Questions/Answers

Three out of ten Koreans die of cerebrovascular disease, and seven of the top ten causes of death in South Korea are NCD(Non-Communicable Diseases). Further, in 2015, the largest medical expenses incurred were for the treatment of hypertension (32%, KRW 2 trillion 6.7 billion) and diabetes (10.6%, KRW 1 trillion 4.5 billion). However, NCD are largely preventable by means of effective interventions that tackle shared risk factors, namely, tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. As WHO stated, 80% of premature deaths due to chronic diseases are also avertible. The strengthening of prevention has become of vital importance. Eleven years ago, the only place Gangdong’s half-million people could obtain public services to help prevent NCD was the Public Health Centre (Public Health Center). One Public Health Center was not enough, and public health programs and services offered at the Public Health Center were often limited to people residing near the Public Health Center. A survey carried out during that time revealed that residents needed more accessible primary health care centers. An innovative initiative was desperately in need to target a larger group of residents in Gangdong. To increase outreach to the entire community, the Public Health Center led an initiative to create a “Healthy 100s Counselling Centre” in each of the district’s 18 Community Services Centre offices that provide administrative and social services. Each new Healthy 100s Counselling Centre is staffed by a full-time nurse, who checks residents to detect early NCD, provides health education to reduce people’s risk of developing NCD, recommends community-based groups for physical exercise, and refers residents to health care professionals. The initiative also placed health issues higher on the policy agenda in Gangdong to address health issues more effectively across sectors.

The initiative started off to introduce an innovative way to tackle NCD issues by reaching out to everyone including the poorest and most vulnerable groups. Public health services have become far more accessible than before because in the current administrative structure in Korea, Community Services Center offices are located at the most convenient location for the residents (usually within a 10-minute walk from a residence). Now people are able to receive administrative and health care services at the same time. Anyone (age 30+ years) residing in Gangdong is welcome to use the services. The target of the initiative is very broad because the district also aims to improve health equity through this initiative. When someone visits the Healthy 100s Counselling Centre for the first time, he/she goes through five tests (abdominal circumference, blood pressure, blood sugar, triglyceride level, and HDL level). Early detection and management of metabolic syndrome are possible through these examinations. Early detection is critical because metabolic syndrome evolves into chronic disease rather quickly. Moreover, after doctors review the test results, the center offers nutrition counseling and exercise prescription. Once a week, a professional dietitian and an exercise specialist visit the center and provide consultations for free.

1.A six-month analysis of 75,265 users showed improved figures in blood pressure levels (decreased by 18.1%), triglycerides levels (decreased by 15.6%), blood sugar levels (decreased by 14.6%), HDL level (decreased by 12.8%), and abdominal circumference (decreased by 8.2%). The figures demonstrate that non-communicable diseases are being prevented and treated properly to prevent premature mortality from non-communicable diseases (SDGs 3-4). 2.The initiative provides health care services for a wider population. This helps society fight against health inequalities, and this leads to reducing “poverty(SDGs 1)” because low-resource settings and health care costs for NCD can quickly drain household resources, driving families into poverty. The initiative provides access to universal health coverage and quality essential health care services (SDGs 3-8). 3.Early detection of diseases. Since 2009, 23,174 residents have been newly diagnosed with NCD at the counseling centers. They were introduced to proper medical care centers, and the early detection of diseases made it possible to reduce complications. This strengthens the capacity of our district for early warning, risk reduction, and management of national and global health risks (SDGs 3-d).

Cultural awareness improvement: The Healthy 100s Counselling Centres raised awareness of the importance of preventing NCD through campaigns and center promotions. Gangdong has hosted the “Red Circle” campaign in past years. “Red Circle” represents “healthy blood vessels.” The campaign promotes healthy lifestyle practices by recognizing the importance of the numerical values of blood pressure, blood sugar, and cholesterol, which are major causes of NCD. The number of center users increased and the importance of NCD prevention was widely known through the events. Promotion of health equity(U-Health project): For those who qualify, five self-assessment tools (blood pressure monitor, body composition analyzer, wearable fitness device, glucose meter) are provided to measure BMI and other figures comfortably at home. The elderly population meeting the requirements(earning less than 120% of the standard median income, taking medicines, exposed to higher risk factors, etc.) has priority over other groups. Based on the results, experts continuously give advice on nutrition and fitness. A survey conducted by counseling centers showed that all five values (abdominal circumference, blood pressure, blood sugar, triglyceride level, and HDL level) dropped after six months of using the U-Health kit (the survey polled 145 people).

The district of Gangdong effectively involved different government departments and community groups to develop solutions to tackle NCD issues. Gangdong Public Health Centre improved its work across sectors to further establish the Healthy 100’s Counselling Centres by drawing on inter-sectoral action (ISA) guidelines developed by WHO Centre for Health Development (WKC). The WHO Western Pacific Regional Office and WKC held training sessions on cross sector collaboration with public officials and academic experts that ultimately helped place health issues higher on the policy agenda in Gangdong. Moreover, by increasing the accessibility of NCD prevention and control centers, the delivery of public services highly improved. Today, more than 29% of Gangdong’s population (126,645 people) are enrolled in Healthy 100s Counselling Centres. Participants reported greater satisfaction with the quality of their health service, and 32% of program participants showed improvements in hypertension and blood pressure, as well as weight loss within six months.

The Community Health Survey (South Korea’s annual national health survey of a sample of 900 people across basic local governments since 2008) results of 2015 show that the obesity rate and moderate physical activity rate of Gangdong District showed the most improvement among 25 municipalities in Seoul. In 2013, Ms. Kim, a 51-year-old single mom raising two children, stopped by a nearby Community Services Center to get her resident’s registration and learned about the Healthy 100s Counselling Centre. She went through several metabolic syndrome tests, and her metabolic syndrome markers were all above average. She had been eating unhealthy processed foods such as bread and ramen because she was too occupied with raising kids as a single working mom. Since then, she has participated in nutrition classes and exercise classes run by the center, and for three months, she followed the instructions given to her by the professionals at the center. Thereafter, her blood pressure and blood sugar levels decreased from 144/96 mmHg to 113/78 mmHG and 111 mgs/dL to 98 mg/dL respectively. Her triglyceride levels significantly improved from the original 392 mg/dL to 62 mg/dL.

Use of underused space: The counseling centers saved money and space because they were established within Community Services Center offices, using the underused space. A professional team: Traditionally, to address health issues, only a limited number of people were involved. In this initiative, a group of professionals including doctors, nurses, nutritionists, and physicians collaborated closely to tackle the issues. Connections: Healthy 100s Counselling Centres are connected with local community medical clinics and related institutions for proper treatment and ongoing management of patients with NCD. This enables them to provide more professional and sustainable care for the patients. Community involvement: The initiative aims to empower community participation by encouraging activities such as creating a food and nutrition study group, running crew, and walking club, etc. People voluntarily shared healthy cooking tips such as low-sodium recipes and low-calorie dessert recipes and ran extra activities on their own. Securing sustainability: In order to ensure sustainability of this initiative, related ordinances, the “Healthy 100s Counselling Centre Operation Ordinance” and the “Community Participation Promotion Ordinance” were enacted in May 2012. An integrated management software was developed to manage all the results and patients’ information for the initiative.

The overall innovation of the initiative is original. The results of Long-Term Health Care Plan for the Socially Disadvantaged Group (2006–2008) clearly revealed that our district lacked of NCD prevention care facilities. The initiative started from that point and it is the most innovative form of a community-based NCD prevention. The originality of the initiative is widely recognized. Government officials and policy makers from Laos, Cambodia, Afghanistan, Iraq and 22 other countries have visited Gangdong to learn the case of Healthy 100s Counselling Centres and to find ways to implement the initiative in their own context. The case was presented in various occasions including Regional framework for urban health in the Western Pacific 2016-2020 as well. The innovation helped Gangdong to put 'Health in All Policies' higher on the agenda and get closer to health equity by providing universal and accessible quality primary health services.

Financial resources: In the beginning, the national government (the Ministry of Health and Welfare) and Gangdong funded the initiative 50:50. Afterward, Gangdong won funding from Seoul City’s Metabolic Syndrome Management Project Competition. Since then, Seoul City has provided financial support (about KRW 2 billion), but the most of the funding comes from Gangdong. During 2009 and 2013, approximately KRW 20 billion was invested in the project. Human resources: The staff from Public Health Center, Community Services Center offices, the Planning Economy Bureau, the mayor, and the municipal council all contributed to the design and the implementation of the initiative. About 19 medical staff and 10 other staff (nutritionists, physicians, software engineers, etc.) are carrying out the initiative in the field. Technical resources: Gangdong developed an online health information management system in which the Public Health Center and all community health care centers can collect health data and use the information to provide services. All services for NCD prevention and control provided in Gangdong at the community levels can be integrated and monitored through this system.

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In terms of disseminating the initiative of strengthening a community-based health system, more than 50 districts and municipalities across Korea have adopted the initiative and operated the initiative appropriately for their local health needs and circumstances. In addition, the initiative has been well recognized internationally. So far, total of 26 countries in particular, countries in the Western Pacific Region in collaboration with WHO WPRO, have visited Gangdong. Public officials and policy makers from countries such as Laos, Cambodia, Philippines, Bolivia, and Ghana have conducted site visits in Gangdong to learn about the innovative and sustainable approaches of the initiative. The transferability of the initiative is very high, any country or region with Community Services Center offices could start implementing the initiative because only small spaces and little manpower are required to carry out the initiative.

Social aspects: To secure sustainability of the initiative, the Healthy 100s Counselling Centres added a program that can foster the independence of the project. The centers held a Healthy 100s class to educate participants on exercise and nutrition. About eighteen classes are held annually, and residents who took the classes voluntarily started extracurricular clubs. As of 2016, 52 clubs have gathered weekly to participate in various activities such as walking, swimming, cooking, and other health-improvement activities. Club members collect opinions on community health issues and present agendas to the residents' autonomy committee. This volunteerism plays a huge role in the sustainability of the initiative. Economic aspects: The national government (the Ministry of Health and Welfare) and Gangdong funded the initiative 50:50 in the beginning. Gangdong improved the financial stability of the initiative by investing money from its own budget rather than relying on the national or the city (Seoul) budget. The initiative was able to provide its service continuously to a wider population thanks to the municipality’s allocation. Normative aspects: Gangdong enacted two ordinances, the “Healthy 100s Counselling Centre Operation Ordinance” and the “Community Participation Promotion Ordinance”, in May 2012 to prepare legal and institutional measures and to ensure successful implementation of the initiative. The ordinances strengthened the community-based health system and facilitated community actions for NCD prevention and control at both the municipal and the community levels. These led to building more sustainable cities and communities. The ordinances show that Gangdong adopts and implements integrated policies for inclusion.

Community participation empowerment: The Healthy 100s Counselling Centres demonstrate how important it is to have community engagement with a focus on the individual to accelerate access to needed health services. Community peer group activities for promoting a healthier life have included the creation of 52 health clubs and “Healthy 100s” classes for nutrition and physical activities. Community involvement improved the overall health of the community, bringing health equity closer and increasing durability of the initiative. Job security increase: Every staff working at the counseling centers was on a two-year contract, 25 hours a week in the beginning. This put continuity and stability of the initiative at risk. The Planning and Economy Bureau secured budget for human resources that enabled the centers to contract the working staff permanently. Working hours were also increased to 35 hours a week to meet user demands. Stable environment: The Community Services Centers provided underused space within their centers for Healthy 100s Counselling Centres. As the counselling centres coexist with Community Services Centre offices, they do not have to worry about the lack of space or resources. The whole administrative system of Korea provides stable environment for the centres. Improved technical skills of personnel: Civil servants in the field of general administration undergo about 24 hours of multiple training sessions per year to build their capacity for the initiative and 19 people who completed the health leader education for persons with disabilities are volunteering or working as assistants at the counseling centers to help the handicapped.

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In moving forward with the initiative, the process and outcomes with related indicators have been monitored and evaluated annually since 2009 using data collected by the integrated health information management system. Additionally, an annual Gangdong health survey conducted by different levels of government has evaluated the changes in the health status of the population. There are four domains for monitoring and evaluating the process and outcome of the initiative: providing services for NCD prevention and control, developing public policies for health, community participation and activities, and changes or improvement in health status. In terms of an external academic evaluation, formal evaluation meetings are annually held with academic experts, community representatives, and other stakeholders such as private community health organizations. Also, from the early implementation phase of the initiative, the local government has held an annual evaluation with all 18 community representatives and community activity groups. In the annual meeting, each community describes its activities for health, and the local government reports the annual progress of the initiative and its achievement to get feedback from the communities and citizens.

Overall, the evaluation has revealed that Healthy 100s Counselling Centres had the ability to reach residents at the community level, increasing access to health promotion services. According to the evaluations done so far, about one third of target population aged over 30, or more than 80,000 people have registered at community Healthy 100s Counselling centers since 2008. Compared to other municipalities in the Seoul Metropolitan region, Gangdong has a much higher rate of annual registration in, and utilization of, programs and services for NCD prevention and control (14,124 persons, 2017). The average across Seoul is 6,708 persons. Early detection of NCD. For the past eight years, more than 20,000 people were diagnosed with NCD at the counseling centers. The number of diagnosed people is increasing every year. In 2016, it increased by 17%(4,213 persons) from 2015(3,594 persons). The smoking rate decreased from 23.3% in 2008 to 20.4% in 2015 and the obesity rate also decreased from 24.6% in 2008 to 23.5% in 2015. 52 clubs have gathered weekly to participate in healthy activities and an average of 18 Healthy 100s classes are held annually. On the other hand, walking practice rate, and diabetes management education completion rate have been steadily decreasing since 2009, indicating that more active intervention is needed.

The list of indicators used to assess the impact of the initiative is as follows: ‘Number of Healthy 100s Counselling Centres’, ‘Number 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’, ‘Number of health counselling’, ‘Continuous care rate of Metabolic Syndrome during 6 month’, ‘Number of health screening and examination’, ‘% of the reduced cases of risk factors for Metabolic Syndrome’, ‘Number of early detection of NCD’, ‘Number of Healthy 100s Classes’, ‘Number of Healthy Clubs’, ‘Number of communities with ‘Health Task Force’ formed in the community council’ etc. Despite these indicators showed positive impact of the initiative, annual community health surveys had not shown, until 2014, much improvement in reducing common risk factors of NCD 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. The overall impact of the initiative reflect these indicators and survey results altogether.

The Public Health Center designed the appropriate means to implement the initiative based on the results of Long-Term Health Care Plan for the Socially Disadvantaged Group (2006–2008). The Community Services Center offices provided unused space within their offices and support for the operation of the new community health system. The Planning Economy Bureau had been involved in the initiative from the later implementation period in 2012 for securement of budgets, thus, ensuring financial stability. The mayor demonstrated strong political commitment, and the municipal council also provided strong support through its financial assistance and passing legislation tied to the initiative. Based on community development approaches, communities were encouraged to participate actively in the initiative to make their communities healthier. Residents developed exercise programs on their own, such as walking courses. On the one hand, each community council participated in the operation and management of the community Healthy 100s Counselling Centres, and individuals and peer groups participated in community activities to promote healthy behaviors and engage in volunteer activities for seniors and socially disadvantaged groups in the community. Public officials in the field of general administration underwent about 24 hours of multiple training sessions per year to build their capacity for the initiative. Private health organizations and academia were also involved. Academic institutions have provided technical assistance throughout the initiative. In 2010, the district made a research agreement with Sungkyunkwan University in Seoul, developing measures to promote community participation and activities to foster basic competence to participate in health problem management. Local and national media also made a contribution in terms of public advocacy.

Lesson 1: The importance of normative stability. The political will and commitment are the major forces underlying the successful momentum of the initiative through inter-sectoral action. The enacted ordinances of the initiative enable the project to be sustainable in the long term and we were able to bring health equity closer through legislation. Lesson 2: The importance of community involvement. Powerful community involvement from the early period of the initiative marked an important contribution to sustaining the initiative by reinforcing the political commitment and the engagement of non-health sectors. Lesson 3: The importance of increasing accessibility of universal health services. Healthy 100s Counselling Centres are by far the most accessible NCD prevention institutions. They are located in the most convenient location for every resident in Gangdong, and those who visit Community Services Center offices for administrative purposes frequently end up visiting Healthy 100s Counselling Centres. As there are no limitations on using the services offered at the counseling centers (except age), this increased the social inclusiveness of the entire community. New ways of tackling NCD issues at Healthy 100s Counselling Centres are being created in collaboration with academia and private health organization as the number of the center users increases every year.