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
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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 staŒ who 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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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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