Health Promotion International Advance Access originally published online on March 6, 2007
Health Promotion International 2007 22(2):155-162; doi:10.1093/heapro/dam004
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PERSPECTIVES |
Health promotion capacity mapping: the Korean situation
1 Healthy City Research Center Institute of Health and Welfare, Yonsei University, Wonju, Republic of Korea 2 Division of Health Promotion, Seoul Metropolitan Government, Republic of Korea 3 Institute for Medical Informatics, Biostatistics and Epidemiology, University of Munich, Germany
* Corresponding author. E-mail: ewnam{at}yonsei.ac.kr
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Ten years ago the Republic of Korea enacted the National Health Promotion Act, setting the stage for health promotion action in the country. A National Health Promotion Fund was established, financed through tobacco taxes, which is now one of the largest in the world. However, despite abundant financial resources, the infrastructure needed to plan, implement, coordinate and evaluate health promotion efforts is still underdeveloped. Currently, health promotion capacity mapping efforts are emerging in Korea. Two international capacity mapping tools have been used to assess the Korean situation, namely HP-Source and the Health Promotion Capacity Profile, which was developed prior to the sixth Global Conference of Health Promotion, held in August 2005 in Bangkok, Thailand. The article summarizes and discusses the results of the capacity mapping exercise, highlights its challenges and suggest ways to improve the accuracy of health promotion capacity mapping.
Key words: capacity; mapping; infrastructure; Korea
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The Republic of Korea is in an exceptional situation: the country has one of the largest funds for health promotion globally. However, many hurdles have been encountered in the process of spending the money in an efficient and sustainable way, mainly due to the country's limited health promotion capacity.
Scholars and politicians are now realizing the urgent need to assess the strengths and weaknesses of Korea's health promotion capacity. Health promotion capacity mapping could be an important tool in Korea, if two things are given: first, if the tool not only looks at the façade—but also behind it, and secondly, if the ‘mappers’ have a good understanding of the tool and of health promotion. Only then can the results of the mapping exercise serve as a catalyst to change old structures.
This article summarizes and discusses the results of health promotion capacity mapping in Korea and highlights some of the challenges of a capacity mapping exercise. Suggestions are made on how to improve the accuracy of health promotion capacity mapping.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Data collection
One of the capacity mapping tools used was HP-Source. The construction of HP-source.net was funded by the European Commission and is now coordinated at the University of Bergen in Norway (IUHPE, 2003
, 2004; Mittelmark, 2005a, Mittelmark, 2005b). HP-Source.net is now a comprehensive database of health promotion policies, infrastructures and practices—and of political, economic and practical aspects of health promotion (www.hp-source.net). Two researchers (one from academia and one from a national research institute) filled out the 2002–2003 version of HP-Source for Korea. Information for the following categories was collected: formulation of policy; evaluation of policy; monitoring, survey and research; implementation; professional workforce; professional associations; and funding. National and sub-national level data were obtained from published and unpublished documents and reports, reliable Internet sites of relevant official agencies and through informal interviews with government officials from the Ministry of Health and Welfare (MOHW) and with public health experts.
The second tool used is the Health Promotion Capacity Profile (Catford, 2005). This tool was developed in preparation for the sixth Global Conference on Health Promotion (GCHP). The national health promotion capacity of WHO member states was mapped through its network of Regional Health Promotion Advisors or focal points and the results were presented at the sixth GCHP. The Korean data was collected by a focal person, identified through the WHO Regional Office for the Western Pacific. The focal person was from the Bureau of Health Promotion, MOHW. The data, which was collected in preparation for the sixth GCHP, is not summarized in detail in the results section, as this would be repetitive. However, the results are referred to in the discussion section.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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General characteristics of the Republic of Korea and a background of health promotion at the national level are shown in Tables 1 and 2, respectively.
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Policy formulation
The MOHW has the final responsibility of health (promotion) policies. Scholars from universities or research centres [especially the Korean Institute for Health and Social Affairs (KIHASA)] are commissioned by MOHW to research about specific topics to assess their public health relevance. The MOHW reviews the research report and if the topic is considered relevant, an ‘advisory group’ is established to assist in formulating the policy.
Public health-related scholars were involved in the formulation of the ‘Health Promotion Act’, which was passed in 1995 (Table 3). An important point of reference of this Act was VicHealth, the Health Promotion Foundation in Victoria, Australia. The Korean Health Plan 2010, which is the white paper on health promotion in Korea, was published in 2002. Other frequently used English names of the health plan include: National Health Promotion Plan, National Health Objectives and Healthy Korea 2010. The health plan is based on the concept of ‘Healthy People 2010’ from the US and on the National Health Objectives developed in Japan, called Healthy Japan 21. Twenty-seven public health-related scholars were involved in the formulation of the ‘Health Plan’ (KIHASA, 2000).
Priority areas include for example: the reduction of tobacco smoking and the consumption of alcohol, an increase in the level of physical activity and healthy nutrition. Other objectives are related to the management of chronic disease, for example diabetes mellitus, arthritis, cerebrovascular and cardiovascular disease and dementia (Nam et al., 2003).
Evaluation of policy
To date there is no systematic evaluation of health promotion policies in Korea and there is no system through which the evaluation results could be communicated from the local and provincial levels to the national level. Information about the evaluation of health promotion is summarized in Table 4.
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Currently, there are different ways through which health promotion policies are evaluated by the Korea Health Promotion Fund (KHPF) under the KIHASA. The KHPF evaluates 16 Regional Centres for Health Promotion (RCHP). The offices of the recently created RCHP evaluate the local health promotion plans, developed by the MOHW. The projects are funded by the KHPF and include only four topics, namely the promotion of healthy nutrition and physical activity, anti-tobacco and anti-alcohol projects (Oh, 2001
). On the other hand, the provincial (metropolitan) government evaluates the local ‘Community Health Promotion Plans’, which are implemented by the public health centres.
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The mid-term evaluation of the Health Plan 2010 took place in 2005. International experts (from Japan and the US) were invited to provide guidance in revising and partially rewriting the Health Plan (CDC and MOHW, 2005
). One of the weak points of the health plan was that it did not propose strategies on how the National Health Objectives could be reached (Nam et al., 2004).
Monitoring, survey and research
Research institutes, including for example the KIHASA, the Korean Health Industry Development Institute (KHIDI) and universities conduct health promotion research. Since the year 1997 the Health Promotion Fund calls for proposals once a year and provides financial support to health promotion research projects, most of which are 10-months projects (Lee et al., 2003).
Korea has a regular National Health and Nutrition Survey, which is conducted every 3 years, since 1998. Prior to 1998, a data collection system also existed, but the survey structure was changed from 2005. The KIHASA is responsible for the health survey and the KHIDI is responsible for the nutrition survey. At the subnational level, the Seoul Metropolitan Government, for example, commissions a regular 4-year health survey. Table 5 summarizes the monitoring, survey and research activities in Korea.
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Implementation
Overall, the MOHW is responsible for supporting and overseeing the implementation of the National Health Plan 2010 (Nam, 2003
). It is difficult to grasp the full scope of ‘implementation’ of health promotion programmes. The MOHW implements nation-wide health promotion campaigns, including for example a recently launched anti-smoking campaign. The MOHW supports national and local bodies in achieving the national health objectives. The sub-national levels develop health promotion work plans, which follow the general guidelines of the national level. At the local level the Public Health Centres and their branch offices are the key players in implementing health promotion (Nam and Nam, 2004). Table 6 shows details of health promotion implementation.
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Professional education in health promotion and professional associations
Currently, only one university in the Republic of Korea offers master's level courses in health promotion, namely the Department of Health Promotion and Education in the Graduate School of Public Health at Yonsei University in Seoul. Post-graduate non-degree courses are offered by the Korean Association of Health Education and non-academic courses are taught at the KIHASA and the Korean Centres for Disease Control (KCDC). In 2005, the MOHW launched a ‘Field Management Training Course (FMTP)’ for health-related staff at the sub-national level.
Korea has 17 health sciences-related academic courses at the undergraduate level and over 28 MA (Master of Arts) or MPH (Master of Public Health) courses. Furthermore, over 10 PhD courses in the health sciences field are offered by universities. Also, the Korean Association of Public Health Administration and the Korean Association of Health Education introduced the Health Education Specialist system in 1999 (Nam, 2003). In December 2004, there were a total number of 1127 Health Education Specialists (class 2). The Korean Government will introduce a national license system for Health Education Specialists (class 1) starting in 2009. The legal backing for the licence system is the National Health Promotion Act (http://healthguide.kihasa.re.kr).
Funding
The budget for health promotion in Korea is abundant and is clearly the strongest part of Korea's health promotion capacity. The Health Promotion Act set the stage for the KHPF, which was created in 1995. The fund is financed through earmarked tobacco taxes. Article 22 of the Health Promotion Act is the legal basis of the provision of financial resources to health promotion programmes through the fund. The KHPF is the primary financial source for health promotion programmes at national and sub-national levels (Nam et al., 2006). When tobacco taxes designated for the Health Promotion Fund were first collected in 1996, only 
0.002 US$ [1000 Korean Won 1 US$] were collected per 20 cigarettes. In 2003, about 0.15 US$ were earmarked for Health Promotion per pack of cigarettes, compared to about 0.354 US$ in 2005. The tremendous increase in the Health Promotion Fund's budget is shown in Table 7. However, it must be said that until 2004 only about 4% of the fund were actually allocated to health promotion activities. The remaining 96% went to the National Health Insurance (NHI). As of 2006 this changed and now about one-third of the budget goes to health promotion activities.
The total amount of health promotion budget in 2005 is estimated to be 14 289 hundred million Korean Won (1 428 900 000 US$). Of the total budget 9288 hundred million Korean Won (928 800 000 US$) goes to the NHI Cooperation and 3567 hundred million Korean Won (356 700 000 US$) are used specifically for health promotion programmes. The surplus budget of about 1321 hundred million Korean Won (132 100 000 US$) and 42 hundred million won (4 200 000 US$) are used to cover the administrative costs of the KHPF (Lee, 2005).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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According to the results of both HP-Source and the Health Promotion Capacity Profile, health promotion capacity in Korea is well-developed. Actually, the resulting ‘map’ of health promotion capacity is quite impressive for a country that has embarked on health promotion only 10 years ago. However, the positive results raise some questions about the utilization of capacity mapping tools.
General limitations of measuring health promotion capacity, which became evident in this mapping exercise, also resulted from multiple understandings of health promotion terminology, which has previously been suggested by Ebbesen (Ebbesen et al., 2004). Subjectivity also posed a difficulty, which has become apparent when comparing results of respondents from academia and from government officials. Academics tended to portray the situation much more critical.
Problems, especially for non-native English speaking countries, include misunderstandings and conceptual misinterpretations of health promotion due to cultural and language barriers. Last but not least, the complex nature of health promotion makes it challenging to measure capacity.
The following shows an example of conceptual misinterpretation. The result of HP-Source shows that numerous policies exist in Korea, which are in theory, based on the Ottawa Charter (WHO, 1986). However, the short version of the Health Promotion Capacity Profile, asks if the national policies are based on the Ottawa Charter, but the name of the Charter is not explicitly referred to. The first item asks if ‘national policies and plans exist that embrace the following action areas: building healthy public policies, creating supportive environments, reorienting health services, strengthening community action and developing personal skills’. Answer options ranged from ‘A’ (fully implemented) to ‘F’ (not currently action). Interestingly, the answer to this question was ‘E’ (being considered), despite the fact that the National Health Promotion Act specifically mentions the Ottawa Charter.
The fact that the Health Promotion Capacity Profile gives the option to group the availability of health promotion capacity into the degree of implementation and consideration ranging from ‘A’–‘F’, could be an advantage. However, a clear understanding of the ‘degrees’ and of health promotion is crucial.
Mapping programme delivery (implementation of health promotion programmes) is difficult because it is often unclear what programmes or activities are considered to be health promoting. In Korea, for example, the concept of health promotion programmes has been limited to four topics: tobacco control, reduction of alcohol consumption, promotion of healthy nutrition and physical activity. These four topics are implemented mainly in the country's 246 district level public health centres. The concept that health promotion programmes include a far wider range of topics and that such programmes can be implemented by settings other than the public health centres is only slowly starting to catch on. This is supported by the answer to the question in the health promotion capacity profile: ‘use of combinations of interventions strategies in different settings [...]’, which was ‘E’ (being considered). The results of HP-Source for the category ‘implementation’ also show that government bodies at national and sub-national level are the main implementing bodies.
Issues that the capacity mapping tools did not address, but that would be important to improve the Korean situation, include for example whether evaluation mechanisms are coordinated, whether professional education and continuing education are positively evaluated by participants or whether the existing guidelines are useful for the health promotion workforce.
As previously discussed by Fosse (Fosse et al., 2005): ‘no single capacity mapping exercise can capture the complexity of policy, infrastructure and key programmes that constitute a nation's capacity to engage in effective health promotion’. This was underscored by the experience in Korea, as both tools were unable to identify the situation ‘behind the façade’. It became obvious that a quantitative tool, even if it includes a rating scale (like the one used in the Health Promotion Capacity Profile), or if it requests links to documents to provide evidence (like HP-Source does), does not truly capture the country's health promotion capacity.
Since subjectivity of the results is an issue for any capacity mapping tool, a team of professionals from various backgrounds is needed to complete the capacity mapping exercise to make the results as unbiased and trustworthy as possible.
A lot of research has focused on community capacity (Goodman et al., 1998; Gibbon et al., 2002; Smith et al., 2003). It is important that the assessment of national capacity for health promotion draws on the experience of the community level, not only regarding the components of capacity, but also regarding the methods of assessing capacity. The importance of a ‘facilitated dialogue’ or workshop approach in assessing community capacity has been emphasized (Gibbon et al., 2002). Numerous researchers have suggested a combination of quantitative and qualitative methods to assess community capacity. Based on the experience of the capacity mapping exercise in Korea, this also applies to the national level.
According to both tools, the health promotion capacity map in Korea looks good. However, what is needed at the current level of health promotion development in Korea is a more ‘fine-tuned’ map, a map that looks behind the façade and which shows speed bumps, construction sites, radar traps and one way streets. To produce such a map, a combination of methodologies is unavoidable. Obviously, more resources (time, manpower, skills, money) are required, and such resources are often limited. However, initial investments in capacity mapping followed by investments in capacity building are key to help strengthen capacity in Korea and to help spend the abundant money available for health promotion efficiently and sustainably.
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