KLRI : KOREA LEGISLATION RESEARCH INSTITUTE

Ⅰ. Background and Purpose of Research

▶ Crisis in the regional medical system in the age of local extinction

○ Concerns have been raised about the sustainability of Korean society due to rapid changes in the demographic structure and aging population, and the limitations of the health care system are leading to deepening health inequality between regions and local extinction. Warnings and countermeasures for local extinction are being seriously discussed due to changes in the demographic structure and population concentration in the metropolitan area, but some point out that the collapse of local medical care due to the lack of local medical infrastructure is a more urgent problem.

○ Under the market-based treatment-oriented health care system, it is difficult to meet the medical needs of the elderly population due to the lack of medical institutions and medical personnel outside the metropolitan area, and problems such as a decrease in access to medical care for local residents are occurring. In particular, the transfer system is insufficient in essential medical fields close to life such as emergency, trauma, and cardiovascular blood vessels.

○ The weakening of regional medical accessibility is also confirmed in the establishment and operation of public medical institutions such as local medical centers. Local medical centers are regional-based public hospitals established by local governments, with 35 nationwide. According to the Act on the Establishment and Operation of Local Medical Centers, it functions as providing local emergency medical care, maintaining essential medical care and operating delivery facilities in vulnerable areas, functioning as a medical safety net for the vulnerable, and implementing public health care policies, but it is struggling due to the financial deficit.

○ As high-quality medical resources are concentrated in the metropolitan area and large cities, the concentration of large hospitals in the metropolitan area has intensified, and the avoidance of essential healthcare by medical personnel has become fixed, leading to a crisis of collapse of the regional medical care and essential medical ecosystem. The vicious cycle of concentration in the metropolitan area continues due to the decline in the region's severe and essential treatment capacity and inefficient medical delivery systems.

○ In our society, the demand for medical care increased rapidly from the time we entered the 'aging society'. In particular, due to the weakening of regional medical accessibility and the medical gap with the metropolitan area, the phenomenon of local patients concentrating on large hospitals in the metropolitan area is becoming serious every year. In response to this, in January 2016, the 'Medical Delivery System Improvement Consultative Group' was launched, centered on the Ministry of Health and Welfare, and hospital-level medical institutions cooperated with general hospitals (secondary medical institutions) and large hospitals (third medical institutions), respectively, to establish the goal of transferring mild patients to primary and severe patients to tertiary medical institutions, but failed to produce clear results. In order to establish a regional medical delivery system and strengthen public medical care, institutional and practical measures must be sought to overcome these problems.

▶ The need for legislative research to improve regional medical accessibility

○ The regional medical care crisis deepens the medical gap between regions and threatens the lives and health of local residents. This can accelerate the problem of local extinction due to changes in the demographic structure and concentration in the metropolitan area. In addition, while experiencing COVID-19, the people came to sympathize with the need to strengthen public health care. Therefore, research on legal and institutional improvement measures to solve the problem of medical accessibility  for residents in population-reduced areas through expansion of local health care is needed.

○ There is also skepticism about solving regional medical care problems due to differences in perceptions of public healthcare, market-based treatment-oriented health care systems, and financial limitations. However, it is necessary to lay the foundation for inducing the improvement of regional medical accessibility in terms of legal and institutional aspects and to improve unreasonable factors that hinder the expansion of regional medical care. To this end, it is necessary to analyze the health care system, including policies on public healthcare and regional medical care, and as a result, related laws and identify problems.

○ In particular, it is necessary to review various policies and projects mentioned as supplementary measures for the establishment and operation of public medical institutions such as local medical centers and the lack of medical infrastructure, and to derive legal improvement measures. In addition, it is necessary to consider the legal and institutional problems required in improving the medical delivery system to improve regional medical accessibility and to look at improvement measures.

II. Key Contents

▶ Policies and legislation on public healthcare and regional medical care

○ Publicity of healthcare and regional medical accessibility

- The publicity of medical care can also be said to mean a direction in which public values, such as the expansion of opportunities to be secured through human life, health, and safety itself, as well as health, are practiced through universal medical care. Therefore, public healthcare should be understood as including securing and managing human and physical medical resources and establishing an appropriate medical delivery system. To secure the publicity of healthcare, the administrative entity allows the public to access essential medical care without gaps in the region and class, and puts the public sector's capabilities into areas that the private sector avoids, such as emergency, infectious disease, and treatment for the vulnerable.

- As a result of analyzing the statistics on the number of nursing institutions by type of establishment by region in the first quarter of 2025 through the Health and Medical Big Data Open System, medical institutions are concentrated in Seoul and other large cities, while some metropolitan cities and new cities such as Sejong, Ulsan, and Incheon have low number of medical institutions compared to the population, and local small cities, rural areas, and military areas have very few medical institutions, so the gap in medical accessibility between regions is wide. Medical personnel are also concentrated in Seoul and Gyeonggi Province. Medical accessibility problems are identified not only in the advanced medical field but also in essential medical fields such as pediatrics due to regional gaps in medical personnel.

- Today, the risk of local extinction is spreading to metropolitan areas in metropolitan cities, leading to the collapse of the entire local infrastructure such as economy, education, culture, and medical care. Securing the publicity of medical care and improving regional medical accessibility plays a decisive role in blocking the vicious cycle of local extinction crisis, strengthening social safety nets, and maintaining regional competitiveness.  In this study, by securing the publicity of medical care and approaching regional medical care issues, we analyze policies and laws on the establishment and operation of public medical institutions, training and distribution of medical personnel, and improving the medical delivery system to derive problems, and to derive improvement measures to improve regional medical accessibility.

○ Related Policies

- Comprehensive Plan for Public Health Care Development in 2018: The 2018 Comprehensive Plan for Public Health Care Development expanded the concept of public healthcare by universally guaranteeing essential healthcare for the life and safety of the people, and included providing essential healthcare services by establishing a medical system for each treatment right. It aimed to bridge the gap between regions in essential healthcare through 12 policy tasks in four areas: strengthening public healthcare accountability to bridge the regional gap, strengthening the guarantee of all citizens of essential healthcare, enhancing human resources training and capacity, and establishing a public healthcare cooperation system.

- The 2nd Basic Plan for Public Healthcare in 2021: The tasks proposed in the 2018 Comprehensive Plan for Public Healthcare Development were reorganized into the 2nd Basic Plan for Public Healtcare in 2021. The plan presented 11 initiatives in three areas: 'expanding the essential healthcare provision system', 'strengthening public healthcare capabilities', and 'strengthening the foundation of the public healthcare system'.

- 2023 Essential Healthcare Innovation Strategy: In 2023, the government promoted an essential healthcare package consisting of four reform tasks: 'expanding medical personnel', 'strengthening regional medical care', 'safety net for medical accidents', and 'fair compensation' as a regional and essential healthcare innovation strategy. Among them, in order to 'reinforce regional medical care', it was decided to promote 'establishment of a function and demand-oriented delivery system, strengthening essential medical networks, securing stable human resources, expanding investment, and minimizing resource outflow'.

○ Related Laws

- Act on Public Health and Medical Services: This Act defines public healthcare, public medical institutions, public healthcare performing institutions, etc., and regulates the establishment and operation of public healthcare basic plans, establishment and operation of public medical institutions, evaluation of public medical institutions, matters related to medical vulnerable base medical institutions, public professional medical centers, responsible medical institutions, and public healthcare support centers and support groups. Chapter 2 stipulates the Public Health and Medical Policy Deliberation Committee (Article 5) and the City/Province Public Health and Medical Committee (Article 5-2), along with matters to be included in the establishment and basic plan (Article 4). Chapter 3 is the head of public healthcare performance institutions, and sought to secure publicity by prescribing the establishment and operation of public health care institutions, the establishment of public healthcare plans for each institution, and the health care that public medical institutions should provide first (Articles 6 to 8). Article 13 and below stipulates the establishment, designation, and compliance of medical institutions based on medical vulnerable areas, public specialized medical centers, and responsible medical institutions that correspond to public health care performance institutions other than public medical institutions. Meanwhile, Article 12 stipulates the designation and notification of medical vulnerable areas and support for the supply of health care to medical vulnerable areas.

- Act on the Establishment and Operation of Local Medical Centers: This Act shall prescribe matters concerning the establishment and registration of local medical centers, articles of association, business, board of directors, executives and employees, and matters concerning the operation and corrective measures, guidance and supervision, public disclosure, etc., in addition to matters concerning the financial affairs, such as business year, accounting standards, submission of business plans, subsidies and financial resources, and borrowing funds. Local medical centers shall be established and operated by local governments, and may be entrusted to public medical corporations such as university hospitals or general hospitals, if necessary, pursuant to the Ordinance. Also, if necessary, the State and local governments may receive support. 

- The Act on Special Measures for Health and Medical Services in Agricultural and Fishing Villages, etc.: This Act stipulates the arrangement and job training of public health doctors, the establishment and operation of health clinics, and subsidies for expenses of the State and local governments. Chapter 2 stipulates the status and reasons for disqualification of public health doctors, supply and demand management and fact-finding surveys, and orders to work at workplaces according to list notification, and stipulates matters concerning the change of public health doctors' placement institutions, placement facilities, working areas, etc., prohibition of departure, service, and deprivation of status. Chapter 3 sets out matters concerning the establishment and operation of health clinics, the qualifications, status and appointment of public officials in charge of health care, remuneration education, service, and the scope of medical activities that public officials in charge of health care can do and the prohibition of departure from jurisdiction. It also stipulates matters related to support, such as subsidies. 

- Community Health Act: The main contents of this Act shall be the establishment and implementation of local health care plans (Chapter 2), the establishment and operation of regional medical institutions (Chapter 3), and the implementation of regional medical care services (Chapter 4). In particular, "regional medical institutions" are defined as public health centers, health care centers, health centers, and health life support centers, and "health care-related institutions and organizations" are defined as medical institutions, pharmacies, health care professionals, etc. in the community, and the establishment of a cooperative system with health care-related institutions, organizations, schools, workplaces, etc. is specified as one of the functions and tasks of the public health center. 

- The Health and Medical Personnel Support Act: It was enacted to improve the poor working environment of health and medical personnel and to resolve the imbalance of medical personnel between regions. It stipulated the establishment and implementation of a comprehensive health and medical personnel system and an implementation plan, including the direction of health and medical personnel policy, training and supply of human resources, appropriate placement, improvement of working environment, and welfare improvement, and prepared the basis for the composition and operation of the Health and Medical Personnel Policy Review Committee (Chapter 2). In addition, it stipulates policies for proper supply and demand of health care personnel, support for training and improving the quality of health care personnel, new education and training, implementation of projects for securing health care personnel (Chapter 3), and matters related to labor protection, counseling and support for health care personnel, and improvement of working environment (Chapter 4). In addition, it stipulates the establishment of a policy foundation for supporting health care personnel (Chapter 5).

- The Special Act for Public Health Scholarship: A law enacted in 2012 to fundamentally solve the medical gap between regions and the shortage of public healthcare personnel, grants scholarships to college students who want to become doctors, dentists, and nurses, and is subject to them working at public medical institutions for a certain period of time after graduation. 

- The Act on Integrated Support for Local Care, such as Medical Care and Nursing: This Act was enacted to address the lack of local care services and the implementation of segmented projects, to provide services such as medical care and nursing care centered on consumers, and to legislate an integrated and linked system, and is expected to take effect from March 27, 2026. The integrated provision of health care, health care, long-term care, daily life care, housing, and other services prescribed by Presidential Decree by the head of the state and local governments to those eligible for integrated support is defined as "integrated support," and the elderly and the disabled are defined as those eligible for integrated support. Each chapter stipulates the integrated support plan and procedures, the promotion and support of integrated support policies, and the creation of a foundation for integrated support.

- Act on Public-Private Partnerships in Infrastructure: It is a law enacted to introduce a private investment system to maintain infrastructure by attracting private capital, and stipulates the implementation and operation of infrastructure under the agreement on the implementation of private investment projects and the implementation of private investment projects.

 

▶ Status and Problems

○ Problems in the establishment, operation, and function of public medical institutions

- The shortage of public medical institutions is causing medical gaps in medical vulnerable areas where essential healthcare is not properly provided. In addition to the medical vulnerable areas, there are no local medical centers in metropolitan cities such as Ulsan and Gimhae-gun with a population of more than 500,000, and there is a shortage of public medical institutions in areas other than underpopulated areas.

- The aging of public medical institutions is occurring mainly in local medical centers. As of 2017, 52.6% of local medical centers are aged after 20 years of construction, and the rate of aging of local medical center facilities is high, so improvement is needed. The aging of medical devices owned by local medical centers is also serious. As of 2020, out of 45,799 medical devices owned by local medical centers nationwide, 18,148 medical devices are aged beyond their durability, accounting for 39.6% of all medical devices.

- The regional gap in expanding public medical institutions, aging medical devices, and responding to infectious diseases is also serious. Public medical institutions are insufficient, especially in medically vulnerable areas, resulting in a gap in providing essential medical care in the metropolitan area with relatively sufficient public beds. In the case of the aging of medical devices, the difference in the ratio between the areas that are highly aging and those that are not is 84.5%. The weakening of the infectious disease response function can be exemplified by the surge in COVID-19 confirmed cases in Daegu and the western Gyeongnam area in February 2020. In the aftermath of the closure of Jinju Medical Center, the number of public beds was significantly insufficient compared to other regions, making it particularly difficult to treat COVID-19 patients.

- The chronic deficit, centered on local medical centers, can be said to be the root cause of problems related to public medical institutions. In order to solve the serious fiscal deficit, the structural reform of local medical centers has been implemented since 1998, and the Local Medical Center Act was enacted in 2005 to make local public medical centers a special corporation. Despite these efforts, as of June 2024, 33 out of a total of 35 medical centers were in the red, with about 94.3% of all local medical centers recording a deficit. The cause that greatly affected the recent fiscal deficit is that during the COVID-19 pandemic, local medical centers were designated as hospitals dedicated to infectious diseases, and the number of patients visited was reduced due to the suspension of general patient treatment for the treatment of COVID-19.

- Private Finance Initiative is being used to establish public medical institutions or to solve the aging problem. Private FInance Initiative is a system in which private capital is attracted to build infrastructure, and the private sector maintains and manages infrastructure for a long time. There are currently 16 private investment projects in public medical institutions, all adopting a BTL method in which the private sector builds infrastructure and operates it during the project period, and the competent authorities pay a certain amount of money in exchange for facility operation. The BTL method is a business method that can be used only when it is limited, such as a new facility such as a ward or a new one after relocation, and the same business method is adopted collectively despite the different circumstances of each public medical institution, so legal reform is needed.

 

○ Problems in the Regional Medical Delivery System

- Medical institutions that make up Korea's medical delivery system have a rather complex classification system according to medical laws and national health insurance laws, and there is no clear division of roles between medical institutions. Patients are not dispersed in each stage due to limitations in the medical delivery system under the Medical Law and the Ministry of Health and Welfare's administrative rules and the National Health Insurance Act, and the concentration of local patients in large hospitals in the Seoul metropolitan area is particularly noticeable. Despite the step-by-step classification, patients are free to choose medical institutions, have insufficient referral and forwarding systems or strict medical referral procedures, and patients' strong trust in advanced medical equipment and medical staff owned by large hospitals, the lack of regional medical institutions and medical personnel, and the development of public transportation have accelerated patient concentration in large hospitals in the Seoul metropolitan area.

- Major projects for strengthening regional medical care and improving the medical delivery system

  ① The 'Public Healthcare Cooperation System Establishment Project' is a project to establish an essential healthcare cooperation system in the region by dividing the country into 17 regions (city/province) and 70 regions (heavy medical care area) and designating responsible medical institutions in each region and region. It has been implemented since 2020 to close the health gap and strengthen the publicity of medical care due to the lack of supply of essential healthcare and the lack of linkage of local services. The main contents are to establish and operate a cooperative network between public medical institutions in the region, centering on regional responsible medical institutions and regional base hospitals, and to strengthen the mutual cooperation system in essential healthcare fields such as emergency, trauma, cardiovascular system, mother, newborn and children, cancer, rehabilitation, chronic diseases, mental and disability, infection and patient safety. The Public Healthcare Act stipulates the designation of responsible medical institutions. 

  ② The "Project to Establish a Delayed Completion Medical System" was announced in 2024 with the aim of resolving patient concentration in large hospitals in the Seoul metropolitan area and easing the gap in regional medical accessibility by providing necessary medical services in the residential area. The main contents include re-establishing and restructuring the functions of medical institutions, strengthening the regional cooperation network, including the establishment and operation of essential medical networks, including hospitals and clinics in the region, pilot projects for regional medical innovation, expansion of financial and infrastructure support, and strengthening public medical capabilities, including the establishment of new local fees.

- Legal and institutional problems and limitations: 

  ① Responsible medical institutions not only have the status as public medical institutions, but the roles borne by responsible medical institutions within multiple projects are also complicated. Although it has been given many roles in the public healthcare cooperation system establishment project and the regional complete medical system establishment project, it is unclear which role should be focused on between supplying medical services and building a service model. In order to perform the various roles required by the project, resources and related authority such as manpower, organization, and budget must be granted, but the authority itself is ambiguous. In the ｢Act on Public Health and Medical Services｣, the roles of regional responsible medical institutions and regional responsible medical institutions are not clearly separated, so it is not easy to grasp their roles and compliance matters. In addition, solutions for the right to intensive care that does not have a regional responsible medical institution designated are insufficient. Since the Ministry of Education is in charge of national university hospitals, there are also problems under the Administrative Organization Act, and it is difficult to systematically and efficiently promote essential medical and regional medical policies through support or maintenance for national university hospitals. 

  ② Real and appropriate compensation must be given in order for medical institutions to play a role in local medical and public medical policies, but the level of compensation and compensation system are currently insufficient. It is also pointed out that there is no institutional legal basis that must be preemptively established to improve the medical delivery system like the treatment request delivery system. In addition, in the case of projects to establish a regional complete medical system, there is a lack of clear standards on how to define and distinguish the 'region'.

  ③ Several medical policies present the establishment of a cooperative network as a key task to strengthen public health care or improve the medical delivery system. However, it is difficult to clearly confirm this under the legislation, even though the roles and functions of the network participating organizations as well as the authority must be granted. Although there is a direct and indirect legal basis for a cooperative network, the law does not clearly present the substance, as well as the specific direction of the cooperative network from the perspective of regional medical care and public healthcare, and the role of administrative actors such as the state.

 

○ Problems in securing regional medical personnel 

- Qualification and arrangement of medical personnel: 

  ① The qualification standards and duties of doctors and nurses are prescribed by the Medical Law and the Nursing Law, respectively. In the case of doctors, if a person who meets the requirements for academic background to become a doctor passes the national examination and obtains a doctor's license, he/she may perform medical and health guidance work. In the case of nurses, they obtain a nurse's license pursuant to Article 4 of the Nursing Act and observe the patient's nursing needs, collect data, nursing for nursing judgment and nursing care, assist in medical treatment conducted under the guidance of doctors, dentists, and oriental doctors, plan and conduct activities for education and counseling and health promotion for nursing needs, and other health activities prescribed by Presidential Decree, and guidance on the work of nursing assistants, etc. Article 38 of the Enforcement Regulations of the Medical Law and attached Table 5 stipulate the standards for the number of medical personnel assigned to medical institutions by type of medical institution. The standards for the allocation of medical personnel at public health centers and public health centers are prescribed in Article 4 (1) and attached Table 2 of the Enforcement Regulations of the Local Health Act.

  ② A public health doctor is a doctor, dentist, or oriental doctor incorporated in accordance with the Military Service Act to engage in public health work, and is a person who has been ordered to engage in public health work. Health care is provided to residents in medical vulnerable areas, and the mandatory service period is three years outside of the military education center, and is mainly placed in public health centers, health centers, and public hospitals.

  ③ A public official in charge of health care does not have a medical license, but while working at a health clinic in accordance with the Act on Special Measures for Health Care such as Rural Communities, he/she may perform minor medical activities such as examination and examination to determine disease and injury conditions in medical vulnerable areas, first aid to patients who need treatment and emergency measures, treatment to prevent the deterioration of disease and injury, medical guidance and management of chronic patients, delivery assistance during normal delivery, vaccination and administration of medicines.

- Measures related to regional imbalances in medical personnel: 

  ① As a result of analyzing the current status of medical personnel by city, county, and district in the first quarter of 2024, it can be seen that medical personnel are concentrated in the metropolitan area. In particular, doctors are concentrated in the metropolitan area, and the gap between Seoul and Incheon and Gyeonggi-do is very large even within the metropolitan area. Sejong, Chungnam, Chungbuk, and Gyeongbuk were considered serious medical vulnerable areas, and Gyeongbuk had a particularly serious shortage of doctors. In the first quarter of 2025, Seoul (30,949) and Gyeonggi (49,274) are overwhelmingly large, and Sejong (543), Ulsan (1,854) is relatively small. On the other hand, in the case of nursing personnel, 136,828 people (48.9% overall) in the metropolitan area and 143,620 people (51.1% overall) in the provinces seem to have relatively less regional imbalance than doctors. Public health doctors are most often deployed in public health centers and health centers than in national and public hospitals. The deployment rate of health centers is 93.5%, but in the case of health centers installed in towns and villages, the deployment rate of public health doctors is only 54.4%.

  ② Measures related to securing medical personnel include the public clinical teaching system, contract-type essential agenda, senior doctor support project, public health scholarship system and local agenda system, medical personnel increase, and public medical personnel training. Each of these systems is often based on individual laws or operated in the form of pilot projects. Recently, along with the promotion of local medical and public medical policies, various bills are pending in the National Assembly to establish a legal basis for securing regional medical personnel or to expand related systems. 

- Institutional limitations in securing regional medical personnel:

  ① Concentration of medical institutions in the metropolitan area: Currently, most general hospitals are in the metropolitan area, and more than 60% of medical schools and professional training institutions, which can be called human resources training institutions, are concentrated in the metropolitan area, so local talents will be educated and settled in the metropolitan area. On the other hand, poor local medical environment such as low wages and excessive workload in local medical institutions is considered to be the main cause of regional gaps in medical personnel or concentration in the metropolitan area. The problem of lack of medical personnel seems to be a fundamental cause of the concentration of human resources in specific areas or specific specialized subjects, a large number of idle human resources, or an excessively high turnover rate. In particular, in the case of nursing personnel, it is known that there are more nurses' turnover and idle human resources than the total number of nurses, resulting in manpower shortages.

  ②  Lack of effectiveness of public health doctor policy-The number of public health doctors, which are important medical personnel in medical vulnerable areas, decreased rapidly. The cause is a decrease in the number of support personnel and non-preference for long service periods. Despite the significant decrease in the number of public health doctors, the main reason is the lack of a reasonable management system such as placement standards and role setting. After the discharge of public health doctors, support and linkage have not been provided to settle into regional medical personnel.

 

○ Recent major bills to improve Regional Medical Accessibility

- Enactment of the Special Act on Strengthening Essential Medical Care in 2024 and others: Various policies are being promoted to guarantee the health rights of the people by bridging regional gaps in essential medical and public medical care by expanding public medical personnel and improving the medical delivery system, and a number of bills have been proposed and are pending in the National Assembly to lay the legal foundation for it. The enactment of the Special Act on Strengthening Essential Medical Care (proposed by Representative Kim Yoon-won, agenda number 21618) aims to establish a regional responsible essential medical care network with the aim of providing essential healthcare in the region and closing the medical gap between regions, to save the medical delivery system and to establish a legal basis for the addition of essential healthcare fees. The bill stipulates matters related to the establishment of an essential healthcare plan for each medical right unit, designation of responsible and hub medical institutions, local doctor system, establishment of a regional and essential medical fund, and financial support based on performance evaluation.

- Four bills to strengthen public healthcare: 4 additional laws to strengthen public health were submitted to the National Assembly on November 15, 2024. The amendment to the Public Health Care Act was proposed with the aim of contributing to the improvement of public health by preparing a mechanism for expanding public healthcare institutions centered on the right to treat and increasing access to universal medical care by strengthening the publicity of each medical delivery system. Some of the amendments to the Special Measures Act for Health Care, such as Rural Communities, require the City and Provincial Public Health and Medical Commission under the Act on Public Health and Medical Services to determine institutions and facilities for public health doctors, and expand the target of institutions that can be deployed to public medical institutions. In addition, amendments to the Act on the Establishment and Operation of Local Medical Centers and the Act on Restriction of Special Local Taxation are pending in the National Assembly, respectively.

  

▶ The Legal System of Major Overseas Countries

○ Japan

- Japan's public medical institutions are responsible for treating diseases that require advanced medical technology, such as cancer and incurable diseases, or diseases that make it difficult for private medical institutions to properly provide medical services, such as tuberculosis, and regional medical institutions, such as public hospitals, are responsible for providing general medical services. Japan's regional medical system is a hospital with more than 20 beds, and has a system in which public hospitals and other public organizations established by local governments and local clinics with less than 19 beds or no beds provide local medical care to residents. 

- Policies and laws to improve access to local medical care in Japan include the establishment of a remote medical provision system, a designated manager system, and the use of a public-private cooperation law.

  ① Establishing a medical provision system in remote areas means establishing a medical provision system in vulnerable areas. The remote area medical provision system is configured to provide medical services to remote areas in connection with the state and local governments, remote area medical support organizations, remote area medical base hospitals, remote area medical clinics, and local medical support centers. By establishing such a medical provision system, home-based medicl care and telemedicine collaboration are smoothly utilized in remote areas where access to local medical institutions is very low. 

  ② The designated manager system is being used by regional medical institutions to secure medical personnel from the private sector such as medical corporations. The designated manager system stipulated in Japan's Local Autonomy Act refers to a private consignment system that designates managers from among private businesses to manage public facilities such as public medical institutions. When a designated manager operates a public hospital, the designated manager independently raises the funds necessary for hospital operation, and the designated manager secures medical personnel by himself. Since private medical corporations operate public hospitals in this way, it is possible to quickly secure excellent medical personnel through management know-how of private medical institutions, thereby mitigating the problem of shortage of medical personnel.

  ③ In Japan, in order to solve the serious deterioration of regional medical institutions, the problem of deterioration of facilities is solved by adopting a private investment method among the public-private partnership laws. Japan is conducting private investment based on the Act on Promotion of Private Finance Initiative. Currently, there are a total of 15 regional medical institutions that are adopting Private Finance Initiative in Japan, and they are appropriately coping with the aging of facilities by using various Private Finance Initiative methods according to the situation of public medical institutions. When Private Finance Initiative is used, there is an effect of financial reduction because private business operators repair and maintain facilities at their own expense. Private Finance Initiative differs from the designated manager system, which is a private contractor, in that private businesses cannot provide medical services because private businesses are only capable of construction, repair, and maintenance of facilities.

 

○ UK 

- Public Healthcare and Regional Medical Care System:

  ① The UK provides state-led National Health Service (hereinafter referred to as NHS). The NHS system is largely divided into the part responsible for health care policy and management and the part responsible for health care and clinical practice. The areas dealing with health care and clinical practice are again divided into primary care (community care, general practitioner, dentist, pharmacist, etc.) and secondary care (hospital-based treatment through general recommendation).

  ② Among the regions of the UK, England's health care policy is the responsibility of the central government, and NHS England is leading the financing, planning, and provision of health care services. On the other hand, Scotland, Wales, and Northern Ireland are the responsibility of decentralized local governments, and the NHS in each region also has its own structure and organization depending on the region. The NHS divided the country into 57 regions and divided hospitals by region, transferring authority to the Trust for various medical services such as patient management, financial management, and doctor selection. The Trust is a non-profit organization that provides and manages secondary health care with a budget from the NHS, and is responsible for the operation of NHS hospitals and medical institutions. The Health and Care Act enacted in 2022 formalized the Integrated Care Systems (ICS). The authority was entrusted to the ICS to manage NHS finances at the local level. The ICS operates the organization by dividing the UK into 42 systems and subdividing them into 25–500,000 people (Place) and 30,000–50,000 neighbors depending on the size of the population. The ICS is centered on two institutions: the Integrated Care Committee (ICB) and the Integrated Care Partnership (ICP). The Integrated Care Committee acts as the headquarters responsible for the operation and coordination of budget and medical services and establishes an NHS service plan. On the other hand, the Integrated Care Partnership is a council where local governments and welfare institutions discuss local health care and care together.

  ③ The NHS's medical delivery system is divided into primary and secondary care. Primary care is operated at the local medical level, shares local resources, and provides expanded services through close cooperation with other local organizations. Since it is individually registered with a general practitioner (GP) and operated under a family doctor system, medical records of individuals and families are systematically managed. Secondary medical care is responsible for hospital treatment, emergency medical care, overtime GP treatment, and mental health-related treatment.

- Policies and legislation to improve Regional Medical Accessibility:

  ① The 2019 National Health Service Long Term Plan (NHS) is a 10-year health care strategy roadmap announced in January 2019, suggesting a preventive-oriented, technology-friendly, integrated and sustainable policy direction.

  ② Primary care networks (PCNs) are a policy implemented as part of the 2019 National Health Service Long-Term Plan and are a cooperation-based organization of primary care. GP clinics and community health services team together to provide integrated and preventive-oriented health care to local residents. It is a group of several GP clinics to provide a wider range of services to local residents than those provided by individual clinics. 

  ③ The Health and Care Act 2022 was enacted to support cooperation and partnerships for service integration for patients, recognizing the need for cooperation between hospitals, GPs, social workers and other organizations to improve local services and make the most of public funds. The disconnection of social services such as medical care and care, aging and increasing chronic diseases have required an integrated response to health care and social services, and the need for a region-based integrated service system at the time of COVID-19 and the need to alleviate the systematic complexity of the Health and Social Care Act in 2012 were enacted. The core of this law is to be in charge of regional service planning to improve the health of the people and reduce inequality through ICSs. It also stipulates new legal obligations such as addressing health inequality, promoting research, and responding to climate change, etc. by strengthening the health minister's authority to intervene, mental health and cancer treatment, expanding public participation, and reflecting opinions from patients and caregivers.

- Improving Integrated Medical Accessibility with Digital Technology Utilization: NHS is expanding chronic disease management, home patient monitoring, and non-face-to-face treatment by actively introducing artificial intelligence (AI), data analysis, and mobile health. In 2013, NHS England established 'Health Innovation Networks', an innovative organization under its wing, to introduce technologies and develop solutions for the digitization of medical services. NHS is building integrated medical services by introducing an electronic health record (EHR) system to store individual medical records and share data records with partner organizations through a digital platform. 

- Home-based medical care: The UK's Community Nursing Service supports a wide range of home patients, including adults with complex and palliative care needs, patients with nutritional care needs, and patients with postoperative wound care needs. On the other hand, the Primary Care at Home program provides customized preventive treatment and care in the community by allowing a GP or primary care team (including social workers if necessary) to visit the patient's home and provide comprehensive and continuous medical services.

 

○ Comparison and Implications

- Establishment and operation of public medical institutions: In Japan, private investment methods are used to resolve the shortage of regional medical institutions and the aging of facilities, and public hospitals corresponding to local medical centers are operated in various ways. It has implications in that it has established legislation to respond flexibly to the maintenance of facilities in public medical institutions by adopting the necessary business method according to the situation of each public medical institution.

- Medical delivery system: In Japan, the functions of national hospitals and local medical institutions are divided. National hospitals are in charge of treatment of high-level diseases, and local medical institutions are in charge of general treatment. It differentiates the functions of medical institutions and prevents patients from being concentrated in specific higher hospitals in advance, and improves access to regional medical care by reducing the burden on local medical institutions to secure high-level surgical equipment and medical personnel through a region-centered medical system. The UK also forms a functional differentiation between primary and secondary medical care, and in particular, in the case of primary medical care, it intends to provide health care services suitable for the medical needs of local residents and local reality through an integrated care system and cooperative network.

- Korea also needs institutional improvement measures to differentiate the functions of medical institutions. Currently, projects to strengthen regional medical care and public medical care, centered on regional responsible medical institutions, are also policies to establish a regional-centered public healthcare system like Japan and the United Kingdom. Considering that local governments are financially weak and medical services are provided nationwide through health insurance under a single insurer system, it is not appropriate to follow the regional-centered public medical system model in the same way as Japan and the United Kingdom. 

- Securing regional medical personnel and institutional supplementation: Japan is striving to supply and demand medical personnel through a designated manager system, as well as expanding medical staff, introducing a regional quota system, hospital director requirements, and introducing a local work system for clinical training. In addition, it is actively using home-based medical care and telemedicine collaboration, and is establishing a system to facilitate home-based medical care and telemedicine collaboration in medical vulnerable areas by linking the remote medical support organization, the remote medical base hospital, the remote medical clinic, and the local medical support center. The UK is also promoting policies such as increasing the number of medical schools and training, hiring foreign workers, and improving working conditions, and is expanding chronic disease management, home patient monitoring, and non-face-to-face treatment through artificial intelligence, data analysis, and mobile health. In addition, community nursing services and primary medical home care programs are implemented to improve the accessibility of local residents to medical care.

- In both Japan and the UK, due to the lack of medical personnel and large regional deviations, the issue of access to medical care for local residents is a policy issue, and efforts are being made to implement effective regional medical policies through the use of digital technology and activation of home-based medical care. Japan needs to pay attention to the fact that an independent institution called the Regional Medical Support Center supports the task of dispatching doctors and effectively deploys medical personnel to medical vulnerable areas. Korea also needs to hurry to reorganize legislation to utilize digital technology and revitalize visiting medical care.

 

▶ Legislative Improvement Measures

○ Improvement of establishment and operation of local medical centers and establishment of roles

- Improvement of Private Finance Initiative legislation to improve the establishment and operation of local medical centers: Under the current Act on Public-Private Partnerships in Infrastructure, it is difficult to utilize Private Finance Initiative if only the operation of facilities is required. To solve this problem, it is also a way to consider the introduction of a business method that can only be operated without improvement and expansion. To actively utilize the so-called combined method that combines two or more business methods, it would be effective to specify the improved operation method in the master plan for Private Finance Initiative projects as a combined business method to improve access to regional medical care through the maintenance of facilities in public medical institutions.

- Improvement of the regional responsible medical institution system: In the Act on Public Health and Medical Services, the division of roles and functions with regional responsible medical institutions is not clearly distinguished. Therefore, it is necessary to amend the law to distinguish between regional responsible medical institutions and regional responsible medical institutions. In addition, in the establishment of a medical plan under Article 13-3 of the Enforcement Regulations of the same Act, it is necessary to separate and stipulate the contents of the plan of regional responsible medical institutions and regional responsible medical institutions. At this time, it is also possible to consider a plan to provide medical services tailored to the characteristics of the region by including a 'demand-based medical provision plan according to the analysis of regional characteristics in medical acceptance' in the contents of the plan for regional responsible medical institutions.

○ Establishment of cooperative network to improve regional medical delivery system  

- Analysis and Legislation of the substance of cooperative networks: Policies for building cooperative networks to improve access to local medical care are effective only in connection with legislation, and in order to be legislated, it is necessary to review which areas and how the concept of cooperative networks will be actually applied and realized under the Korean health care system. Accordingly, directions for how to improve the current law to legally support each cooperative network project should be presented. On the other hand, an appropriate cooperative network model should be reflected in the legislation on regional medical care and public healthcare according to the content of each policy (project) or the unit in which the project is carried out.

- Establishing the role of participants

  ① Reestablishing the function of medical institutions: Establishing a cooperative network as an improvement of the medical delivery system should presuppose the re-establishment of functions between primary and secondary medical institutions. In the case of secondary medical institutions, the focus should be on linkage and cooperation between hospitals for the supply of essential medical care. In particular, in order to establish a cooperative system for public healthcare, it is necessary to grant legal authority consistent with the role of the responsible medical institution. In addition, since there will be differences in the geographical, industrial, and demographic characteristics of each region, the specificity of medical demand, and the situation of securing medical personnel, autonomy should be secured to implement health care projects suitable for each region. On the other hand, in the case of primary medical institutions, the system for managing chronic diseases and providing integrated services should be strengthened.

  ② Role of public administrative entity: In public administrative entity, a role shall be assigned to help the functional differentiation between secondary medical institution and primary medical institution, and to ensure that each participant's activity or operation of the system conforms to each legislative purpose or major regional medical care and public healthcare policy. In essential medical care, the State shall respond to key blind spots, such as resolving essential healthcare gaps around the right to intensive care that is not designated even by regional responsible medical institution, set policy priorities through public discussion process, etc., and to link and integrate between institutions in the legal aspect ahead of the enforcement of the Act on Integrated Support for Local Care, such as Medical Care and Nursing. It should meet the prerequisites for establishing an efficient regional medical delivery system, such as linkage between health care information systems, maintenance of related laws, and accumulation and sharing of data and experience cases that can be used to determine and promote medical projects in each region. Metropolitan local governments need to establish cooperative relationships with regional responsible medical institutions and share functions, and basic local governments should play a central role in identifying medical needs in each region through health care administrative organizations such as public health centers, managing vulnerable groups, and linking related organizations.

○ Legal and institutional supplementation for the lack of regional medical infrastructure

- Expansion of telemedicine collaboration and non-face-to-face care: The lack of regional medical infrastructure is can be partially supplemented by using digital technology in the medical field, so telemedicine collaboration and non-face-to-face care should be further expanded. In accordance with Article 33 of the ｢Medical Law｣, telemedicine is prohibited in principle, and the pilot project for telemedicine collaboration and non-face-to-face treatment is being implemented to a limited extent. The pilot project for telemedicine collaboration in medical vulnerable areas is based on Article 34 of the ｢Medical Law｣, Article 44 of the ｢Basic Health Care Act｣ and Article 19 of the ｢The Act on Special Measures for Health and Medical Services in Agricultural and Fishing Villages, etc.」. It is a pilot project to enhance medical accessibility of the vulnerable and medical vulnerable groups by providing telemedicine collaboration services using information and communication technology (ICT) by medical personnel centered on regional medical institutions. The pilot project for non-face-to-face treatment is a project in which doctors, dentists, and oriental doctors provide medical services such as examination and prescription using information and communication technology such as computers and video communication to patients who need non-face-to-face treatment based on Article 44 of the ｢Basic Health Care Act｣. Since telemedicine collaboration is centered on the medical vulnerable areas and medical vulnerable groups, it contributes greatly to improving medical accessibility and is also an institutional opportunity to realize integrated medical, caring, and welfare services. However, in order to revitalize the project, an information transmission system for remote cooperation and public health personnel acquisition and education must be carried out together, and the scope of medical vulnerable areas must be expanded. On the other hand, non-face-to-face treatment is essential to solve the aging population, the explosive increase in chronic diseases, regional medical inequality, and the shortage of medical personnel. Along with the clear legal basis for non-face-to-face treatment, problems that may arise in the actual system operation process should be reviewed and the countermeasures should be legislated. 

- Activation of home-based medical care: Visiting medical care not only enables the provision of medical services through face-to-face even in areas where medical infrastructure is insufficient, but also can contribute to resolving medical inequality between regions, but can also support customized health care and continuous follow-up management in connection with social services such as care within the community. In accordance with Article 44 of the Framework Act on Health Care and individual laws, the pilot project for home medical care, the pilot project for visiting medical care, the pilot project for health doctors of the disabled, and the pilot project for home-style hospice are carried out in various ways. Visiting medical pilot projects shall be legislated to integrate them to enable duplicate adjustment and supplementation according to their practical contents, and it is also necessary to consider revising Article 33 of the Medical Law, which restricts medical treatment to take place only within medical institutions. It is also necessary to prepare a plan to provide various pilot projects in an integrated and efficient manner by a primary medical institution in the community or a separate public institution. Efforts are needed to integrate various home care services, linkages between various visiting nursing institutions, human resources providing services, develop service contents, and develop appropriate fees. On the other hand, it is necessary to institutionalize the connection with universities, education on the importance of visiting nursing, and practice systems for acquiring visiting nursing professional skills, and prepare related regulations in medical laws, nursing laws, and public healthcare laws so as to secure professional manpower necessary for visiting medical care.

- Improving the treatment of medical personnel, etc.: The reason why doctors avoid working in public hospitals in medical vulnerable areas is because of the heavy burden of the lack of fellow doctors and poor working conditions, in addition to the salary level. On the other hand, nurses are an important medical resource that can alleviate the gap in regional medical care due to the lack of doctors, and their role in home-based medical care will become more important in the future, so it is urgent to improve the treatment of nursing personnel. It is necessary to support the return of idle nurses, guarantee the role and authority of nurses in the local medical system, especially in chronic disease management projects in medical vulnerable areas, and to improve the treatment of nurses in local small and medium-sized ospitals.

Ⅲ. Expected effects

▶ Academic contribution

○ It provides basic data necessary for research on public healthcare legislation by analyzing Korea's public healthcare and regional medical care laws and systematically organizing regional medical accessibility from a legal perspective.

○ It can be used as a reference in conducting detailed research on public healthcare and regional medical care through comparative research.

▶ Policy Contribution

○ It contributes to policy improvement and future improvement legislation to redefine the roles and functions of public healthcare and regional medical care systems.

○ Considering the recent technological advances and the inherent limitations of health care policies under the Korean social structure, implications for realistic and rational system improvement are presented.