Do Public Hospitals increase the performance of responding infectious disease?

                                                                                                        Kilkon Ko, 

                                                                                     Prof, Seoul National University

(Posted : November, 03, 2020) 

Does Public Hospital Matter?

 There is a controversy that quality and quantity of public hospitals matter when it comes to pandemic situation. Since Korean hospitals are mainly private, there is never ending dispute whether government should increase the number of public hospitals since SARS and MERS. Thus, we would like to do comparative research to find out the real effect of public hospital in the situation of COVID-19 Pandemic.

Data Availability of Public Hospitals

 Unfortunately, public hospital data is not sufficient to see all countries. Only the OECD provides the hospital data consist of publicly owned hospitals, not-for-profit privately owned hospitals, for-profit privately owned hospitals and etc. Therefore the analysis below is based on the OECD countries and total hopitals and public hospitals data were used for the comparison.

Number of Public Hospitals in OECD and its Response

 According to the OECD, the total number of hospitals in Korea is 3,924 (94.3 %), and the number of public health and medical institutions is 224 (5.7 percent), indicating that the number of public health institutions is overwhelmingly small. However, it is hard to argue that the number of public health and medical institutions leads to improved quality of responding to infectious diseases. This is because private hospitals will also be controlled by the Ministry of Health and Welfare in accordance with the Emergency Medical Service Act.

 Figure below is a visualization of the total number of confirmed cases, total number of hospitals and public health institutions per million of OECD countries provided by the OECD, based on the 30th day since the number of total cases reached 50 or more. The correlation coefficient between the total number of confirmed cases and the total number of hospitals is –0.33, which is statistically significant under a significant level of 10%, but the number of public health institutions was not statistically significant. This means that the number of public health institutions is not related to the total number of confirmed patients, and the total number of hospitals may be important when responding to infectious diseases. 

Trend of Confirmed Cases & Ratio of Public Hospitals

 There is a claim that the initial response has failed due to a lack of public health institutions. To confirm this, the trend of total confirmed cases in countries with more than 90 percent of public or private health institutions is as follows. Iceland (100%), Britain (100%), Canada (99%), and Slovenia (90%) have an overwhelming proportion of public hospitals, while Switzerland (100 percent), the Netherlands (100 percent), and South Korea (94 %) have a high proportion of private hospitals. However, it is hard to say whether private or public health care affected the initial response given the trend of total confirmed cases in the countries. Figure below shows the trend of total confirmed cases per million people in the number of days after 50 cases. In Iceland, where the proportion of public health institutions is high, the number of confirmed cases is rapidly increasing due to the failure of initial response. However, Slovenia and Canada see a relatively slow start in the early stages of COVID-19. In South Korea, where the proportion of private hospitals, the increase is very small compared to other countries despite the outbreak of the Shincheonji Daegu Church Incidence, and Switzerland and the Netherlands have failed to respond in the early stages. Through this, it is difficult to simply interpret that the large number of public health institutions leads to the performance of initial response in  infectious diseases such as COVID-19. In fact, Korea's experience of overcoming the shortage of medical facilities through the provision of facilities by private companies and public institutions suggests that the establishment of a public medical institution itself is not the only solution. 

Regional Confirmed Cases and Negative Pressure Isolation Sickbeds

 It is the number of negative pressure isolation beds that has been raised as an important issue in discussions on expanding public health and medical institutions. Because negative pressure isolation rooms have high initial investment costs and facilities management costs, while there is problems in profit reduction caused by poor utilization during non-pandemic situation,  private hospitals are not operating or installing negative pressure isolation rooms. Therefore, the compulsory increase of negative pressure isolation beds by increasing public health care institutions is the hypothesis of those who insist on expanding public hospitals.

 The time when negative pressure isolation beds were needed the most was Feb. 29, when the number of newly confirmed cases reached a record high of 813 people. Although the absence of daily available negative pressure isolation patient data or regional isolation patient count data limits accurate analysis, considering that the average hospitalization period for inpatients is 20.7 days, comparing the cumulative number of newly confirmed patients with negative pressure isolation with the number of newly confirmed patients as of February 29 shows significant analysis results.

According to the Ministry of Health and Welfare's press release on February 23, the total number of negative pressure isolation beds used in the analysis is 1,027 as of 2019, but the total number of negative pressure isolation beds that used for the analysis is 1,077 according to Statistic Korea. Also the number of negative pressure isolation beds used for diseases other than COVID-19 is not known, so it is necessary to be noted when interpreting the analysis results.

As you can see in the figure below, the number of negative pressure isolation beds is less than 50 in Seoul (383), Gyeonggi (143), Busan (90), Gyeongnam (71), Incheon and Daegu (54), and 51.6% of the total is concentrated in Seoul and Gyeonggi Province. In the case of Daegu and North Gyeongsang Province, the Daegu area recorded 2,236 confirmed cases in 10 days, starting with one confirmed case on Feb. 18, while North Gyeongsang Province recorded 488 confirmed cases on Feb. 29 from zero confirmed cases on Feb. 18. Considering that the number of confirmed patients in Daegu and North Gyeongsang Province is about 2,700, it means that the number of negative pressure beds that were needed was more than twice that of the nation's total. While a large number of negative pressure isolation beds are expected to be needed only in situations related to infectious diseases such as COVID-19, securing negative pressure isolation beds, which require 200 million won per room for construction alone and 30 million won per month for operation, may do more harm than good by expanding public health institutions.

 In the early stages of COVID-19, it was difficult to grasp the fact that there were many asymptotic or mild cases. As a result, the overload of hospital services due to the increase in patients has emerged as a serious problem. Under these circumstances, what was raised at the scene was the life therapy center, which began operating on March 2. The policy was implemented by the government after receiving on-site opinions, but the provision of facilities could be implemented by providing idle facilities in the private sector, such as corporate training centers such as Samsung, LG, and Hanwha, dormitories at universities, Catholic welfare facilities, and the Korea Football Association. 

 It is clear that expanding public health and medical institutions or expanding certain medical facilities can help treat infectious diseases. However, the effectiveness of the policy should be examined because it should efficiently allocate limited social resources. The lesson we should learn from the COVID-19 response is that we can wisely solve the problem of insufficient public health institutions through cooperation with the private sector, not that the state should expand more public health and medical institutions.