Strengthening Community Health System for NCDs Prevention and Control at the Local Level, Gangdong
Gangdong-gu

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
With the rising incidence and prevalence of non-communicable diseases (NCDs) worldwide, the morbidity, mortality and socioeconomic burden of NCDs in Korea, as in other countries, have rapidly increased in recent years. Health disparities in the prevalence rate of most NCDs such as obesity, hypertension, diabetes, stroke, and depression are noticeably identified among different populations according to their socioeconomic status, income, and gender. In particular, lower income groups have a higher prevalence of NCDs than higher income groups, and health inequalities were more prominent amongst women than men. Meanwhile, Korean society is rapidly developing into an aged society with increased life-expectancy and a very low birth rate. It is expected that the health expenditure and socioeconomic impact caused by NCDs will grow sharply in Korea in the near future. Therefore, all levels of Korean government have made collective efforts to develop and implement effective strategies and actions for the prevention and control of NCDs. Gangdong-gu municipality, one of Seoul Metropolitan City’s 25 municipalities, is located in the southeastern part of Seoul along the Han River. Gangdong-gu’s population of about 500,000 people is slowly growing, and men slightly outnumber women. Compared to other municipalities, Gangdong-gu has a smaller elderly population - 8.51% of total population (2011), but Gangdong-gu is also rapidly becoming a more aged society. The Gangdong-gu geographical district comprises 18 administrative communities (called as ‘dong’), and each community has a population of between 16,000 and 52,000 people. Gangdong-gu had a rising incidence and prevalence of NCDs with shared common risk factors of NCDs, creating an increasing socioeconomic burden growing at a faster rate than the average across both Seoul Metropolitan City and Korea. The municipality’s medical expenses for NCDs such as hypertension and diabetes had increased more than four times from 2006 to 2011. Therefore, addressing these health challenges is one important means of achieving improved health and health equity in Gangdong-gu. However, there was a major problem in addressing these health issues, which was the low accessibility and availability of public health programs and services for NCDs prevention and control. In Korea, as in other countries, the Public Health Center (PHC) at the district or municipality level provides public health programs and services, including NCDs prevention and control. However, in urban areas, in particular a metropolitan city, the access to, and the availability of, these public health programs and services are often limited to people residing near the PHC. In urban areas with more well-distributed private health organizations, no administrative community has its own primary health care centre at the community level. So peoples’ accessibility to, and the availability of, public health programs and services in urban areas are relatively low. With its relatively large population, Gangdong municipality needs a more effective community health system to make available comprehensive health services for NCDs prevention and control and to improve accessibility for everyone residing at the community level, especially the socially disadvantaged population.

B. Strategic Approach

 2. What was the solution?
In 2008 Gangdong-gu set up an initiative to strengthen its community health system by creating more intensive intersectoral collaborative efforts and enhancing the accessibility and availability of comprehensive health services for NCDs prevention and control. To improve the community health system and community actions, an initiative was developed consisting of aligning the integrated model for NCDs prevention and control with the on-line integrated health information management system, community health care centers (called the ‘Healthy 100s Counseling Centers’) at the administrative community (‘dong’) level, and efforts to strengthen community actions for a healthier community. Since then, Gangdong-gu has implemented the initiative successfully at the administrative communities within the district or municipality and by 2014 all 18 Gangdong-gu communities had established new community health systems. Today, each community has its own community health care center inside a Community Service Center (CSC).

 3. How did the initiative solve the problem and improve people’s lives?
To make public health services for NCDs prevention and control accessible and available to anyone residing in the communities, community Healthy 100s Counseling Centres have been placed inside the Community Service Center (CSC) of each administrative community in Gangdong municipality. In the current governing administration system in Korea, each administrative community has its own CSC at the most accessible and convenient place for residents. Generally, the CSC provides administrative services for community residents and supportive social services to special groups living in difficult conditions, including seniors, low-income groups, disabled persons, people with chronic diseases, and other disadvantaged groups. As well, the CSC supports the community council and facilitates community activities and the operation of the community center, which provides various programmes for community residents. The target populations of this health initiative are the communities and people over 30 years old who reside in Gangdong-gu. The intention of achieving equity was explicitly addressed in the development and implementation of the initiative. One of main purposes of this initiative is to reduce exclusion and health disparities across communities in Gangdong-gu. According to the vision and hierarchy of objectives within the initiative of strengthening Gangdong-Gu’s health system, there are parallel tracks of objectives: one to improve community health and health equity and another to build community capacity for health. The long-term health objectives are to decrease NCDs morbidity and mortality through a reduction of NCDs burden, while the intermediate objectives are to create a supportive healthy environment, to facilitate healthy lifestyles, and the early detection and treatment of NCDs. To attain these objectives, Gangdong-gu government officials set up the organizational objective of providing integrated services for NCDs prevention and control at the community level. To establish this new community health system, the Gangdong-gu municipality has process objectives of establishing health related public policies, developing, operating and promoting integrated NCDs prevention and control service models, and building an integrated service support system at the community level. On the other hand, related to community capacity building for health, the long-term objective is to enhance community capacity for health, while the intermediate objective is to strengthen community action. To attain these objectives, Gangdong-gu has process objectives of establishing health-related public policies and developing community structures or peer groups for healthy communities.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The Gangdong-gu’s initiative was quite innovative and creative in several aspects as follows: First, the municipality used the current community governing administration system and existing resources like in-kind resources of non-health sectors at the municipality level to establish a new community health system. This organization makes the initiative sustainable and diffusible in the local Korean context, a critical innovation for the local communities and the municipality as a whole. Second, with the PHC’s leading efforts, the Gangdong-gu Office made an innovative intersectoral collaborative approach a key element of its efforts to set up the initiative at the local level, which even today remains quite new and unfamiliar in the public health field. However, given the local health needs and expectations about the positive impact of intersectoral action for health (ISA), Gangdong-gu chose and implemented ISA as part of its initiative. Third, the municipality established parallel tracks of objectives: one of improving of community health and health equity and another of building community capacity for health to facilitate community participation and strengthen community actions for building healthier communities.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The PHC, on behalf of the public health authority, has led the intersectoral efforts at the Gangdong-gu Office to strengthen the community health system and community actions. In 2007 the PHC, the AMB and CSCs of the Gangdong-gu Office started their collaborative efforts by optimizing resources for developing the new community health system. In time, more sectors, including the Planning and Economy Bureau (PEB), became involved in the coordination mode to implement the initiative, attain financial stability, and provide support for the legislation to make the initiative sustainable. As well, the Gangdong-gu communities and the private health sector in the municipality have been involved from the early implementation phase of the initiative. The current mayor’s political commitment to improve the health of the municipality, with his pre-election public promise in 2010, has provided the trigger or enabler to go forward with the intersectoral action for the initiative at the local level so as to diffuse the newly strengthened community health system into all the Gangdong municipal communities. The municipal council was actively involved in enacting legislation in 2012 to formalize the initiative through collaborative actions across sectors in Gangdong-gu and community participation in the operation of the new community health system. Between 2008 and today, in all 18 administrative communities of Gangdong-gu municipality, about 80,500 people over 30 years old, or about one third (30%) of the target population have registered in the new community health system and used comprehensive programs for NCDs prevention and control. So far, 16% of the total population of Gangdong-gu have benefitted from the initiative.
 6. How was the strategy implemented and what resources were mobilized?
We can highlight the prominent features of the Gangdong-gu’s initiative as below: - Establishment of community health care centres (‘Healthy 100s Counseling Centre’) at the community level through collaborative efforts across sectors: To make public health services for NCDs prevention and control accessible and available to anyone residing in each community, community Healthy 100s Counseling Centres have been placed inside the CSC in each administrative community (‘dong’) in the municipality. - Operation of the new community health system efficiently through the integrated model of health services and programs for NCDs prevention and control: According to this integrated model, the PHC first reorganizes its operations to integrate health services and programs related to NCDs prevention and control and to provide efficient support to community Healthy 100s Counseling Centres. Each community Healthy 100s Counseling Centre at the community level takes primary responsibility to provide comprehensive health care services for NCDs prevention and control to community residents, while the Gangdong PHC takes more responsibility for supporting and coordinating community Healthy 100s Counseling Centres while retaining responsibility for providing services at the district level to any citizen residing in the municipality. In 2009 Gangdong-gu, with funds from Seoul Metropolitan City, developed an on-line screening and management program specifically for Metabolic Syndrome control. Since then, in collaboration with the Seoul Metropolitan government, Gangdong-gu has provided comprehensive health services for NCDs prevention and control at both the community Healthy 100s Counseling Centre and the PHC. The services for NCDs prevention and control provided by community Healthy 100s Counseling Centres include health exam and health screening for early detection of NCDs (except cancer), health counseling and health education for reducing common shared risk factors of NCDs, continuous follow-up care, and patients’ referral for treatment to private community health organizations in Gangdong-gu. In providing these services, community health care centres are equipped with a one-stop health exam and screening system supported by the national governmental fund for heart disease and stroke prevention and control. One-full time community coordinator nurse works with a supportive circulating team of a doctor, a nutritionist and an exercise specialist at each community Healthy 100s Counseling Centre. As well, the community coordinator in each community is responsible for facilitating community participation and actions for developing a healthier community. Private community health organizations and private health care clinics in Gangdong-gu are also involved in NCDs prevention and control through the provision of treatment to individual patients referred to them from community Healthy 100s Counseling Centres and by participating in health education for the community. - Utilization of the on-line integrated health information management system: Gangdong-gu developed an on-line health information management system in which the PHC and all community health care centres can collect health data and use the information for providing services. All services for NCDs prevention and control provided in Gangdong-gu at the community and district levels can be integrated and monitored. - Approaches for strengthening community actions for healthier communities: Facilitating community participation and strengthening community action are critical elements in the new community health system in Gangdong-gu. Based on community development approaches, communities in the new health system are encouraged to participate actively in the initiative to make their communities healthier. On the one hand, each community council participates in the operation and management of community Healthy 100s Counseling Centres. On the other hand, individuals and peer groups participate in community activities to promote healthy behaviors and engage in volunteer activities for seniors and socially disadvantaged groups in the community.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The main sectors of the local government, Gangdong-gu Office involved in strengthening the community health system for NCDs prevention and control were the PHC, the AMB, CSCs, and the PEB. The PHC has led the intersectoral action initiative across sectors. Its work has involved articulating the initiative, developing appropriate means to implement the initiative, making the other sectors involved from the beginning, obtaining external funds from Seoul Metropolitan City government, and the national government, building up the internal capacity for the initiative, making the community involved in the initiative, and supporting the mayor and the municipal council in their efforts to enact legislation for the initiative. The AMB and CSCs have been involved in the initiative from the earlier initiation period in 2007 to provide supports for the operation of the new community health system and legislation of the related ordinances, and to facilitate community participation and participate in annual formal evaluation meeting of the initiative. The PEB has been involved in the initiative from the later implementation period in 2012 to provide support for the legislation and the financial stability. The mayor has shown strong political commitment and the municipal council also have provided strong support through its financial assistance and passing legislation tied to the initiative. The other main sectors involved in the initiative are the 18 communities, private health organizations, and academia. Community and private sector‘s role and activities are stated above (see C-6), while academic institutions have provided technical assistance throughout the initiative. Academics have thus been intimately involved in the design, implementation, and evaluation of the initiative. Local and national media also made a contribution in terms of public advocacy of the initiative. The national government (the Ministry of Health and Welfare), and Seoul Metropolitan City have provided fundamental financial support for implementing the initiative.

 8. What were the most successful outputs and why was the initiative effective?
We can highlight the following outputs from the implementation of the initiative at the Gangdong-gu local level : First, with respect to the provision for NCDs prevention and control, Gangdong-gu established the new community health system with community Healthy 100s Counseling Centres in all 18 communities by 2014. This new community health system provides comprehensive health services and programs for NCDs prevention and control to anyone residing in the community, including socially disadvantaged groups like seniors, low-income groups, and disabled persons. Second, considering peoples’ utilization of various NCDs services, the new community health system has efficiently enhanced the availability and accessibility of comprehensive health services and programs for NCDs prevention and control. Since 2008, about one third of target population aged over 30, or more than 80,000 people have registered at community Healthy 100s Counselling centers. Compared to other municipalities in the Seoul Metropolitan region, Gangdong-gu has a much higher rate of annual registration in, and utilization of, programs and services for NCD prevention and control (9,839 persons). The average across Seoul municipalities is 7,295 persons (2016). Third, Gangdong-gu’s enacted ordinances for the initiative in 2012 have provided the municipality with a capacity to build and sustain its healthy policies in order to strengthen the community health system and facilitate community actions for NCDs prevention and control at both the municipality and the community levels. Fourth, regarding community development to foster community participation and strengthen activities for promoting healthier communities, local populations have gradually mobilized over time. The ‘health task force teams’ of each community council have been organized in all eighteen communities. Community peer group activities for promoting healthier life have included the creation of 52 health clubs, and “healthy 100s” classes for nutrition and physical activities organized across all 18 communities. These outputs of the Gangdong-gu initiative indicate that the municipality can make Gangdong-gu achieve higher levels of health and well-being and to become more inclusive, equal and actualizing social justice, regardless of sex, age, socioeconomic status, etc. with high levels of community and citizen participation. Therefore, the initiative is expected to make contributions to achieving several SDGs including SDG 3, 10, 11,12, and 16.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles encountered in the implementation of the initiative for strengthening community health system and community action include a lack of public understanding of the initiative, frequent employee turn-over, heavy front-line staff work in the non-health sectors, a lack of space and facilities for the Healthy 100s Counseling Centres within CSCs, unfamiliarity with working cultures between public civil servants of different sectors, instability of infrastructure as a result of the biennial turn-over of working staff at community Healthy 100s Counseling Centres, and the changeability of funding from the upper level government. Some barriers still remain now, but the critical barriers were overcome as a result of intersectoral efforts. The lack of public understanding of the initiative was overcome with community involvement from the early implementation phase, based on the community development approach and public advocacy activities, with media participation as well as viral marketing among Gangdong-gu people. Instability of infrastructure caused by the biennial turn-over of working staff at community Healthy 100s Counseling was addressed and overcome with the support from the PEB by securing financial stability to afford costs associated with the initiative including human resources costs. On the whole, the initiative has received highly positive responses from communities, and citizen and social recognition at the national, provincial, and international levels. The positive feedback to the initiative enabled political leaders and civil servants across sectors of Gandong-gu local government go forward with the initiative. As a result of financial and workforce stability, internal capacity build up, legislated ordinances, and highly positive responses from the communities of Gangdong-gu and outside the municipality, we expect that the initiative by ISA can be sustainable in the long-term.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
With respect to the impact of the initiative, the Gangdong-gu Office annually measured the indicators of the following four domains: on-line health information management system of Gangdong-gu, and the annual Gangdong community health survey, which has been co-sponsored and conducted by the Gangdong-gu municipality and the national government (‘Korea Centres for Disease Control and Prevention’, KCDC). - Successful provision of comprehensive health services for NCDs prevention and control at the community level : ‘No. of Healthy 100s Counselling Centres’, ‘No. of registered community residents at Healthy 100s Counselling Centres’, ‘% of registered residents among total population of each community above aged 30 at Healthy 100s Counseling Centres’, ‘No. of health counselling’, ‘Continuous care rate of Metabolic Syndrome during 6 month’, ‘No. of health screening and examination’, ‘% of the reduced cases of risk factors for Metabolic Syndrome’, ‘No. of early detection of NCDs’ - Legislation related to the operation of community Healthy 100s Counseling Centre and community participation and actions for healthier communities : ‘Gangdong Healthy 100s Counselling Centre Operation Ordinance’, ‘Gangdong Healthy 100s Counselling Centre Community Participation Promotion Ordinance’ - Facilitation of community participation and community activities for healthier communities : ‘No. of Healthy 100s Classes’, ‘No. of Healthy Clubs’, ‘No. of communities with ‘Health Task Force’ formed in the community council’ - Improvement of health status: reduction of common shared risk factors (smoking, high-risk drinking, moderate physical activity, weight control, and obesity), perceived health status, NCD patients (hypertension, DM, etc.) treated adequately Regarding the provision of services for NCDs prevention and control, we can confirm that the new community health system has efficiently enhanced the availability and accessibility of comprehensive health services for NCDs prevention and control in Gangdong-gu municipality with the indicators measured on people’s utilization of various NCD services. The increasing number of detected NCD cases and the growing percentage of reduced cases of risk factors for metabolic syndrome also give us an indication of the effectiveness of the new community health system. By two ordinances enacted, ‘Healthy 100s Counseling Center Operation Ordinance’ and ‘Community Participation Promotion Ordinance’ the initiative was formalized to diffuse into all 18 communities and to become more sustainable in the long-term in Gangdong-gu. Considering the increasing number of community structures and various community activities measured, the strengthening efforts of community action has successfully facilitated community participation and community activities for healthier communities. Despite these indicators of the positive impact of the initiative, annual Gangdong-gu community health surveys had not shown, until 2014, much improvement in reducing common risk factors of NCDs or in the treatment of chronic diseases. Recently, however, positive changes of risk factors, including current smoking rate, harmful use of alcohol, moderate physical activity and weight control, and obesity rate, have been observed.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The initiative does not include the measures to improve integrity and/or diminished corruption in the public service. On the whole, the initiative has received highly positive responses from communities, and citizen and social recognition at the national, provincial and international levels. Community people have been quite satisfied with Gangdong-gu’s new approach to their health: highly accessible community health services for NCDs prevention and control. According to biennial Gangdong Social Survey reports, satisfaction with health services among people in Gangdong-gu municipality has continuously increased from 30.3% in 2009 to 59.2% in 2015; among all services provided in Gangdong-Gu, people were satisfied the most with health services. Gangdong-gu people have also shown appreciation for the mayor and the Gangdong-gu Office’s role in creating the new community health system and Healthy 100s Counseling Centres. This positive response has made the policy-makers, especially the municipal council, the mayor, and other sectors of Gangdong-gu Office more committed to the initiative and accountable on the delivery of public health services. This positive feedback from outside the local government about the initiative could enable political leaders and civil servants across sectors of Gandong-gu local government to continuously support the initiative.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The initiative does not include special measures to ensure the benefits for women and girls. Even so, women are more likely to register in the new community health system with Healthy 100s Counseling Center than men, and the group with the highest utilization of community Healthy 100s Counseling Center are women aged over 40 who cannot get benefits easily from social services outside communities. In addition, the considerate approaches in the implementation of the initiative have been made for both disabled persons in the communities and low-income groups by developing more convenient facilities and ubiquitous devices for health exams and health screening as well as home visits.

Contact Information

Institution Name:   Gangdong-gu
Institution Type:   Local Government  
Contact Person:   HAE SIK LEE
Title:   mayor  
Telephone/ Fax:   82-2-3425-5385 / 82-2-3425-7227
Institution's / Project's Website:  
E-mail:   i1243@gd.go.kr  
Address:   Gangdong-gu Office, 25, Seongnae-ro, Gangdong-gu
Postal Code:   05397
City:   Seoul
State/Province:  
Country:  

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