Questions/Answers

The COVID-19 pandemic has put immense pressure on health systems worldwide. In this unprecedented time, digitally transformed universal health coverage of the Republic of Korea has turned out to be a safeguard of national security. Korea’s renowned National Health Insurance (NHI) that ensures all residents have access to healthcare services, combined with the cutting-edge digital technologies, has emerged as a key factor in tackling the pandemic crisis. The original role of Health Insurance Review & Assessment Service (HIRA) is to decide the health benefits package, evaluate the cost and quality of healthcare services, and manage the oversight of health resources nationwide. Korea legally requires that all residents and healthcare providers enroll in its single-payer centralized NHI system. Therefore, HIRA can integrate health data from a wide range of sources on a single platform, allowing for swift and efficient responses. By means of its exceptional Information and Communication Technology (ICT) system, HIRA can collect, connect, and utilize health data from all across the country like a neural network. As such, new obligations have been given to HIRA to take full-fledged actions against the pandemic crisis. HIRA has utilized three main factors to undertake the pandemic pre-emptively and systematically which include: nationwide data aggregated from all healthcare patients and patients; pre-existing ICT network; and real-time data exchanges. As HIRA promptly set up the emergency response framework to widen the use of this interconnected system and develop into a multifunctional network, Drug Utilization Review (DUR) system was added to an additional function making the most of the exceptional real-time data exchange feature to detect high-risk groups, test cases early, and distribute masks to prevent the community spread. This proactive response utilizing the single centralized NHI and ICT system continued throughout the pandemic allowing HIRA to put forth maximum effort to tackle the crisis.

As a public institution responsible for quality universal health coverage, HIRA has shifted to a wartime posture after the first confirmed case of COVID-19 to take innovative and collective actions while maintaining relatively resilient health systems. With big data from patients and providers, ICT networks, and real-time data exchange nationwide, HIRA has taken full advantage and adapted their functionality rapidly to prevent the spread of COVID-19. From the early pandemic, HIRA has expanded health benefit packages to test and treat patients, detected high-risk groups, and stabilized face mask supply across the country responding to surge capacity through flexible resource reallocation.

The HIRA initiative is aligned with Goal 3 (Ensure healthy lives and promote well-being for all at all ages), Goal 16 (Promote just, peaceful and inclusive societies), and Goal 17 (Revitalize the global partnership for sustainable development). (Goal 3.8) Specifically, Korea achieved universal health coverage that ensures access to quality essential healthcare services and safe, effective, quality, and affordable essential medicines and vaccines for all without hardship. Therefore, all Korean residents are automatically eligible for access to test, treat for COVID-19 free of charge. (SDG 3.d) Early in the pandemic, the DUR/ITS system of HIRA was used to prevent further influx of COVID-19 into Korea, and the duplicate mask purchase prevention system prevented imbalances in mask distribution, giving everyone access to them. (Goal 16.10) HIRA is committed to ensure public access to real-time information and protect fundamental freedoms, in accordance with national legislation and international agreements that guarantee access to up-to-date information and services against COVID-19. (Goal 17.17.) The open data and network policy of HIRA to share nationwide health data supports and promotes a whole-of-society approach to tackle the COVID-19 crisis. This encourages effective public, public-private and civil society partnership, building on the experience and resourcing strategies of partnership.

As unprecedented pandemic responses involve whole-of-society cooperation among government and relevant stakeholders, the initiative has a high chance of continuing as an always-on crisis response system thanks to its stable national budget. If undertaken by a single institution, it would likely end as a one-time endeavor. Other reasons for the initiative’s sustainability are the shortening period of time between epidemics and growing consensus on the necessity for better response capability. Also, given the effectiveness of digital technologies in this initiative, there is growing interest in the private sector in creating value and projects utilizing real-time COVID-19 data across the country.

Due to the unique and unexpected nature of COVID-19, existing public services were limited in their responsiveness. To minimize the exponential rise in confirmed cases, HIRA helped evenly distribute masks to all citizens. Early in the pandemic, mask prices skyrocketed in Korea due to high demand, resulting in shortages and the inability of economically- and socially vulnerable individuals to obtain masks. This prompted HIRA to create a system to prevent over-purchasing and suggest that the government employ the “five-day rotation face mask distribution system” (policy limiting the number of masks bought per person), which not only alleviated the supply imbalance but also stabilized prices. DUR/ITS also supports to maintain essential health services by identifying high-risk groups such as recent overseas travelers and people who are released from quarantine to prevent the spread of COVID-19 in healthcare facilities.

Under the principle for the fair distribution of face masks, all residents in Korea have been equally allowed to purchase two masks per week regardless of gender or social status as a basic human right to be protected against the viral spread. Also, all residents of Korea are automatically eligible to get tested, treated for COVID-19 free of charge. According to the analyses conducted by HIRA, the risk of death due to COVID-19 did not correlate with sex, which suggests that gender has little to do with access to healthcare services.

The initiative of HIRA was primarily designed to minimize the threat of COVID-19 for all citizens. Utilizing the Drug Utilization Review (DUR) and International Traveler Information System (ITS), HIRA can detect and track high-risk groups during the COVID-19 pandemic and thus prevent spread of virus within healthcare providers at the reception, consultation, prescribing and dispensing stages. This includes identifying groups such as recent overseas travelers, people who have had close contact with confirmed patients, and positive cases who are released from quarantine. Due to this, frontline healthcare providers can easily detect high-risk groups vulnerable to COVID-19, protecting them from potential infection which eventually prevents the collapse of the healthcare system. Furthermore, HIRA has contributed to stabilizing the face mask supply and distribution across the nation. Through the pre-existing network with all healthcare providers, the duplicate mask purchase prevention system was swiftly added to the HIRA ICT system, ensuring all resident access to personal protective equipment to prevent the spread of virus.

The initiative, which set up a system for responding to COVID-19 pandemic, was not built from scratch. The DUR systems were created in 2010 to manage pharmaceutical distribution data and share such data with physicians/pharmacists. After Korea’s MERS outbreak in 2015, an infectious disease response function was added to the DUR. HIRA then added two new functions: 1) real-time data exchange on MERS among medical facilities and pharmacies nationwide and 2) the International Traveler Information System (ITS), which provides data to doctors/pharmacists on travelers from regions experiencing MERS outbreaks. This provided data on approximately 350,000 entrants from MERS-infected countries to medical facilities. In 2017, the DUR system was used to efficiently block the spread of Ebola (from the Democratic Republic of the Congo), Lassa fever (from Nigeria), and plague (from Madagascar). When COVID-19 hit Korea, the efficacy of the DUR/ITS systems had already been confirmed. DUR/ITS have been used since January 10, 2020, to provide real-time information on overseas entrants to medical facilities. It soon became clear, however, that they were unable to cope with COVID-19, prompting HIRA to add more functions. In late February 2020, when COVID-19 first spread nationwide, Korea experienced a severe mask shortage. On March 3, the Ministry of Food and Drug Safety (MFDS) asked HIRA to create a system for preventing duplicate mask purchases, while the Ministry of Health and Welfare requested a negative pressure room monitoring system to better manage limited medical resources. HIRA benchmarked the existing DUR system to quickly create the duplicate mask purchase prevention system and used its own data on medical resources to create the negative pressure room monitoring system. Following the spike in cases after March 8, the government requested a system for managing the treatment history of COVID-19 patients, which HIRA completed on March 20.

The biggest obstacle was time and the network between multiple stakeholders. In response to the unprecedented mask shortage caused by the sudden surge in COVID-19 cases, the government announced the five-day rationing system. Given the urgency of the situation, HIRA utilized its own skilled IT personnel to design the duplicate mask purchase prevention system requested by the MFDS in five days. This was possible because HIRA’s IT personnel had a much better understanding of health-related data than those of other institutions and experiences responding to disaster and infectious disease outbreaks.

What makes the initiative set apart from any other country is its expandability through connections with internal/external knowledge databases: namely, by being updatable, flexible, and optimizable for urgent responses against infectious diseases through the use of pre-existing data, network, and ICT systems. The core of the initiative, the DUR system, was originally designed to prevent duplicate prescriptions of medicines through real-time information exchange among doctors and pharmacists. The mask purchase prevention and ITS functions are the results of updating and revising the system’s supplementary functions given the infectiousness of COVID-19.

Due to the unprecedented nature of COVID-19, rather than seeking outside inspiration, HIRA created the initiative based on its own experience with previous infectious diseases. In short, the initiative is a combination of several HIRA systems that were modified for the COVID-19 response. The DUR/ITS system, which was successfully used on two recent occasions (MERS in 2015 and Ebola in 2017), played a major role in early response efforts and served as the model for the duplicate mask purchase prevention system.

The initiative is applicable nationwide as a real-time, 24-hour service and can be linked to any healthcare organization for monitoring. In addition, it offers data on health resources and face mask sales to related stakeholders and the public that is updated every five minutes.

This initiative has been successfully transferred and adapted to the context of the Kingdom of Bahrain. Korea and the Kingdom of Bahrain completed the project to build the IT-based national social health insurance scheme (SEHATI-IT) in a short span of time (26 months), enabling Bahrain to construct the foundation for introducing SEHATI: long-term and stable financial management, effective and safe distribution of drugs, and collection of medical data at the national level. This project serves as a proud example of international cooperation in the healthcare sector at its best. Korea implemented its well-known National Health Insurance in an exceedingly short period of time and HIRA used its own institutional memories as a basis for helping Bahrain accomplish its goals. The objective of the SEHATI-IT project of Bahrain includes supporting and improving the healthcare system of Bahrain throughout their endeavors to establish the national health insurance built upon an IT workflow. HIRA advised Bahrain on how to develop a health insurance system that fits the nation and assisted in constructing such a system in Bahrain. To operate stably in accordance with the Bahrain roadmap, an off-premises (cloud-based) IT infrastructure was employed.

The initiative is highly applicable and transferable to other countries/regions. The successful SEHATI-IT project of Bahrain will act as a useful model for other countries aiming to introduce a digitalized national health insurance management system of their own. Because of Korea’s successful implementation of quarantine without closing its borders, HIRA has received requests from many governments about this initiative and its operation. In 2021, it began advising the 10 ASEAN countries on the installation of their own disease response systems. The initiative’s COVID-19 response outcomes were also introduced to international bodies (e.g. OECD) through presentations and eight foreign press conferences, including that of Bloomberg, and three presentations were given on the initiative’s outcomes for the World Bank/WHO Annual Meeting. The outcomes were also conveyed via HIRA-led online symposiums and training programs.

In terms of human resources, HIRA created a COVID-19 task force (1 unit, 18 departments, 178 employees) in January 2020 to implement the initiative. The task force is comprised of: 71 administrative staff for overall initiative operation/management, 22 healthcare/public health experts with professional medical backgrounds, 65 IT staff for system development and maintenance, and 20 staff for COVID-19 research. In terms of budget, since the pre-existing DUR/ITS system was utilized, no additional costs were incurred. After overcoming the urgent situation, the system was restored to its existing use.

The initiative’s upkeep is based on a regularly-allocated budget. Part of the funds procured from the National Health Insurance Service is allocated to HIRA based on the National Health Insurance Act, and is used for system upkeep/maintenance. The reason for such consistent funding is that the initiative will likely be used to respond to future epidemics and therefore needs to be well maintained. Furthermore, the enactment of a law in February 2020 (immediately after the COVID-19 outbreak in Korea) requiring DUR/ITS confirmation established the legal grounds for healthcare experts to check pharmaceuticals through the DUR/ITS, thus ensuring this initiative’s sustainability.

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Internally, assessments were done by the Performance Management Division of HIRA. Quantitative assessment was done of the initiative’s social cost reduction, usage rate, and provision of disease-related information, with qualitative assessment done of procedures (initiative creation and cooperative system creation). These assessments resulted in HIRA receiving a grade A rating on the government’s assessment of public institution management practices. The initiative also received several prominent Korean awards: National Quality Management Award (service innovation category, 2020), presidential citation for contributions to COVID-19 response (Apr. 2021), presidential citation for government innovation (2021), and presidential citation in the Korea Intelligence Awards (2021).

The assessment of the management practices of Korean public institutions, which is annually carried out by the Ministry of Economy and Finance, is done for the roles of each institution. In terms of the pandemic, an assessment was done on efforts/contributions toward the COVID-19 responses, responsiveness to government policy, and implementation of the Korean New Deal. For each category, an assessment was done of implementation background, the content of implementation, obstacles, efforts to overcome obstacles, and quantitative outcomes as well via comparison of circumstances before and after the initiative’s creation.

The ITS system’s usage rate was just 54.1% at the time of the outbreak of COVID-19. This figure has since increased to 99.7% through promotion by Korean media, funding for installation, and cooperation with related institutions. Afterward, infectious disease data obtained through the DUR/ITS was legally required to be reviewed (amendment made in March 2021). The creation and operation of the duplicate mask purchase prevention system resulted in KRW 404.5 billion saved in social and administrative costs through the drastic decrease in purchase lag time (over two hours → under 10 minutes). The above-mentioned outcomes on the initiative’s excellence in terms of quality, sustainability, and necessity have been recognized in assessments conducted by the central government and Korean Standards Association. Moreover, the promotion of these outcomes through press releases made the public aware of HIRA’s contributions to the COVID-19 response.

HIRA undertakes unique legal tasks related to managing the cost and quality of healthcare services. It is based on the existing IT system connecting HIRA with healthcare institutions and central/local governments that it was able to carry out this initiative. Regarding the DUR/ITS, the Korea Disease Control and Prevention Agency (KDCA) sends to HIRA data on overseas entrants collected from relevant ministries, which HIRA conveys to healthcare institutions so that they can ascertain the status (number) of entrants from at-risk countries. HIRA also sends information on hospital visits by such at-risk entrants to the KDCA for sustained patient monitoring. For COVID-19 response, the Central Disaster and Safety Countermeasures Headquarters, which is headed by the prime minister and includes the MOHW and MOIS, asked HIRA to create a duplicate mask purchase prevention system that allows the public to see mask inventories of sellers (e.g. pharmacies) in real time through data links with such sellers. Korea Post was later added as a seller to increase the number of places that sell masks. Information on mask supplies was sent in real time to the National Information Society Agency (NIA), which converted the information into usable data.

For the DUR/ITS systems, a link was established with the KDCA’s data on overseas entrants to send data on those from at-risk countries to healthcare institutions in real time. The system was also used by healthcare personnel to minimize the spread of infection within hospitals. The duplicate mask purchase prevention system began from an idea submitted by a pharmacist in Chungcheongbuk-do on how to resolve the mask shortage. The idea was accepted by the central government and delegated to HIRA for implementation. Because the system required pharmacies nationwide to enter their sales data, the cooperation of pharmacists was essential. Eventually, mask inventory management per seller was made possible through pharmacists’ participation and existing IT infrastructure. The information was conveyed to the NIA, where it was converted into data that is readable by citizens, and used by private portal companies (Naver and Kakao) and startups to create apps/websites that provide data on mask sales per seller in real time in ways that are accessible to the public. For example, Naver’s map service (the most frequently-used in Korea) was used to provide real-time information on inventories of masks at pharmacies.

First, we learned the value of the whole-of-society contribution and cooperation to tackle the global health crisis. No aspect of the initiative would have been possible without collaboration in order to take rapid and flexible decision-making to mitigate the harm. Close inter-organizational cooperation—the goal of this initiative—was necessary to maximize the effective use of our limited funds, data, and medical resources. HIRA disclosed its data to government players and also received data from related institutions, much of which was also disclosed to private companies. It is thanks to this flexible system of cooperation that each institution was able to effectively play its part in the COVID-19 response. Another lesson learned was the importance of digital infrastructure enabling rapid, flexible, and responsive strategies. We realized that, in order to create an always-on monitoring system that utilizes data for diverse disasters that can be used to make decisions, preparations need to be made well in advance. This initiative will continue to be developed and expanded in order to respond to future epidemics and address current policy needs.