The healthcare delivery system is crucial for using healthcare resources effectively and for providing appropriate healthcare services to consumers.
The establishment of a healthcare delivery system in Korea would be significant; therefore, previous governments have made efforts to do so. However, creating a national healthcare delivery system has proven challenging due to the predo-minance of private medical organizations over public ones.
As the number of childbirths decreases, maternity hospitals have been closing, especially in rural areas (
Lee et al., 2021). Therefore, it is necessary to introduce various systems to ensure safe childbirth.
Hwang (2021) reported that a safe delivery environment can be established through a maternity healthcare delivery system in the current situation, where there is a shortage of obstetricians and maternity hospitals.
Recently, the government has attempted to establish a new medical cooperation model by utilizing National Health Insurance Service (NHIS) payment rates for medical cooperation projects such as the “Cardio-cerebrovascular Disease Network Pilot Project.”
This network project differs from the existing insurance payment system, which is based on specific actions and procedures. Under the pilot project, NHIS pays a maintenance fee to each hospital if the participating hospitals continue to operate a cooperative system.
The government is now preparing to establish a maternal and child healthcare delivery system by applying a network model similar to that of the “Cardio-cerebrovascular Disease Network Pilot Project.”
Therefore, I would like to present my opinions here and propose policies that will contribute to the network's success.
Current Status of the Healthcare Delivery System in Korea
The current healthcare delivery system was introduced in 1989, when the national health insurance system was first implemented.
At the time, there was a shortage of medical resources, in-cluding hospital equipment, facilities, and medical personnel, so several policies were introduced to limit patient selection and prevent congestion.
First, the nation was divided into eight large-scale regional medical districts, and the principle was that regional patients should be treated within their respective districts. Hospitals in these districts were classified into primary, secondary, and tertiary institutions by size. Patients could only be treated at a higher-level hospital with a referral from a medical professional, rather than by patient choice, thus controlling patient flow and ensuring appropriate use of medical resources.
However, due to the special nature of emergencies and deliveries, outpatient care has been allowed at tertiary hospitals without a referral document for emergency patients and pregnant women (
Yun et al., 2014).
In 2011, as part of regulatory reform, the principle requiring regional patients to visit hospitals within their large-scale regional medical district was abandoned because it had not actually been followed for a long time. During this period, specialized maternity hospitals were also reclassified based on the ratio of inpatients and treatment volume, and the healthcare delivery system was re-established.
In actual medical practice, however, these healthcare delivery systems were not effectively implemented.
Patients often requested referral documents from their primary and secondary care physicians for higher-level hospitals. In response, doctors issued these referrals not only based on their medical judgment but also to accommodate patient requests, aiming to prevent disputes or medical lawsuits.
The maternity healthcare delivery system was no exception. In particular, for childbirth, patients could use a higher-level hospital without a referral, so even in nonemergency situations, many chose a higher-level hospital of their preference.
Recently, it has become common for pregnant women to visit two or three hospitals to prepare for any emergencies.
Is the Maternity Healthcare Delivery System Working Well?
For the maternity healthcare delivery system to function properly, there must be sufficient medical resources, and the cooperation of healthcare consumers is essential.
In terms of medical supply, primary, secondary, and tertiary medical institutions should be appropriately distributed within each delivery care area. Additionally, medical consumers should trust their maternity doctors and follow medical advice rather than seeking higher-level hospitals based on personal judgment.
However, this is not the case in actual practice. As of 2022, 72 out of 250 municipal areas across the country do not have a maternity hospital (
Ahn et al., 2024).
As a result, the maternity healthcare delivery system is largely operating only in large cities, and rural areas have no primary or secondary hospitals that can refer patients to higher-level facilities.
This also poses a problem from a demand perspective. Ac-cording to 2020 statistics, among local governments in Korea that do have maternity hospitals, the average delivery rate within their jurisdiction was 48.0%.
This rate was 54.9% in urban areas and only 22.1% in rural areas.
These findings indicate that 52% of pregnant women give birth outside of their region for various reasons, even though they have a local delivery hospital (
Lee et al., 2022).
It is believed that the low delivery rate in rural areas is related to the poor facilities at local maternity hospitals, along with an increasing number of high-risk pregnancies.
From the perspective of medical consumers, limited facilities and a lack of support for high-risk pregnancies mean they often have no choice but to seek care in other regions, volun-tarily or involuntarily.
Government's Efforts to Establish a Maternity Healthcare Delivery System for Mothers and Children
The current healthcare delivery system, which began with the introduction of the medical insurance system in 1977 and was expanded to the entire population in 1989, has, over the past 30 years, played a role in providing patients with appro priate services and served as a limited social safety net. However, the maternity delivery system is severely disrupted compared to other areas, making it difficult for medical consumers to receive appropriate medical services.
To address this, the government established the first Public Health and Medical Care Basic Plan in 2016, focusing on essential medical care in medically underserved areas. This plan included strategies to strengthen the link between projects supporting obstetrically underserved regions and integrated treatment centers for high-risk mothers and newborns.
Furthermore, the second Public Health and Medical Care Basic Plan was announced in 2021, and the plan to create a cooperative network for maternity healthcare was included in the second National Health Insurance Comprehensive Plan in 2023.
Policy Proposal for a Successful “Maternal and Child Medical Healthcare Cooperation Project”
The Maternal and Child Medical Healthcare Cooperation Project aims to connect regional maternity hospitals around the “Regional High-Risk Maternal and Neonatal Integrated Treatment Center” to facilitate rapid responses to high-risk mothers and newborns in emergencies.
For this project to succeed, the participating maternity hospitals must maintain a cooperative system, and in the event of an emergency, high-risk pregnant women must be transferred quickly and receive 24-hour urgent medical care.
In addition to existing insurance payments based on acts and procedures, the NHIS will provide differential support for “medical cooperation fees” to each medical institution that participates in the medical cooperation project.
If the Maternal and Child Healthcare Cooperation Project is implemented as the government intends, it will have several implications for the maternity and childbirth healthcare system.
First, this is the first project to establish a maternity delivery system in Korea. Second, a new “medical cooperation fee” will replace procedure-based insurance fees, which may help overcome the limitations of fee-for-service structures amidst declining birth rates. Third, it marks the first step toward re-gionalizing maternal and child healthcare.
However, there are concerns about how the project will be established because no detailed action plan has been presented yet. I would like to suggest a few points for building a robust maternal and child healthcare delivery system.
To ensure effective collaboration in maternal and child healthcare, the existing delivery infrastructure—maternity hospitals, medical professionals, and referral systems—must remain intact. For maternity hospitals to continue operating, it is essential to have adequate income. Despite the introduction of new public policy fees in 2023, the shutdown of delivery hospitals continues due to the rapid decline in births, and few new obstetricians are entering the field, resulting in an aging workforce.
It is therefore necessary to adopt various policies that mini-mize hospital closures and secure maternity care personnel. In particular, new labor-related payment systems should be established—such as those linking the number of deliveries to the number of newborns, labor management fees, fetal moni-toring interpretation fees, and newborn care fees in the delivery room. Additionally, when medical malpractice occurs due to force majeure, 100% national support and increased compen-sation are needed to fulfill the state's public responsibility.
In the long term, one possible alternative is to implement conditional admissions for medical and nursing students who will serve in maternity healthcare upon graduation.
Conclusion
An appropriate healthcare delivery system is essential for the efficient use of healthcare resources and for ensuring that healthcare consumers receive adequate medical services. In particular, as more areas become obstetrically underserved, establishing a maternity delivery system is vital because it can help use maternal and child healthcare resources efficiently and provide a safe childbirth environment for pregnant women in those regions.
The regional maternal and child healthcare cooperation project currently being promoted by the government is meaningful in that it will establish the first maternity delivery system in Korea. It is also significant for introducing a fee for medical cooperation rather than relying on procedure-based fees. For this project to be successful, it is crucial to maintain existing maternity hospitals and secure medical personnel involved in childbirth.
In my opinion, the government must develop further measures to address these challenges.