INTRODUCTION

The South Korean healthcare system has recently plunged into a significant crisis following a February 2024 announcement by the government to increase medical school admissions by 67%, equating to 2,000 additional students. This decision, intended to address national physician shortages and regional disparities, faced fierce opposition from the medical community. The backlash resulted in over 95% of medical students taking a leave of absence and more than 90% of resident physicians resigning, signaling widespread dissatisfaction [1].

Building on our previous publication about South Korea’s healthcare crisis [2], this article explores the longstanding systemic challenges in the nation’s healthcare system. We examine how these issues have contributed to the current crisis and critically evaluate the government’s rationale for increasing medical school enrollment as a proposed solution.

We suggest that expanding admissions is unlikely to effectively address these healthcare problems; therefore, we present alternative approaches that could offer a more sustainable and equitable path to reform.

LONG-STANDING HEALTHCARE CHALLENGES

South Korea’s healthcare system, known for its quality and efficiency, faces deep-rooted struggles. Persistent issues such as low reimbursement rates, specialty imbalances, regional disparities, and high legal risks for doctors have strained the system. These structural problems have created significant obstacles for healthcare providers and patients, affecting the system’s ability to adapt to growing demands. The sections below outline these key challenges and their impact on the healthcare landscape in Korea.

Inadequate Reimbursement System

Since its launch in the 1970s, South Korea’s national health insurance system has faced ongoing challenges with low reimbursement rates. Initially, medical costs were 55% below existing rates [3, 4]. Despite government promises to raise fees with the gradual increase in enrollment, significant changes did not occur after universal health insurance was fully implemented in 1989. As a result, healthcare providers sought alternative revenue by boosting patient numbers, prescribing more medications, and providing services not covered by insurance to offset the insufficient reimbursements [4].

University hospitals have responded to financial constraints by prioritizing high-revenue medical services, such as advanced imaging tests, over less profitable ones. This approach has resulted in a workforce heavily reliant on resident physicians: 46.2% of Seoul National University Hospital physicians and 40.2% of Yonsei Severance Hospital are residents [5]. This staffing model has led to significant challenges, including low pay and heavy workloads for residents, which can affect both the quality of training and the overall standard of patient care.

Specialty Imbalances

The distorted reimbursement system has created significant disparities across medical specialties. Fields like plastic surgery, psychiatry, and dermatology have become highly attractive because they offer opportunities for higher revenue from noninsured services, coupled with a lower likelihood of dealing with critically ill patients. These specialties also provide better prospects for establishing private practices after completing training [6].

On the other hand, less popular specialties face significant challenges, including frequent surgical procedures, higher risks, lower compensation despite the workload, and uncertain career paths. For instance, the thoracic surgery residency program has encountered these difficulties, with recruitment rates fluctuating significantly—47.4% in 2010, 36.8% in 2011, 41.7% in 2012, and 46.7% in 2013. Despite government intervention through increased reimbursement rates for these fields, the improvement to 60.8% in 2014 was temporary, falling back to 39.6% in 2015 [3].

Geographic Disparities

When the universal health insurance system was first implemented in 1989, a healthcare zoning system was introduced as an effort to prevent the concentration of patients in big cities. Patients were required to seek treatment within designated zones, with the exception of delivery, emergency, or other inevitable occasions. However, the system was abolished in 1998 due to the inconvenience it caused to patients, who often faced restrictions in accessing preferred medical facilities outside their designated zones [7]. The launch of the KTX high-speed rail in 2004 further centralized healthcare access, driving more patients to the capital and worsening the uneven distribution of services.

With these factors at play, patients remain heavily concentrated in metropolitan areas. Data from the National Health Insurance Service show that from 2016 to 2022, approximately 30% of cancer patients outside Seoul traveled to the capital for care, while only 53.9% received treatment in their local cities [8]. The asymmetry between the demands for urban medical services and the demands for rural medical services is one of the reasons fueling the regional disparity in the provision of medical services.

Government efforts to address these disparities have largely fallen short. Public medical centers established by the government are not running efficiently owing to a lack of sustainable funding. Few physicians are willing to work in public medical centers because of inadequate equipment, which forces them to provide care below their desired standards. Moreover, excessive workloads and frequent overnight shifts are common, as hospitals operate with minimal staff to reduce costs. This strain on doctors further discourages them from taking positions in these facilities. 

As a result of the complex interplay between the aforementioned elements, healthcare services in South Korea remain heavily concentrated in metropolitan areas, leaving many regions significantly underserved. As of August 2024, around 14.8% of cities and counties (34 out of 229) lack an emergency medical facility [9].

Medical Litigation Concerns

South Korean physicians face extraordinarily high litigation risks compared to their international counterparts. From 2013 to 2018, Korean doctors were 15 times more likely to face criminal charges than their Japanese counterparts and 566 times more likely than UK physicians [10]. A notable case in 2017 involved the deaths of four newborns at a university hospital, leading to the arrest of three medical staff members. Though ultimately acquitted, the case demonstrated that even the possibility of unclear medical negligence could result in a criminal charge [11].

In obstetrics, severe compensation rulings have exacerbated the problem. A May 2023 ruling ordered an obstetrician to pay $900,000 in damages in a cerebral palsy case, highlighting the excessive penalties imposed in cases involving medical uncertainty [12]. Consequently, most obstetrics residents now choose to specialize in gynecology instead, leaving some major university hospitals without obstetricians for the past two years [13].  

WHY SIMPLY ADDING MORE DOCTORS IS NOT THE SOLUTION

The government’s proposal to increase medical school enrollment by 2,000 students fails to address these fundamental issues. The justification for this increase relies on selective data from scenarios that predict a physician shortage while disregarding other scenarios that do not indicate a deficit. Even the authors of the cited studies have stated that their findings do not support the government’s claims [14]. 

South Korea already exceeds OECD averages in the number of physicians committed to certain specialties, such as pediatrics; yet many specialists choose not to practice in their trained fields [15]. This indicates that the issue is not with the total number of physicians, but rather with their distribution and the systemic obstacles mentioned earlier, such as low reimbursement rates and a significant risk of medical lawsuits. These factors ultimately hinder board-certified specialists from practicing their specialties in a sustainable way. Furthermore, the current medical education infrastructure is not equipped to accommodate a significant increase in student intake, raising serious concerns about potentially compromising the quality of training and future physician competency [16].

Expanding medical school admissions is unlikely to resolve the healthcare system’s core issues, as it overlooks the deeper problems of workforce distribution and systemic barriers. A more effective approach would involve a targeted plan to guide new doctors into underserved specialties and regions. Such a strategy should focus on reforms that improve workforce distribution, ensure equitable healthcare access, and establish a sustainable, high-quality training environment for future physicians.

A PATH FORWARD

Resident physicians and the healthcare community have proposed key reforms to effectively tackle these challenges, as discussed below [5].

Evidence-Based Workforce Planning

Creating an objective scientific organization to forecast South Korea’s medical workforce is crucial. This effort has significant and lasting impacts on the healthcare system and goes beyond mere political decisions. It is vital to integrate robust scientific data and insights from the medical community to formulate comprehensive, informed policies that tackle the fundamental issues affecting the workforce. 

Legal Framework Reform

Protective measures for unavoidable medical accidents are urgently needed. The current system’s high risk of litigation has deferred interest in specialties associated with higher patient mortality rates, leading to imbalances in the medical workforce. A robust legal framework is essential for allowing healthcare professionals to prioritize patient care without the constant threat of legal action. Such legal support can help create a healthcare environment that is not only more effective but also genuinely patient-centered.

Training Environment Improvements

Resident working conditions must be improved. The current financial constraints at university hospitals have led to a reliance on resident physicians over higher-cost, board-certified doctors, burdening residents with excessive workloads and limiting their training opportunities. University hospitals should prioritize hiring more board-certified doctors to enhance resident training conditions and overall patient care. This reform would help balance workloads, allowing residents to gain comprehensive training experiences. It would also encourage board-certified doctors to return to practicing their specialties rather than opting for more lucrative cosmetic procedures.

CONCLUSION

South Korea’s ongoing healthcare crisis, marked by student strikes and resident protests, underscores the urgent need for systemic reforms. The government’s plan to increase medical school admissions falls short of addressing core issues like low reimbursement rates, uneven specialty distribution, regional disparities, and high litigation risks, all of which undermine the healthcare system and impact training and patient care. Meaningful change requires a comprehensive, evidence-based approach that includes establishing an impartial medical workforce planning body, reducing litigation pressures through legal reforms, and improving residents’ working conditions. Collaboration between the government and the medical community is vital to building a resilient, equitable, and patient-centered healthcare system for the future.

Acknowledgement

We would like to thank Dr. Chul S. Hyun for his guidance, editorial input, and invaluable feedback in preparing this article.