In the following section, we explore the history of the Korean health screening system and the present national health screening and workers’ health examinations. We believe that, to understand the modern Korean health screening system, it is necessary to look back on the history of health screening. This will provide some information on how the current policies, institutions, and attitudes and culture of the people concerning this topic have been formed.
History of health examination and domestic system of national general health screening
Although the specific origin of organized health examinations (OHEs) is uncertain, the first recorded regular health examination/screening dates back to the 14th century [8]. In modern medical science, the concept of performing a health screening for those without particular symptoms was first suggested by Horace Dobell, a medical scientist in the UK [9]. In the US, the first health screenings were conducted in the mid-19th century among immigrants in line with quarantine inspections [10]. In the 20th century, Gould suggested the necessity of OHEs for general population groups, becoming the first promoter of general health examinations in the formal academic literature [11, 12]. Until the early 20th century, health examinations were conducted in the western world mainly in order to control outbreaks of infectious diseases such as tuberculosis [13].
As the number of patients with tuberculosis decreased in the late 1950s, more doctors began proposing that the scope of disease prevention through health examination should be broadened to cover chronic diseases [14, 15]. Thereafter, changes in the roles of medical doctor groups [16] and life insurance companies, the emergence of preventive medicine, the lingering effects of the World Wars, etc., [17] resulted in an expansion of health examinations throughout various areas of society. In the 1960s, several critical and scientific studies revealed that many elements of the health examinations conducted at those times were not scientifically verified in terms of their predictive ability of treatment outcomes [18–20]. This led to a number of the more detailed questions and physical examinations, which had once been key elements of regular health examinations, no longer being recommended. Thereafter, general medical preventive examinations conducted as part of the national insurance system for the general population became relatively rare in western countries [10].
Given this background, it can be said that the Korean NGHE is a rather unique medical service around the world. The concept of health examination for groups without specific symptoms was first introduced in the Republic of Korea around the time of the national liberation in 1945. After the liberation in 1945, health examinations began being institutionalized, starting with the examination of parasites and infectious diseases such as tuberculosis [21]. The national health examination system was initiated as part of the national medical insurance in 1977; before this, health examinations were conducted individually according to specific needs and subjects.
From 1977, all companies with more than 500 employees were required to provide health insurance services. The health insurance coverage expanded to cover companies with 300 or more employees, public workers, and school personnel in 1979, and thereafter its coverage expanded to even smaller companies. Finally, the self-employed were included under national health insurance coverage in 1989 as regional policyholders. Since 1995, national medical insurance covered both public health services and national health screening. However, between 1977 and 1995, the Ministry of Labor took charge of both the WGHE and WSHE; during this period, the national health screening service could not be used as a substitute for the WGHE. In 1995, authority of the health examination service was transferred to the Ministry of Health and Welfare as part of the National Health Promotion Act; thereafter, health insurance policyholders were able to claim health examination services under their insurance coverage [21]. The employers’ obligation of reporting the results of the WGHE to local branch of the Ministry of Labor ceased in 1997, while the obligation of reporting to the Korea Occupational Safety and Health Agency (KOSHA) was ceased in 2005 [22]. All health insurance societies were integrated into a single insurer, the National Health Insurance Program, in 2000 [23]. The health examination system has been continually expanded with successive acts since, including the Framework Act on Health Examination in 2008, the 1st 5-year plan for the NGHE in 2010, etc., and with the establishment of the 2nd 5-year plan for the NGHE in 2016. This act has led to the current examination system and framework of operation [1, 24].
Beginning of current WGHE and participation rates of workplace policyholders
The NGHE, which is provided to workplace policyholders (i.e., beneficiaries of national health insurance), is a replacement of the WGHE originally specified as a duty of business owners for employee health protection designated by the Industrial Safety and Health Act. One major historical change in the domestic health examination system for workers [25] was the Labor Standard Act’s stipulation in 1953 that enterprises with 16 or more employees must provide regular health examinations for workers. The major subjects of this legislation were miners. In 1961, regulations on workers’ health management were announced, specifying the types, subjects, contents, and intervals of the health examinations. Then, in 1972, health examinations were divided into the WSHE and WGHE, depending on the hazardous substances that workers would be exposed to in their workplaces. The enforcement ordinances of the Industrial Safety and Health Act were subsequently revised in 1981, which stipulated that business owners of business entities with 5 or more employees were obligated to provide workers with health examination services. This also led office workers to being distinguished from non-office workers, and the interval of the WGHE for office workers being extended from 1 year to 2 [26]. In 1995, when the national health examination service was transferred to the Ministry of Health and Welfare, the coverage of national health examination services was expanded to include the general population in accordance with the National Health Insurance Service Act. As the national NGHE was acknowledged as a type of general health examination service, the expenses for the WGHE, which had previously been borne by business owners, were taken up by the National Health Insurance Service. The enforcement regulations of the Industrial Safety and Health Act were again revised in 1997, thus leading to the abolishment of business owners’ obligation to report general health examination results. In 2002, every workplace with 1 or more workers was required to offer health examination services, while 2005 saw the discontinuation of health examinations specifically targeting new employees. Since then, the NGHE for workplace policyholders has replaced the WGHE according to the Industrial Safety and Health Act [24].
The increase in the WGHE participation rate and health effect
We found that participation rates have rapidly increased over the last decade, from 51.6% in 2005 to 56% in 2006 and over 70% in 2011; since then, the rates have continued at a steady rate of around 70%. It is possible that these findings are the results of increasing income, the low-cost medical services of the NGHE, and a chronic disease prevention project. Another possibility is that the Industrial Safety and Health Act's mandating business owners to provide general health examinations for workplace policyholders has helped maintain the relatively high participation rates among such policyholders. Indeed, the participation rate of workplace policyholders was already 77% in 2006, which was substantially higher than the participation rate of the total population of the NHIS beneficiaries. Since 2007, the rates have been continually high, reaching upwards 80%. Another reason for the high participation could be the fact that examination agencies dispatch examiners to each workplace to provide these services, making them easily accessible by workers. However, it should be noted that a number of problems with the onsite health examination service have been pointed out, and its discontinuation has been discussed [1]. Thus, the effectiveness of this service should be discussed further in the future.
Regarding the comparison of participation rates among different enterprise sizes, we noted that the participation rates were lower among workers employed at enterprises with fewer than 50 employees than among those with 50 or more employees, and this gap remained consistent over the study period from 2006 to 2013. A possible reason for this is that National Health Insurance Program began by targeting workers of relatively large enterprises, who are more likely to be able afford to pay health insurance taxes; it has only rather recently expanded to workers from smaller enterprises and the self-employed, who generally have more unstable incomes. However, the consistent gap in health examination participation may mean that there remains a disparity in health examination opportunity due to socioeconomic status. In summary, participation rates are high overall, but there remain problems of unequal opportunities of health examination [27].
As for the age groups, the participation rates among the older generations—those in their 40s and 50s—were relatively low from 2006 to 2013 compared to examinees in their 20s and 30s, although the rates of each age group have been increasing. It should be noted, however, that these are merely the participation rates of NGHE beneficiaries. The dependents and household members of individuals in their 20s and 30s who were not workplace or regional policyholders would not be included among such beneficiaries. According to the Law for Health Promotion in the Republic of Korea [7, 28], only dependents or household members of an employee subscriber (i.e., workplace policyholder) or district subscriber (i.e., regional policyholder) who are 40 years old and above can receive the NGHE every other year. Thus, the participation rates of individuals in their 40s and above may reflect the total rate of all of these individuals in the NGHE because they are all given the opportunity to take it for free. In contrast, the dependents of national health subscribers below 40 years old would be excluded from the opportunity to take the NGHE. Thus, our results do not indicate that certain age groups show higher participation rates, but rather illustrate the number of beneficiaries in each age group who actually took the health examination.
Follow-up management of health examination and secondary examination participation rates
In general, there is no common formal definition of concepts such as OHEs, periodic health exams, and screenings. Nevertheless, they all refer to health screening services utilizing tests to identify possible disease [13]. Additionally, the basic purpose of such examinations is to prevent targeted diseases and promote health. To this end, routine screenings and immunizations are strategically performed [29].
Article 52 of the National Health Insurance Service states that the “The Corporation shall conduct health examinations to find diseases among policyholders and their dependents as early as possible and to provide medical care benefits.”[28] Furthermore, Article 43 of the Industrial Safety and Health Act and Article 98 of the enforcement regulation of that same act state that “health examination shall be conducted regularly for workers’ health management”[30]. In other words, it may be considered that the concept of health examination includes efforts for improving the health conditions of examinees with abnormal results in addition to providing diagnoses.
Despite the increasing participation rates for the primary health examination, we observed no concomitant increase in the secondary health examination for examinees with abnormal results to ensure early detection and treatment. As was suggested in the secondary health examination results, we assume that this is due to the lack of follow up management in the NGHE system. Follow-up management refers to “additional intervention for those who are found to need further measures as a result of screening such as confirmation of a diagnosis, education, and consultation” [1]. In other words, the combination of a health examination with follow-up management would include all the procedures necessary to designate which examinees with abnormal results should visit medical centers for treatment or management services. Problems in this regard have been pointed out in the past as well [22, 31]. Furthermore, the ratio of examinees with abnormal results of diabetes and hypertension who visited outpatient department hospitals to diagnose their abnormal results and receive a prescription was low. This accords with a previous study among examinees who received medical treatment—specifically, those who had visited a medical center for their hypertension or diabetes with 90 days of examination accounted for only 2.21% and 1.18%, respectively [32].
Notably, the secondary examination participation rates were substantially higher among workplace policyholders than among other subjects; however, their participation rates did not show any increases over the study period. In particular, in comparing secondary examination participation rates among the different enterprise sizes, we found that participation rates in small enterprises (those with less than 50 employees) decreased somewhat over time, and were far below the rates of workers in enterprises with 50 or more employees. This gap in participation rates was even greater for the secondary examination than for the primary. Previous studies have shown that, among examinees who were suspected of having diabetes or showed abnormal results on the fasting glucose level test, only 5.66% sought out further medical examination for diabetes within 90 days [33]. In addition to follow-up management, there should be further research on the contribution of health examinations—both secondary and primary—to early diagnosis and treatment.
It may be helpful for specialized agencies for workplace health management and their affiliated health care professionals to fulfill the health management tasks of small-to-medium size enterprises through utilization of the current system. According to one survey conducted among medical practitioners of specialized agencies for workplace health management, workers showed a high level of compliance with advice for further medical treatment when diagnosed with abnormal results as a result of a health examination [34]. Thus, making good use of the existing system will be a way of maximizing the preventive effects of health examinations.
Prevalence of diabetes and hypertension
Our results indicated that the prevalence rates of diabetes and hypertension have increased since 2006. This coincides with the increase in participation rates during that same period. Similarly, the prevalence rates leveled off at the same point—around 2011—as did the participation rates. However, these findings merely indicate the similarities in the graphs of participation rates and prevalence rates of diabetes and hypertension; they do not prove that higher participation rates indicate a higher probability of detecting more patients with diabetes and hypertension. In order to control for various factors possibly influencing this similarity, such as aging of the screening population, in the future, it would be necessary to observe the situation over the long term (Fig. 1).
As noted above, high blood glucose and blood pressure can be risk factors of CCVDs. Diseases of the circulatory system are the second most common cause of morbidity and mortality next to cancer in the Republic of Korea. Furthermore, CCVDs are compensable occupational diseases in the Republic of Korea, as in Japan or Taiwan [35]. They are a major cause of death and workforce loss among workers as well as in the general population in the Republic of Korea. When we classified workplace policyholders by their enterprise size, we noted that the prevalence and odds of having abnormal results relating to diabetes and hypertension were relatively higher among workers at an enterprise with less than 50 employees, who also demonstrated low participation rates. This same trend was found among the different age groups as well. As was mentioned above, the national health care and worker health care policies in Republic of Korea have only recently expanded their coverage from large enterprises to small ones [21]. Thus, the disparity between workers of these two types of companies indicates a health disparity due to socioeconomic status. Socioeconomic disparities in the prevalence of CCVDs and their risk factors in the Republic of Korea [36] and other countries [37, 38] have also been described in other studies. However, Korean examination agencies are allowed to dispatch their examiners to each workplace to provide such services. It is possible that examinees' blood pressure in the onsite examination is not as stable as that measured in the hospital, and some examinees, particularly those who have just a finished night shift, may not have fasted before a health examination.
Health examination opportunity and health disparity
Small enterprise workers have less WGHE opportunity and have more abnormal results relating to diabetes and hypertension. A reason for the lower participation rates and higher rates of diabetes and hypertension among workers from smaller enterprises may be related to inequality in health and socioeconomic conditions. Specifically, the Ministry of Employment [39], the difference in monthly wages increases along with the scale of the business entity in South Korea: namely, the monthly wage at business entities with 300 or more employees was about 147% that of entities with 10–29 employees. When the difference in monthly wages between enterprise size was examined according to the Korean standard statistical classification of occupation (http://kssc.kostat.go.kr/ksscNew_web/ekssc/main/main.do), service workers (170%) and craft and related trades workers (165%) showed the largest gaps in monthly wages, while managers (116%) showed a relatively smaller gap. These differences in wages, along with other socioeconomic factors, may help to limit opportunities for health examination. Further support for this comes from a previous cohort study, wherein the occurrence of cardiovascular diseases was observed among examinees for 7 years [27]. The authors found that the occurrence rate was lower among individuals who regularly underwent health examinations. Furthermore, the subjects were broken down and examined by insurance type—non-office workers, who could take a health examination every year; office workers and regional policyholders, who would take a health examination every two years; and dependents of these policyholders for comparison. The results revealed that the gap in occurrence rate of cardiovascular disease between individuals who took health examinations regularly and those who did not was smallest among non-office workers (who could take a health examination every year). Thus, relatively healthy workers with better working conditions appear to be given more opportunities for health examination. Taken together, these previous studies indicate that the gap of health conditions narrows as the interval between health examinations shortens, suggesting that health examinations can serve as a social safety net so long as they are conducted regularly and further necessary treatment is provided through follow-up management.
Cho et al. pointed out that the differing participation rates by socioeconomic factors is one problem of the Korean national health examination system [40]; Myeong et al. also noted a participation disparity of workers in small workplaces (i.e., those with less than 50 employees): they estimated the odds ratios of participation in the WGHE by the size of enterprise, and found that workers employed at enterprises with less than 50 workers were less likely to participate in the WGHE than were those employed at enterprises with more than 300 workers [41]. Among public officials, whose working conditions are relatively stable, the difference in participation rates by enterprise size was non-significant. Overall, our results suggest that the poorer working conditions at small workplaces may limit opportunities for health examination.
