines the involvement of ministries of health in making health service coverage decisions in Denmark, England, France and Germany. The study aims to inform debate in England about the feasibility of reducing perceived ministerial and bureaucratic ‘interference’ in decisions affecting the National Health Service, based on interviews with senior government officials and other health system stakeholders. Ministries of health differ in their involvement in health system governance and coverage decisions (‘the benefits package’), reflecting differences in institutional arrangements. In all four countries, organizations at arm's length or independent from government are either involved in providing technical advice to the ministry of health or have been mandated to take these decisions themselves. However, ministries of health occasionally intervene in the decision‐making process or ignore the advice of these organizations. The Department of Health in England is not an aberrant case, at least in relation to coverage decisions. Indeed, ministries of health in Denmark and France play a larger role in making these decisions. Public pressure, often amplified by the media, is a shared reason for ministerial and ministry involvement in all four countries. This dynamic may thus limit the feasibility of attempts to further separate the NHS from both the Department of Health and wider political pressures.     

Policy Changes in Community Mental Health: Interventions and Strategies Used in Sweden over 20 Years

The deinstitutionalization of mental health care has changed the responsibilities of involved authorities and has led to a continuous need for new treatment forms and interventions. This article describes this development in Europe, and in particular how these new conditions have been handled in Sweden over the past 20 years at the level of governmental policy‐making. Three major policy documents from 1994, 2009 and 2012 were included in this study. To increase our understanding of the policies' contents, we have used theoretical concepts concerning governance, implementation and political risk management. Although our main interest was to find out how the government handles interventions for users of the mental health care system, we found that the policy work is progressing stepwise. The first document, from the deinstitutionalization era, did not discuss interventions clearly. Instead, it was mainly concerned with both practical and economical areas of responsibility. The second document, from the post‐deinstitutionalization era, was more focused on what services should be delivered to the users, while the most recently published document to a greater extent addressed the question of how the support is supposed to be designed. The trend in European community mental health policy has been to advocate services in open forms that are integrated into the society's other care systems. This is also the case in Sweden, and continuous work is being done by the government to find strategies to support the development, and to meet the needs at both political and local levels.     

Lighting up communities: the worship streetlamp project in Luodong Township

To improve the performance of local streetlamp maintenance and management under the effects of the regional economic recession following the 1997 Asian financial crisis, the Luodong (Yilan County, Taiwan) Township Office implemented a streetlamp sponsorship project in 2010 which combining streetlamp sponsorship and the installation of worship lamps at local religious organizations. With successful promotion and marketing strategies, many local residents and merchandisers participated in the project. This study analysed the project to investigate how a Taiwanese local government office employs innovative public policies to strengthen its governance. In-depth interviews with critical policy stakeholders and geographic information system-based spatial analysis was employed as the main methods. Several suggestions are offered in the conclusion of this study.     

Strategic Government Spending in South Korea and Taiwan: Lessons for Emergent Democracies*

Objectives. How is government spending used strategically in South Korea and Taiwan? As nations generally considered to have weathered democratization, government allocations in South Korea and Taiwan are instructive on how spending may be used strategically without undermining democratization. Methods. The similar sociocultural, historical, political, and economic experiences of the two nations underlie a most‐similar‐systems approach to study how their differences influence diversity in strategic spending and, correspondingly, political outcomes such as size of the government party in the legislature. This article evaluates defense and civilian expenditures for South Korea and Taiwan from 1975 to 2006. Results. Three results are interesting. First, different elections—legislative elections in South Korea, presidential elections in Taiwan—lead to increases in spending. Second, in both nations, defense spending increases in election years but not social spending; however, defense spending benefits the government‐party in the legislature in South Korea but not in Taiwan. Third, when the strategic uses of spending are accounted for, democratization does not directly affect allocations. Conclusions. These results explicate that government spending is a viable resource for party building in new democracies; however, the results also underscore that governing parties in new democracies benefit from spending only insofar as it is used to build the nation's or party's strengths—not undermine the opposition—under competitive elections.     

Diverging Paths? A Comparative Look at Childcare Policies in Japan,South Korea and Taiwan

This article compares state policies to support childcare in Japan, South Korea and Taiwan, using fuzzy set ideal type analysis to determine the nature of institutional arrangements with respect to labour, money and time provisions. We then note their implications for familialization and defamilialization in the three countries. Our analysis suggests a common pattern towards the increased use of financial support amongst the three countries over time; however, this commonality does not mean their childcare policies are converging, as the financial supports differ in focus, with Japan concentrating on familialization by valuing family care, and Korea exclusively employing policy to facilitate the use of market‐based care services. For its part, Taiwan has been strengthening familialization by increasing the leave compensation to value time off to provide care. The different labour, money and time dimensions vis‐à‐vis the familialization/defamilialization matrix suggest varying implications of institutional arrangements for gender.     

Economic crisis and social policy reform in Korea

The economic crisis that broke out in Korea in December 1997 has had a chilling impact on social development in the country. Today unemployment is the highest that Korea has experienced in the past thirty years. This paper aims to examine the impact of the economic crisis on social development and the role of public policy to mitigate the problems caused by the crisis. The economic crisis has hit vulnerable groups harder, increased the proportion of part-time and daily workers, and reversed the trend of steady improvement of income distribution. The economic crisis along with the trend of aging population, globalization, and competition calls for an expanded role of social policy, which the Korean government has neglected for a long time. The main targets of social policy reform in Korea include the expansion of government programs and safety nets for the unemployed and redesigning the national pension and health insurance scheme to provide adequate income security as well as to improve the system sustainability.     

From Successful Family Planning to the Lowest of Low Fertility Levels: Taiwan's Dilemma

Since the implementation of family planning in the 1960s, Taiwan's fertility rate has rapidly decreased. This was praised as a family planning achievement. However, in the 21st century Taiwan has become one of the lowest of low fertility countries like European countries [ Kohler, H. P., Billari, F. C., & Ortega, J. A. (2002) . Population and Development Review , 28 (4), 641–80]. The government has begun to worry that these extremely low birthrates will result in rapid population aging and bring about other negative socio-economic effects. Thus, in its Mega Warmth Social Welfare Program (MWSWP) of 2006, the Taiwanese government targeted the issue of low birthrates. Based on secondary data analysis, we found that the reasons for rapid decrease in Taiwanese birthrates are: (i) a declining marriage rate; (ii) later marriage; (iii) changing attitudes towards child bearing; (iv) the burdens of child care; and (v) an increase in female labour participation rates. The MWSWP includes maternity leave benefits, parental leave benefits, a childcare subsidy system and early children education and care (ECEC). First, this article presents a chronological understanding of the demography in Taiwan. Second, we attempt to evaluate the reasons contributing to the low birthrates. The policy response to this is discussed next. Finally, the article provides a careful conclusion: that the extent to which these policies can significantly stop the population from declining requires further observation.     

Balancing Efficiency and Legitimacy: Institutional Changes and Rural Health Organization in China

The aim of this article is to contribute to the understanding of the institutional arrangements within which China's rural health facilities are embedded and of the contribution of policy to the creation of these arrangements. Information collected through field observations and in‐depth interviews with the managers, staff and patients of a township health centre indicates that with the gradual evolution of markets, encouraged by state policies, health care in rural China took on more of the characteristics of a commodity. In order to adapt to this change, the health centre and its employees are adjusting their behavioural norms and reconstructing an institutional network within which daily activities of simultaneously fulfilling public health responsibilities and pursuing economic gain are legitimized. This article focuses on the interwoven relationship between politics and markets at the micro level and examines the negotiations between stakeholders in constructing new institutional arrangements. It also describes how health sector managers are creating regulations to influence the performance of their facility. The article argues that while government policies play a crucial role in shaping the direction of development, institutional arrangements strongly influence the attempts by rural health organizations to implement them. It concludes that it is critical to take institutional factors into account in analyzing China's rural health‐care reforms.     

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.     

Social health protection in Cambodia: Challenges of policy design and implementation

The Government of Cambodia is implementing ambitious reform initiatives to improve the country's social health protection system. In January 2018, it was announced that the Health Equity Fund (HEF), which is fully subsidized by a joint government‐donor initiative for the reimbursement of user fees for the poor at public health facilities, is to be expanded to some segments of informal workers belonging to associations, as well as to commune and village chiefs. Since 2017, the National Social Security Fund (NSSF) has provided social health insurance for formal economy workers in enterprises with eight employees or more. In January 2018, it was expanded to civil servants and all employees regardless of the size of the enterprise. However, this article highlights that the new ambitious reforms are not accompanied by careful planning as regards funding, service delivery, human resources and institutional design. This article therefore aims to examine key policy issues and challenges for Cambodia's ambitious reform of its social health protection system in terms of resource generation, population coverage, strategic purchasing and governance.     

Development strategy in Korea reexamined: an interventionist perspective

This article reexamines the controversial issue of development strategy in Korea. Two conflicting views on the Korean development experience are introduced. The key questions discussed herein include the following: Which perspective outperforms the other in its explanatory power? If government did play a pivotal role in Korea’s development, what exactly are the essential features of that role? This article confirms the interventionist notion that the successful economic development of Korea was mainly rooted in the aggressive role of government. Korean policy has strategically changed in direction but not in degree. Carefully sequenced “target shifting” and “constant upgrading” by government were the ultimate sources of Korea’s outstanding economic performance in the early stages of development.     

A governance network perspective on environmental conflicts in China: findings from the Dalian paraxylene conflict

Employing the Governance Network framework, this article presents an in-depth case study of the conflict that evolved from 2003 onwards over the construction and operation of a paraxylene plant in Dalian, China. The study explores the usefulness of this framework as an empirical tool to describe and make sense of policy processes and governance in multi-actor situations in China. The analysis shows the lack of anticipation and deliberation by Chinese governments, resulting in the buildup of citizens’ concerns, mediated by social media beyond government control. This results in an outbreak of protest followed by uncoordinated governmental responses, with high costs for all parties. It is argued that, because of the underlying institutional causes, the challenges are even greater for Chinese governments to come to grips with the increasing need for internal coordination, deal with new social media, and balance economic and environmental values.     

Divergence in the development of public health insurance in Japan and the Republic of Korea: A multiple‐payer versus a single‐payer system

Japan and the Republic of Korea achieved universal health insurance coverage for their populations in 1961 and 1989, respectively. At present, Japan continues to operate a multiple‐payer social health insurance system, while the Republic of Korea has moved to an integrated single‐payer national health insurance structure. This article analyzes the influence of political economy in shaping the policy divergence found between these two Bismarckian health insurance systems. Issues addressed include differences in political power, the policy influence of business, the extent to which regional autonomy has developed and regional traits have been preserved, the level of political democratization, the form of political leadership, and the scale of development of the health insurance system. The article offers policy lessons derived from the two countries' experiences.