The occupational health service outsourcing (OHSO) system in the Republic of Korea was implemented as a measure to provide occupational health service (OHS) to workers of small- and medium-sized enterprises. This system allows owners of eligible businesses (determined according to the type and size of business as dictated by a presidential decree) to commission health management activities from certain institutions designated by the Minister of Employment and Labor [1]. This system was initiated after the success of the group health care test-implemented in the Masan Free-Export Zone in 1973, and the OHSO system was fully implemented after the amendment and promulgation of the Enforcement Decree of the Occupational Safety and Health Act (OSH Act) in July 1990 established legal grounds for specialized agency for occupational health services (SA) to take part in health management [2]. Through this Act, health management was expected to be performed more efficiently by commissioning the work from such a SA. Since 2014, there have been some amendments to the enforcement decree and enforcement regulations of the OSH Act, which changed some of the terms [3], but the overall scope of the health management tasks remained largely unchanged. According to the current Enforcement Decree of the OSH Act, all businesses (excluding those in the construction industry) that have less than 300 full-time employees or businesses that are located in remote areas designated by the Minister of Employment and Labor can outsource health management tasks to SAs.

The tasks of SA healthcare professionals are as follows: General disease consultation and care guidance- consultation and care guidance for general diseases, including hypertension, diabetes, dyslipidemia, liver disease, and obesity; occupational disease consultation and care guidance- consultation and care guidance for occupational diseases. Includes providing advices regarding abnormal findings in Workers’ Special Health Exam (WSHE), musculoskeletal diseases, and exposure to hazardous factors; lifestyle habit consultation and guidance- consultation and guidance regarding individual lifestyle habits. Includes providing advices regarding smoking, exercise, dietary habits, and drinking for the purpose of improving health of individual workers; health promotion activities in workplace I- includes tasks of surveying the health status within the workplace and establishing plans to promote health; health promotion activities in workplace II- includes operation of health promotion programs to assist smoking cessation/exercise/dietary habits/temperance/stress relief.

The OHSO system has been continuously expanded since its implementation, with 45 agencies being designated as SAs by the Ministry of Employment and Labor (MOEL) in 1994, 52 in 1995, 66 in 1998, and 101 in 2010; as of February 4, 2016, there are a total of 114 SAs carrying out health management in workplaces throughout the Republic of Korea. When calculated based on the designated cap for the management by one physician (i.e., 100 workplaces and 10,000 employees per one physician), then a total of 28,000 workplaces have outsourced their health management duties to SAs. Although the OHSO system has been credited with preventing industrial hazards and occupational diseases to a certain extent, there have also been some critiques of the system [4]. The most notable policy-related problems include the deregulation of the legal obligation for assigning occupational health physician, reduction in the mandatory number of health managers in workplaces, and abolition of the mandatory provisions regarding job training for health managers (Article 55 (2) of the Act on Special Measures for the Deregulation of Corporate Activities. Removed on August 3, 2007), all of which were brought upon by the amendment of the Act of Special Measures for the Deregulation of Corporate Activities in 1997 [4]. Problems related to the performance of health management remain as well. For instance, both SAs (i.e., the service providers) and workplaces alike have not been actively engaging in their health management tasks. Additionally, there are problems pertaining to the incongruence between the service recipients (employees) and service payers (employers), insufficient primary care due to prohibition of certain medical practices, and competition between SAs. In fact, a study surveying the perceptions of SA professionals has found that many are skeptical about the effectiveness of the OHSO system in managing health of employees [2]. Moreover, some people have raised concerns regarding the fact that most health management tasks are performed perfunctorily by SAs, which further undermines the effectiveness of the system [5].

Although there has been considerable research on the OHSO system until now, there has been no recent study on its current status. Furthermore, almost none of the past studies have endeavored to identify how these identified problems with the OHSO system actually influence the performance of health management. Hence, we surveyed the current status of SAs and their workforce, and identified their current practices and the factors that influence performance.

We surveyed the current status of SAs and their health management performance. In doing so, we shed light on the SA tasks that are relatively well performed and those that are neglected, and determined those factors that are associated with performance.

In terms of the SA workforce in 2014, SAs in Gyeonggi Province appeared to have the greatest number of physicians and nurses. Notably, however, there were no significant regional differences in terms of per-physician and per-nurse numbers of firms and employees managed. Hence, the numbers indicate that there are few regional gaps in workforce supply (Table 1). The findings of the survey of physicians’ ages indicated that a considerable proportion of physicians who engage in health management are relatively older. Because we included all physicians working in an SA (i.e., both physicians who undertake health management and those who undertake health exams) for the age survey, the results may differ when the physician pool is limited only to physicians who perform health management. However, considering the amendments to the enforcement decree stipulating the qualifications for physicians who perform WSHE and those who perform health management in SAs [6], it is likely that the proportion of physicians aged 70 or older is much higher among the group of physicians who perform health management. In further support of this notion, when we exclusively analyzed 24 SAs that only perform health management tasks, 19 of the 36 physicians (52.8%) at these SAs were 70 years old or older (data not shown). Thus, it is likely that the proportion of physicians aged 70 or older among those who carry out health management tasks is higher than the 21.4% found in this study. Note that this is a very high number, particularly considering that only about 105 thousand out of the 5.56 million (about 1.9%) managers and professionals (physicians fall under this category as per the Korean Standard Classification of Occupations) in the Republic of Korea are 65 years old or older, according to the Korean economically active population survey [7].

In general, workplace health management comprises management of work and the working environment, health management, health consultations and health promotion, healthcare education, first aid training, healthcare information management, and risk assessment. Nurses’ duties include health management through health consultations and healthcare education; primary nursing services; overall operation of SAs and management and adjustment of them to promote occupation-specific business ties; health management for workplaces to maintain a disease- and hazardous-agent-free working environment; and record management. In contrast, physicians’ primary duties are assessment of health examination findings and protection of workers’ health through appropriate job allocations and transpositions and reducing working hours; survey of causes of health problems for workers and the implementation of medical measures to prevent recurrence; implementation of medical measures to maintain and improve workers’ health; health consultation, health education, and health improvement guidance for workers; inspection of workplaces and provision of guidance and suggestions; and inspection of causes of occupational diseases and ensuring the establishment of response measures. Despite delineation of these specific duties for both physicians and nurses, the health management tasks have not yet been standardized. In fact, there are various limitations (both temporal and spatial) preventing health managers from performing all of the tasks listed in the OSH Act. In our examination of the current performance of health management workers and proportion of tasks performed, we found that the time taken for health management was on average 74 min per one firm with less than 100 employees and 104 min per one firm with more than 100 employees. Furthermore, worker consultations and management accounted for the highest proportion of all tasks. However, health managers in general visited 2 to 3 firms on a given day and spent 30–50 min on average for worker consultation and management, depending on the size of the firm, while spending 1 h and 24 min for transit. Considering that they consult about 23 workers daily on average, it is assumed that health managers cannot select workers who require consultation and provide effective consultation in workplaces without workers’ health examination data (Table 3).

Regarding follow-up care, more than 43% of health professionals thought that over 60% of the workers with illnesses they had advised to seek medical care actually obtained it. Furthermore, more than 76% of health professionals responded that they had followed up on more than 60% of the workers with illnesses. Although the proportion of patients who seek medical care was merely a estimation by respondents, considering this finding in connection with the outcomes of follow-up care suggests that health managers are performing follow-up care to a certain extent (Table 3).

Health managers’ performance scores were, on average, higher than 5 out of a possible 10 points for all kinds of health management tasks. These scores are quite high, especially considering that the number of employees consulted daily was higher when a shorter time was taken for worker consultation per day. More specifically, tasks such as “general disease consultation” and “lifestyle habit consultation” were performed relatively well, and “occupational disease consultation” was also performed moderately well. However, further improvement is still needed for health promotion activities in workplaces. OHS fundamentally serves a preventive function [8]. In addition, the general goals of OHS suggest the principles of health promotion. Therefore, health promotion activities in workplaces should be a priority in OHS. These tasks—despite their importance—may be relatively underperformed in part because of the limitations of visiting management. In addition, as the commissioned health management tasks have not been standardized, the tasks that are relatively more impractical would be underperformed. Particularly, to carry out health promotion activities, company-wide environmental interventions would be crucial. Furthermore, team approaches, promotion of participation from the business owner and employees, and bidirectional communication play critical roles in these activities, which would further undermine performance of these activities in the current system of management on a short-term, visiting basis. Therefore, the scope of the commissioned tasks for health management should be clearly defined and specific tasks should be standardized, during which health promotion activities in workplaces should be acknowledged as a distinct category (Table 4).

The linear regression analysis showed that the numbers of firms visited daily and employees consulted daily were significantly associated with performance of health management tasks. However, it was difficult to conclude that these variables significantly affected performance, as the results were inconsistent across the models. On the other hand, utilization of health exam results consistently showed associations with performance of all tasks. Utilization of the WGHE results had a greater impact on performance of general disease consultation, lifestyle habit consultation, and health promotion in the workplace, whereas utilization of the WSHE results had a greater impact on the performance of occupational disease consultation. This was an expected finding in consideration of the target diseases for each task category and the nature of the examination items (Table 5).

When comparing the specific effects of utilization of health exam results on individual tasks, performance was higher among tasks that relied more heavily on utilization of health exam results, such as general disease consultation and lifestyle habit consultations (Table 5). Furthermore, many respondents noted in the comments section of the questionnaire that useful reference data for health management in firms is often scarce. This implies that, under the current OHSO system, health management is performed solely based on workers’ health exam results. Unfortunately, access is limited even to these data (i.e., the results of the WSHE and WGHE). As stipulated by the OSH Act, health examination institutions must send exam results along with a written follow-up management recommendation for employees with abnormal findings to employers. For the WSHE, reports for the statuses of all workers with abnormal findings within a firm and follow-up care recommendations are submitted, but even these only provide a brief note on the findings regarding a disease and follow-up care. The problem of limited accessibility is even worse for the WGHE results. Currently, workers are able to replace the WGHE with a health screening covered under the National Health Insurance (NHI) Act, which most workers end up doing. As such, health examination institutions that only perform the health screening covered under NHI and not the WSHE do not write up or submit follow-up management recommendations [9]. This would, in turn, further hinder health managers or occupational physicians from utilizing WGHE results. In other words, it appears to be difficult to access health examination results unless the health exam is performed at the same agency, and even when they are available, they do not necessarily provide detailed health-related information to workers. These problems appear to be more prominent in the service sector than in the manufacturing industry: whereas many workers in the manufacturing industry receive company-wide group health examinations, service sector employees individually receive examination at medical facilities close to their residences in place of a WGHE, thereby making it difficult for firms to receive follow-up care recommendations for group health management.

If health examination reports are the sole utilizable data under the current health management system, and if utilization of these reports is verified to increase performance, more efforts should be made to increase the use and accessibility of these data. Won et al. has found that the most highly demanded services by firms and employees were care guidance and management of individuals whose health examination reports had indicated an illness [10]. Therefore, in order to increase performance of such tasks and enhance accessibility of these data, a comprehensive and systematic OHSO must be developed by integrating health examinations and health management services. Furthermore, efficiency of health management in firms could be enhanced by providing services integrated with the measurement of the working environment and outpatient service for OEM.

However, only relying on health exam reports for health management of firms increases the risk of limiting the function of health management to follow-up care for employees. As such, the current OHSO system should be modified in order to ensure that the fundamental functions of OHS—beyond mere follow-up care of workers with illnesses—can be performed. In other words, OHS should take a step beyond care of individual workers with illnesses by instituting health promotion activities, which encompass activities that improve individual lifestyle habits and behaviors as well as those that improve working environments and organizational cultures via health education in workplaces. Previous studies have shown that reducing small risks among many people can prevent more disease than can reducing larger risks in a small number of high-risk people [11]. It seems appropriate for SAs to carry out health promotion activities in workplaces, but it would be difficult to realize the task under the current health management system, which is centered around the number of visits to firms. Regarding this matter, stakeholders should reach an agreement regarding changes to the current health management system or standardization of workplace health promotion projects.

This study also has some limitations. First, although we had distributed our questionnaire to all agencies, we only analyzed those that offered voluntary responses; in addition, there is a risk of non-respondent bias. Second, performance was measured based on a self-report questionnaire; as such, it was a subjective, rather than an objective, assessment. Third, as mentioned before, health management that relies solely on health exam results may limit the function of the management to follow-up care rather than preventive healthcare services. Thus, the performance findings must be interpreted carefully in consideration of the purpose of health management in workplaces. Finally, this study only examined physicians and nurses that work in SAs. In the future, studies should examine a wider pool of subjects to increase the validity of the results, as OHSO is performed not only by medical professionals (i.e., physicians and nurses) but also by occupational hygienists.

Notwithstanding these limitations, the present study is the first to survey and analyze the current status of health management performance by SAs and the factors influencing them. Particularly, this study shed light on the important fact that the current range of health management tasks is largely limited to follow-up care, instead of the much more important tasks of actively managing risk factors within the workplace. Therefore, it is critical to develop a more comprehensive OHSO system that could more effectively manage the overall processes of health management—namely, the prevention and diagnosis of diseases, and follow-up care. To this end, not only are efforts on the part of the SAs important, but also development of policies and support, such as standardization of health management tasks (including workplace health promotion activities and support for integration with other healthcare services), are required. Since its first implementation twenty years ago, the OHSO system in the Republic of Korea has maintained the same performance structure, and thus has continually been criticized for the same problems. Therefore, a standard guideline should be devised to improve the performance structure by reinforcing tasks that are performed well already and complementing tasks that are currently underperformed. Additionally, these notes should be reflected onto agency evaluations for a more practical and useful evaluation, which in turn would increase the quality of the OHSO system by preventing agencies from endeavoring to boost meaningless performance measures.

This study sought to examine the current status of SAs and their workforce, and to identify the current practice status of SA professionals and the factors that appear to affect performance. Overall, there appears to be no or very few regional differences in the supply of SA healthcare professionals, with consideration of the number of managed firms and employees per healthcare professional. However, our results may suggest that there is a regional difference in age distribution for physicians, and that physicians who practiced health management tended to be in the older age groups.

Currently, the categories of tasks for workplace health management are as follows: health management, health consultation and improvement, health education, first aid instruction, and health information management. However, none of these tasks have been standardized yet. The findings of this study indicated that health managers are limited in their ability to perform these health management tasks when considering the number of employees consulted daily and the actual working hours. Whereas follow-up care for workers with illnesses is performed relatively well, workplace health promotion activities are relatively underperformed. Notably, utilization of health exam results was found to be associated with an increase in health management task performance, which was noteworthy because the other factors generally considered to influence performance were not found to be significant (e.g., number of firms visited daily, number of employees consulted daily).

In light of our findings, the current range of health management tasks is likely limited to individual interventions or follow-up care for workers with illnesses, and health exam results may be the only utilizable data. However, even these health exam results have low accessibility, which calls for efforts to increase such accessibility. One of the means of achieving these goals and effectively performing health management would be to establish a comprehensive and systematic OHSO system that integrates health management services with health examinations. Additionally, the current system, which is centered around follow-up care, should be modified to better perform preventive medicine and health promotion—the fundamental functions of OHS. However, this would be difficult to achieve, given the current system’s focus on the number of visits. Therefore, stakeholders should reach an agreement on matters regarding changes in the current OHSO system and standardization of tasks for workplace health improvement projects.

In conclusion, standardization of health management tasks, including those regarding workplace health promotion activities, and implementation of policies and support projects, such as integrative support with other healthcare services, must be realized to increase the quality of OHSO system and reinforce its effectiveness. In addition, these matters should be reflected in agency evaluations to increase the quality of the actual health management business.