d i s a b i l i t y a n d r e h a b i l i t a t i o n , 1999; v o l . 21, n o s . 10± 11, 484± 489

Community-based rehabilitation in SouthKorea

YUN HEE KIM ‹ and NAM KWON JOŒ

‹ North Wanju Community-Based Rehabilitation Project, Department of Rehabilitation Medicine,

Presbyterian Medical Centre, Chonju, Republic of Korea 560-750

Œ Rehabilitation Division, Ministry of Health and Social AŒairs, Seoul, Republic of Korea

Summary

This paper gives a brief introduction to the geography anddemographyof the Republic of South Korea. Since 1988 SouthKorea has been actively legislating and implementing welfarepolicy for the disabled of the Republic. An overview of thesepolicy changes is presented. The extent to which the policy hasbeen implemented using community-based rehabilitation(CBR) is illustrated using an example from the North WanjuProject. Finally, there is a discussion of the future of CBR inSouth Korea and the means whereby there can be more socialintegration of the disabled.

Introduction

South Korea is a country of approximately 22015

square kilometres with a population of 42 million people.

The population density is very high and the population

rate of growth is 0.97% per annum. The proportion of

older people in the population is 4.73%, consequently

there is a very high proportion of younger people in the

population who are concentrated in urban centres. As a

consequence of the recent changes in industrial structure

there are high rates of tertiary and secondary industries

when compared with primary industries. The current

rate of unemployment is 2.6% and there is 70% house

supply rate. More than 30% of the national budget was

spent on defence and only 10.4% on social development

(includes social security, health care, and environmental

reform).

Prior to the Korean war the people and the govern-

ment showed little concern for the disabled. After the

war, through foreign foundations and missionaries,

several rehabilitation institutions were established for the

disabled and war veterans. These institutions focused on

the institutionalization of the disabled rather than

providing rehabilitation services to the disabled in their

communities. At that time several Korean physicians

were studying rehabilitative medicine in the United

States of America under the sponsorship of Dr Howard

Rusk and, through these physicians, rehabilitative

medicine was disseminated to the general public.

After the United Nations declared the statement of

rights of the disabled in 1975, and designated the

International Year of the Disabled in 1980, the Korean

government established the laws for promoting special

education in 1977 and the laws for the welfare of the

disabled in 1981. However, it must be noted that the

general attitude of the government was passive rather

than active.

Since 1984, when Seoul was nominated for the 1988

paralympics, perception and interest in the welfare and

rehabilitation of the disabled were dramatically changed

among the people and the government. Society’ s

attitudes were actively changed to prepare a positive

environment for the rehabilitation of the disabled, and

various activities such as the expansion of rehabilitation

facilities, abrogation of disadvantageous articles of laws,

public enlightenment to abolish prejudice against the

disabled, and revision of construction laws for the

accessibility of wheelchair-bound were put into op-

eration. Following the successful execution of the games

there was a positive change in the attitude of the people

towards the disabled, the building of self-con® dence

among the disabled themselves, and the implementation

of a disabled welfare policy progressed rapidly.

Overview of the welfare policy for the disabled in the

Republic of Korea

In 1988 a countermeasure committee for the welfare of

the disabled was organized by the President of Korea.

This committee was charged to discuss comprehensive

rehabilitative methods for the disabled, means whereby

disability could be prevented, and to provide a focus on

the medical, educational, and vocational aspects of

rehabilitation. The outcome of this committee’ s

deliberations in¯ uenced the implementation of the

following social welfare policies.

Disability and Rehabilitation ISSN 0963± 8288 print} ISSN 1464± 5165 online # 1999 Taylor & Francis Ltdhttp:} } www.tandf.co.uk} JNLS } ids.htm

http:} } www.taylorandfrancis.com} JNLS } ids.htm

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CBR in South Korea

r e v i s i o n o f l a w s f o r t h e w e l f a r e o f t h e d i s a b l e d

Old laws were overhauled to emphasize the rights of

the disabled and to support the needs of the disabled.

The revisions included the establishment of a welfare

committee for the disabled, registration of the disabled,

® nancial support for medical and education pro-

grammes, as well as living expenses, provision of

prostheses and orthoses, and a regular survey of the state

of the disabled. These laws did not make clear the

detailed policies for the social integration of the home-

bound disabled.

e s t a b l i s h m e n t o f l a w s f o r m a n d a t o r y e m p l o y m e n t

o f t h e d i s a b l e d

These laws provided for a 25% mandatory em-

ployment rate for the provincial governments and public

companies and a 1± 5% rate of public cooperation for

employment promotion, a vocational training centre for

the disabled, and an arrangement for vocational

counselling. These laws established the basic structure of

vocational rehabilitation for the disabled. However,

there were still great di� culties in meeting the actual

needs of the disabled because of a lack of trained

professional personnel and well-organized vocational

training programmes.

r e g i s t r a t i o n o f t h e d i s a b l e d

This activity began in 1988 but, due to a lack of

adequate registration procedures and advantageous

services, only 200372 disabled persons were registered by

December 1990."

Other bene® ts which ¯ owed from the changes in

legislation and community attitudes were :

(1) The establishment of a national vocational centre

and a national rehabilitation hospital.

(2) The promotion of sports activities for the disabled

through the establishment of the Disabled Sports

Association.

(3) Support for medical costs, braces and prostheses

for poor families with disabled members.

(4) Expansion of the number of medical facilities,

welfare centres and sheltered workshops for the

disabled.

(5) A reduction in taxes, educational expenses, and

more support for cost of living to disabled persons.

(6) Abrogation of disadvantageous articles for the

disabled in relevant laws.

Future prospects and suggestions for CBR

In spite of the government’ s eŒorts to establish welfare

for the disabled in recent years, many of the disabled are

not receiving any rehabilitation services. In the national

survey one-quarter of the disabled replied that they had

neither a medical examination nor treatment since they

acquired their disability. The nationwide disability rate

was 2.22% 1985 and this rate was obtained as a direct

consequence of the then very limited de® nition of

disability.Most musculoskeletal and neurological impair-

ments were considered to be disabilities at that time.

However, there is still no mutual agreement concerning

a comprehensive de® nition of disability in South Korea.

There are only 102 psychiatrists and 140 occupational

therapists in Korea, which are very low numbers.

Licensing systems for orthopaedists, prosthetists, and

speech therapists are not yet in place, and training

programmes for rehabilitation nurses and social workers

are also limited. There are relatively few vocational

councillors and teachers.

Korea has the highest rate of tra� c and industrial

accidents in the world. The existence of slum areas, high

population density, poor hygiene and housing status are

all factors which mitigate against the disabled accessing

rehabilitation. In rural areas the lack of rehabilitation

institutions and personnel, shortage of adequate trans-

port, poor housing conditions, and a general lack of

manpower are factors which limit the social integration

and participation of the disabled. Under these conditions

it is little wonder that many of the disabled are suŒering

from additional complications with little hope for their

future.

To overcome the above di� culties there is a need to

seek diversi® ed approaches and attempt to decentralize

the present centralized policy. Clearly there is a need to

utilize personnel and resources which currently exist in

communities. Community-based rehabilitation provides

many practical and attractive means of mobilizing

community resources to meet the various needs of the

disabled themselves. The following approaches appear to

be realistic adaptations of CBR principles for Korea.

u t i l i z i n g e x i s t i n g c o m m u n i t y r e s o u r c e s

Frequently the initial training of health workers has

excluded consideration of other options available in their

® eld of health care. The initial training should also

include an educational programme which ful® ls at least

a second purpose. For instance, trainees should be made

aware of the need for, and the processes whereby,

rehabilitative medical services could be integrated into

the existing primary health-care system.

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Public physicians and community health practitioners

who are currently working in the remote areas with poor

supporting medical resources should be educated, to

provide them with the required knowledge of and skills

for eŒective rehabilitation delivery. This training will

also allow for the provision of rehabilitation services to

the disabled and local residents in remote areas. The

educational programme should include techniques of

disability prevention, early detection, and the man-

agement of disability and chronic pain.

In Korea there are 15 expanded public health centres

which are equipped with proper medical equipment and

personnel. A CBR programme must be operated and

supported by these centres, including education for the

disabled themselves, family members, local residents,

community leaders, and visiting therapists. The centres

should also provide support for disabled support groups.

Once established these activities could be expanded

systematically to the 240 nationwide public health

centres.

e s t a b l i s h m e n t o f a r e f e r r a l s y s t e m

Tertiary medical institutions should be obliged to

establish departments of rehabilitation medicine. Sec-

ondary medical institutions should have smaller depart-

ments of rehabilitation charged with the responsibility of

establishing and maintaining the rehabilitation referral

system.

The number of rehabilitation specialists must be

increased. There is also a need for adequate education,

for quality control of that education system, and an

increase in the numbers of orthotists, prosthetists, speech

therapists, psychologists, rehabilitation nurses, and re-

habilitation social workers in training.

The existing medical insurance payment system must

be changed and developed to adequately cover the

expenses associated with rehabilitation medical services.

Such changes will stimulate the non-governmental

medical institutions to invest money in the further

development of rehabilitation services. Government

support for the medical costs for disabled persons from

poor families must be expanded to enable them to have

access to adequate and proper medical services.

Vocational rehabilitation and the social integration of

the disabled

The government o� cials responsible for rehabilitation

activities at township or county level should be replaced

by professional staΠwho will assume an on-going

responsibility for rehabilitation. These professionals

should be able to communicate with the disabled,

establish the needs of the disabled, and subsequently

provide rehabilitation services.

Voluntary group activities for the disabled should be

encouraged. There should be encouragement for, and

promotion of, the disabled taking an active participation

in the social activities of their community. Community

leaders should be identi® ed whose function would be to

recommend participation, and to support the disabled as

they participate in group activities. This leadership will

instill in the community leaders a sense of responsibility

towards the integration and rehabilitation of the disabled

in their communities.

Needs and abilities of the disabled for vocational

rehabilitation are diversi® ed so case-by-case counselling

and support are needed in the majority of cases rather

than merely establishing a single-purpose training centre.

A vocational rehabilitation committee can be organized

with a government o� cer, community leaders, and the

leader of the disabled in their community. Such a

committee can act as a coordinating body between the

vocational needs of the disabled, the available com-

munity resources, and government policies.

The manner in which the above changes have impacted

on rehabilitation in the Republic can best be illustrated

by describing one of the earliest CBR projects in Korea.

This project illustrates the relationship between non-

governmental organizations and government

organizations in the development of a CBR program.

The North Wanju CBR project

The North Wanju CBR project commenced in July

1987 under the sponsorship of the Evangelishe

Zentralstelle fu$ r Entwicklungshilfe E.V (EZE) and the

ChristoŒel-Blindenmission (CBM) in Germany. North

Wanju County has an area of 520 square kilometres and

supports a population of 52000 people. About 25% of

the population is over 60 years of age. This typical

agricultural community is located about 24 kilometres

from Chonju City where the Presbyterian Medical Centre

(PMC) provided comprehensive medical care including

rehabilitation.

The Department of Community Health in the PMC

had worked for 5 years to establish the primary health-

care network in this county. StaŒfrom the department

educated the public health physicians, community health

providers, and village health workers in rehabilitation

skills. The village health workers were trained volunteers

from among the village people. These workers learned to

take charge of health education, prevention and the

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CBR in South Korea

treatment of minor wounds. In addition, the PMC had

established a small community hospital of 10 beds in

Kosan, which is the central township of the county. This

branch of the PMC provided medical care at the

community level. Thus, relatively adequate preventative

and curative medical care and personnel had become a

reality in this county. Prevention and treatment of

diseased patients was provided, but there was no

rehabilitative treatment for disabled persons. The CBR

project was directed towards the utilization and

mobilization of the existing medical rehabilitation of

physically disabled people and their integration into

social activities.

The ® rst year of the project was spent in laying the

foundations for subsequent years and the future success

of the project. A baseline survey gathered information

about the prevalence of disability in the county and

identi® ed local resources. At that time the CBR project

was attached to the community hospital. Allocated to the

project at the hospital were examination and therapy

rooms, a vocational training room, and a small dor-

mitory for vocational trainees. The staŒcomprised a

physiatrist (medical practioner specializing in physical

medicine), a rehabilitation nurse, two physical therapists,

an occupational therapist, a driver, a manager, an o� ce

aid, a vocational teacher, and a part-time councillor.

The baseline survey found that the prevalence of

disability in the county was 2.83%. Of the total disabled

73% were physically disabled. The most frequent

diagnosis (30%) of physical disability was hemiplegia

subsequent to a stroke. The next most frequently

occurring disability (21% of the disabled) was joint

contracture due to either arthritis or trauma. One-half of

the physically disabled were over 60 years of age, while

the most common age groups in which disability occurred

were under 10 and over 60 years of age.

Approximately 23% of the physically disabled who

were detected had not previously had either a medical

examination or treatment, and only 14% were receiving

physical therapy. Of those identi® ed as disabled 27%

required assistance in activities of daily living. The most

frequently expressed desire, to facilitate rehabilitation,

was to receive medical treatment. The prevalence of

illiteracy, low income and unemployment among the

disabled was much higher than among the non-disabled.

More than 50% of the disabled persons and the local

residents expressed the opinion that disability was one’ s

destiny, and the disabled would be a burden to their

families and friends. There was also an opinion that

having a disabled family member caused problems in a

family and posed an obstacle to marriage for other

family members.

Local resources were found to include 115 village

health workers, 249 village leaders, 16 community health

physicians, seven public health physicians, and 63 church

pastors.

Following the survey and the ® rst year of planning

four main project activities were implemented. These

activities were home-based rehabilitation services for the

elderly or severely disabled persons, education of and

publicity about the existing resources, comprehensive

rehabilitation services including vocational training, and

a cooperative society of the disabled.

Mobile teams consisting of a physical and occu-

pational therapists, nurse, councillor, community health

physician, and a village health worker were established

to provide home visits to the home-bound disabled.

These disabled had been referred by either community

health workers or community leaders for further evalu-

ation and the establishment of a plan for home treatment.

Treatment is carried out two or three times a week and

includes education of family members or volunteers. The

mobile team gives speci® c advice on home modi® cations

to enhance the mobility of the disabled person. The team

also encourages families to equip the home with

appropriate aids developed using local materials.

Occasionally the mobile team recommends to the project

manager that ® nancial assistance be given to the disabled

or the family.

Home visiting is discontinued as soon as the family

member or volunteer learns the skills and assumes

responsibility for the treatment of the disabled person.

Approximately 500 visits are made annually. It was

concluded by the project team that, as a result of these

home visits and the subsequent rehabilitation, there has

been remarkable improvement in the mobility and social

participation of disabled persons.

In order to promote better understanding and

participation in the rehabilitation of the disabled,

community health personnel (CHP) who have been

trained for 5 years in maternal care, prevention and early

detection of chronic diseases such as hypertension,

and, volunteer health workers (VHW) are given several

refresher classes in rehabilitation every year. These

classes focus on the care of patients with hemiplegia,

spinal cord paralysis or chronic pain, as well as on the

prevention and detection of various disabilities. This

continuing education is participatory training and is

carried out in villages.

The mobile rehabilitation clinic also visits the CHP’s

posts, even those located in the most remote areas. These

clinic visits as well as providing additional training, also

assist further in the screening of the disabled, especially

those with more sophisticated and hidden disabilities.

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Community leaders and local clergymen are

encouraged and educated concerning the necessity and

the important features of the rehabilitation of disabled

people, especially their social and community activities.

Vocational services are provided by the community

rehabilitation centre and include disability diagnosis by

the physiatrist, physical and occupational therapists,

nursing care, brace ® tting, education and counselling.

Vocational evaluation and referral services are also

provided at the centres. At these centres young people,

who have relatively good bilateral hand function, are

taught jewellery processing. After this training they may

continue in their work at a sheltered workshop in the

rehabilitation centre or in their own homes. The

rehabilitation centre personnel assist in the marketing of

the ® nished products.

Those with relatively good mobility are encouraged to

get together and talk about the di� culties and problems

encountered in their communities. These groups help the

disabled to discuss and resolve their problems. It was

through such conferences that the disabled voluntarily

organised the `North Wanju Co-operative Society of the

Disabled ’ . The purposes of this society include: fostering

friendships among the disabled, support and encour-

agement of families with disabled members, promoting

the need for and bene® ts of rehabilitation, and fund-

raising to encourage self-reliance in and independence of

the disabled.

The society has 105 regular disabled members and a

further 93 supporting members who support the disabled

® nancially and give them encouragement. To date the

society has raised $US3000. The society’s steering

committee, which comprises representatives from all

districts, meets monthly.

There have been two annual get-togethers organized

by the society. These occasions provide opportunities for

recreation, meeting new friends, and leadership training.

The steering committee is developing plans for a health

screening programme for disabled people. Another

activity is fund-raising to provide ® nancial assistance to

support home modi® cations. It is anticipated that the

society may grow into a political lobby group, en-

couraging governments to establish and implement better

policies for the disabled in their communities.

Since its implementation there have been a number of

notable outcomes of the Wanju CBR project. Among

these outcomes have been :

(1) The project contributed to the establishment of a

rehabilitative medical delivery system for disabled

persons in rural areas. These disabled people had

previously been ignored by the community health

workers. The CBR project has also been suc-

cessfully integrated into the existing primary health

care system.

(2) Continuous home visit therapy enhanced the

mobility of the disabled and promoted their

participation in social activities. The attitudes of

family members and local residents have changed

and disabled persons are accepted into the com-

munity and are expected to participate positively

in home and community activities.

(3) Through continuous publicity and the education

of community leaders these signi® cant persons

now have greater concern for and understanding

of the disabled in their communities.

(4) It has been demonstrated that disabled persons in

rural communities can be helped by community

health workers through the latter’ s newly acquired

skills in rehabilitation techniques.

(5) The Co-operative Society of the Disabled has

created major changes in the attitudes and be-

haviour of the disabled. From passive recipients of

help they are now more active and positive about

their condition. The society has encouraged the

disabled to participate in social activities and has

provided the disabled with the skills and

con® dence to problem-solve on their own behalf.

Despite the above positive outcomes of the Wanju CBR

project there have also been identi® ed some problems

and limitations associated with implementation and

continuance. These include:

(1) There is a lack of concern and interest of the

Korean government in CBR; close cooperation

between project members and government o� cers

was lacking.

(2) Since medical insurance and medicaid does not

pay for rehabilitation services performed at the

community health worker’ s posts or health sub-

centres, the community health workers’ capacity

to provide rehabilitative services was limited.

(3) Because of the relative poverty of rural people, as

a result of the government policies of urbanization

and industrialization, most of the families with

disabled members do not have su� cient ® nancial

resources to provide the devices or modify their

homes to assist the disabled. Expenses associated

with the provision of aids and modi® cations are

not covered by insurance in the Republic of

Korea.

(4) Due to the shortage of manpower in rural areas,

owing to the emigration of youth to the cities, it

has proved di� cult to maintain home care for the

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severely disabled who rely on a family member or

community volunteer to continue the rehabili-

tation process after cessation of project staŒvisits.

(5) There is a large proportion of older disabled

people who have a low level of motivation to

participate in social activities and seek vocational

engagement. Often these seniors have multiple

problems such as hypertension or diabetes

mellitus.

(6) Since the needs and abilities of the vocational

rehabilitation of the disabled are so varied, there

are di� culties in oŒering an individualized ap-

proach to vocational training.

The majority of existing rehabilitation institutions still

concentrate on the institutionalization of the disabled

rather than supporting them for independent living.

There are no proper education and licensing systems for

rehabilitation professionals such as orthotists,

prosthetists, and speech therapists. There is an absolute

shortage of medical rehabilitation institutions and,

moreover, public medical institutions do not oŒer

enough rehabilitative services for the disabled. Most of

the rehabilitation institutions are concentrated in large

cities and there is an inadequate insurance payment

system for rehabilitation medical services.

There is an urgent need for realistic policies for

providing for independence and rehabilitation of home-

bound disabled people in rural areas. These disabled

persons are isolated from the bene® t of social welfare

and the detailed enforcement regulations for the ad-

equate and useful operation of the many diversi® ed

policies. Training and deployment of professional ad-

ministrative personnel are also required to ensure

consistent execution of the policies. In addition to

government support, and participation of non-govern-

ment foundations, there is a need for publicity and

education to promote understanding and participation

of the general population in the CBR programme.

Reference

1 Nam KJ. Rehabilitation programmes in the Republic of Korea.IntercountryWorkshop on Planning and Managementof Community-based Rehabilitation Programmes. Guangzhou, Guangdong Prov-ince, China, 10± 14 June. World Health Organization, RS} 91} GE}10(CHN), 1991.

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