Abstract:

The studies published on the South Korean response to COVID-19 point to different reasons for the country’s success. No reviews were identified on South Korea from January 2020 to April 2021 or that analyzed the pandemic’s recrudescence. Aimed at better systematization of South Korea’s success in controlling the epidemic, we conducted an integrative review to analyze that country´s experience with the COVID-19 pandemic, seeking to identify the relationship between the measures adopted, the health system’s characteristics, and evolution of the selected indicators. Various databases were used, beside epidemiological bulletins and press conferences of the Korea Centers for Disease Control and Prevention (KCDC). We also analyzed reports by the World Health Organization (WHO) and the European Observatory on Health Systems and Policies. The study’s results allow identifying a set of lessons based on the South Korean experience with control and management of the disease. The response by South Korea was successful, due to action in the control of risks and harms, action on social determinants to mitigate the socioeconomic effects of the health crisis, prior experience with other respiratory disease epidemics, and effective national coordination.

Keywords:
Pandemics; COVID-19; Health Systems; Surveillance; Health Policy

Introduction

The COVID-19 pandemic is one of the most serious global health problems of the 21st century ¹1. Barreto ML, Barros AJD, Carvalho MS, Codeço CT, Hallal PRC, Medronho RA, et al. O que é urgente e necessário para subsidiar as políticas de enfrentamento da pandemia de COVID-19 no Brasil? Rev Bras Epidemiol 2020; 23:e200032.^,22. Greer S, de Ruijter A. EU health law and policy in and after the COVID-19 crisis. Eur J Public Health 2020; 30:623-4.^,33. Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: a review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020; 76:71-6.. Comparisons of responses to COVID-19 by different countries show similarities and differences in the measures adopted and the results. Understanding the aspects that influenced greater or lesser success in control of the disease is essential to back decision-makers and contribute to planning to respond to future pandemics.

Various studies have reported South Korea as a successful case in the control of COVID-19 ⁴4. Singer DRJ. Healthcare impact of COVID-19 epidemic in India: a stochastic mathematical model. Med J Armed Forces India 2020; 76:147-55.^,55. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,66. Hitchie H. Emerging COVID-19 success story: South Korea learned the lessons of MERS. https://ourworldindata.org/COVID-exemplar-south-korea (acessado em 16/Fev/2021).
https://ourworldindata.org/COVID-exempla... ^,77. Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. COVID-19: how doctors and healthcare systems are tackling coronavirus worldwide. BMJ 2020; 368:m1090.^,88. Yoon YK, Lee J, Kim SI, Peck KR. A systematic narrative review of comprehensive preparedness strategies of healthcare resources for a large resurgence of COVID-19 nationally, with local or regional epidemics: present era and beyond. J Korean Med Sci 2020; 35:e387.. In the first two months of the health crisis, the incidence was reduced, maintaining a low case-fatality rate ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464. and quickly flattening the epidemic curve without closing borders or commercial establishments ⁶6. Hitchie H. Emerging COVID-19 success story: South Korea learned the lessons of MERS. https://ourworldindata.org/COVID-exemplar-south-korea (acessado em 16/Fev/2021).
https://ourworldindata.org/COVID-exempla... , even given the geographic proximity to China ⁸8. Yoon YK, Lee J, Kim SI, Peck KR. A systematic narrative review of comprehensive preparedness strategies of healthcare resources for a large resurgence of COVID-19 nationally, with local or regional epidemics: present era and beyond. J Korean Med Sci 2020; 35:e387..

However, the reasons cited for this successful response vary. One study ⁸8. Yoon YK, Lee J, Kim SI, Peck KR. A systematic narrative review of comprehensive preparedness strategies of healthcare resources for a large resurgence of COVID-19 nationally, with local or regional epidemics: present era and beyond. J Korean Med Sci 2020; 35:e387. attributed the country’s success to its preexisting capacity, especially due to the revision of the legal and organizational frameworks after MERS in 2015, allowing a rapid and effective response during the first wave of COVID-19, plus available financial support, the governance system, and a workforce experienced in outbreak management ⁸8. Yoon YK, Lee J, Kim SI, Peck KR. A systematic narrative review of comprehensive preparedness strategies of healthcare resources for a large resurgence of COVID-19 nationally, with local or regional epidemics: present era and beyond. J Korean Med Sci 2020; 35:e387.. Another set of studies claims that the country’s success is due to mass testing of the population, leading to early case identification, isolation, contact tracing and quarantine ⁹9. Chen H, Shi L, Zhang Y, Wang X, Sun G. A cross-country core strategy comparison in China, Japan, Singapore and South Korea during the early COVID-19 pandemic. Global Health 2021; 17:22.^,1010. Wang Z, Duan Y, Jin Y, Zheng Z. Coronavirus disease 2019 (COVID-19) pandemic: how countries should build more resilient health systems for preparedness and response. Glob Health J 2020; 4:139-45.^,1111. Lee SM, Lee D. Lessons learned from battling COVID-19: the Korean experience. Int J Environ Res Public Health 2020; 17:7548.^,1212. Park J. Institutions matter in fighting COVID-19: public health, social policies, and the control tower in South Korea. In: Greer SL, King EJ, Peralta-Santos A, Fonseca EM, editores. Coronavirus politics: the comparative politics and policy of COVID-19. Ann Arbor: University of Michigan Press; 2021. p. 106-26..

Another study highlights the high reliability of records of confirmed and suspected cases (around 95%), which facilitated timely management of information and interventions ¹³13. Reis RF, Quintela BM, Campos JO, Gomes JM, Rocha BM, Lobosco M, et al. Characterization of the COVID-19 pandemic and the impact of uncertainties, mitigation strategies, and underreporting of cases in South Korea, Italy, and Brazil. Chaos Solitons Fractals 2020; 136:109888.. Other studies cited the effective use of mobile technologies for tracking, timely supply of personal protective equipment to workers, adequate treatment of patients, and population awareness-raising ¹¹11. Lee SM, Lee D. Lessons learned from battling COVID-19: the Korean experience. Int J Environ Res Public Health 2020; 17:7548.^,1414. Nageshwaran G, Harris RC, Guerche-Seblain CE. Review of the role of big data and digital technologies in controlling COVID-19 in Asia: public health interest vs. privacy. Digit Health 2021; 7:20552076211002953.. According to Nageshwaran et al. ¹⁴14. Nageshwaran G, Harris RC, Guerche-Seblain CE. Review of the role of big data and digital technologies in controlling COVID-19 in Asia: public health interest vs. privacy. Digit Health 2021; 7:20552076211002953., the use of these digital technologies in COVID-19 contributed to South Korea’s response to the epidemic. These authors pointed out that digital surveillance proved effective in mapping patients’ movements and strengthening traditional public health measures ¹⁴14. Nageshwaran G, Harris RC, Guerche-Seblain CE. Review of the role of big data and digital technologies in controlling COVID-19 in Asia: public health interest vs. privacy. Digit Health 2021; 7:20552076211002953..

Park ¹²12. Park J. Institutions matter in fighting COVID-19: public health, social policies, and the control tower in South Korea. In: Greer SL, King EJ, Peralta-Santos A, Fonseca EM, editores. Coronavirus politics: the comparative politics and policy of COVID-19. Ann Arbor: University of Michigan Press; 2021. p. 106-26. attributed the reduction of SARS-CoV-2 transmission to both testing and a combination of public health and socioeconomic policies, the existing public health infrastructure, and timely and transparent information from public health authorities comprising the control tower. Meanwhile Choi ¹⁵15. Choi S. A hidden key to COVID-19 management in Korea: public health doctors. J Prev Med Public Health 2020; 53:175-7. highlighted the strong national coordination in the production of collaborative governance in which public and private stakeholders worked for the public good.

Various authors have analyzed the health systems ¹⁰10. Wang Z, Duan Y, Jin Y, Zheng Z. Coronavirus disease 2019 (COVID-19) pandemic: how countries should build more resilient health systems for preparedness and response. Glob Health J 2020; 4:139-45.^,1111. Lee SM, Lee D. Lessons learned from battling COVID-19: the Korean experience. Int J Environ Res Public Health 2020; 17:7548., surveillance measures, and respective strategies ⁹9. Chen H, Shi L, Zhang Y, Wang X, Sun G. A cross-country core strategy comparison in China, Japan, Singapore and South Korea during the early COVID-19 pandemic. Global Health 2021; 17:22.^,1414. Nageshwaran G, Harris RC, Guerche-Seblain CE. Review of the role of big data and digital technologies in controlling COVID-19 in Asia: public health interest vs. privacy. Digit Health 2021; 7:20552076211002953.. Others have focused on governance, surveillance measures, and the health system ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,1616. You J. Lessons from South Korea's COVID-19 policy response. Am Rev Public Adm 2020; 50: 801-8. with analyses in various periods, mostly in the first semester of 2020. However, no reviews were identified on South Korea from January 2020 to April 2021 or that analyzed the pandemic’s recrudescence.

This justifies the importance of systematizing the explanations cited for South Korea’s success. The current study aimed to answer the following question: “How did the linkage work between the health system and surveillance measures in response to the COVID-19 pandemic in South Korea?”.

To better understand South Korea’s success in controlling the epidemic, the study aimed to analyze that country’s experience in tackling COVID-19, seeking to identify the relationship between the measures, the health system’s characteristics, and the evolution of selected indicators.

Methodology

An integrative review was conducted, adapted from the proposal by Whittemore & Knafl ¹⁷17. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005; 52:546-53., with South Korea’s response to the COVID-19 pandemic as the object. Three searches were performed: the first from May to July 2020, the second in November 2020, and the third in April 2021, to identify articles on South Korea’s response to the increase in new confirmed COVID-19 cases in the country and with the epidemic’s recrudescence from August 2020 to April 2021.

The strategy used in the first search included all parts of the articles (title, abstract, and full text) in PubMed (https://pubmed.ncbi.nlm.nih.gov/) and Science Direct (https://www.sciencedirect.com/). Through the Brazilian Graduate Studies Coordinating Board (CAPES) Periodicals Portal (https://www.periodicos.capes.gov.br/), we accessed PubMed Central and Science Direct, MEDLINE, One File (Gale), Directory of Open Access Journals (DOAJ), Web of Science, Wiley Online Library, Taylor & Francis Online, BMJ Journals, Oxford Journals, and SAGE Journals. We used combined descriptors associated with the terms “COVID-19” and “South Korea” (Box 1). The same databases and search strategies were used in the second and third searches, with restriction only by title, abstract, and keywords. In the CAPES Periodicals Portal, we used restriction by title and subject.

We also included articles (via manual search) that were found in the references of the selected articles to complement information on the country’s response to the pandemic or to allow a better understanding of the South Korean health system’s organization.

The searches yielded 528 articles with the respective descriptors, imported to EndNote (http://www.endnote.com/) and removing duplicates (Figure 1). After excluding duplicate articles, 44 were selected for reading the full text. We also excluded studies that did not focus on this response or that conducted comparative studies of countries, but without demarcating the response as the object of study.

Data were extracted in Microsoft Excel (https://products.office.com/) and analyzed for identification of measures adopted by the country, the relationship to the epidemic’s evolution, and the health system’s characteristics. Article selection was performed by two independent researchers who reached consensus on the selected studies. The data extraction procedures were recorded in matrices containing the year, title of the article, authors, periodicals, and principal findings in relation to the adopted measures.

We also used the available data from the World Health Organization (WHO) COVID-19 dashboard from January to April 2021 for South Korea (https://COVID19.who.int/table), the Korea Centers for Disease Control and Prevention (KCDC; http://ncov.mohw.go.kr/en/), the databases from the European Centre for Disease Prevention and Control (ECDC; https://www.ecdc.europa.eu/en/COVID-19-pandemic), and Our World in Data (https://ourworldindata.org/). We analyzed reports by WHO, the European Observatory on Health Systems and Policies, and KCDC, available in English, on the South Korean health system and the country’s response to the pandemic.

Information on mobility in different locations and types of establishments was obtained from the Google Mobility database (available at https://www.google.com.br/COVID19/mobility/). The data were imported in csv format and the graphs were produced in Microsoft Excel.

The data were analyzed according to three dimensions: (i) characteristics of the country, government, and health system; (ii) evolution of the epidemic; and (iii) measures adopted in response to the COVID-19 pandemic. The health system’s characteristics included infrastructure, population’s healthcare coverage, physicians per inhabitant, form of services provision, healthcare financing and expenditures, organization of services, and the health system’s history. The evolution of the pandemic included date of the first case, evolution up to the hundredth case and later, and case-fatality in relation to the surveillance and control measures adopted by the country.

Results

Characteristics of South Korea and its health system

South Korea is the world’s 13th largest economy according to its GDP ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... . The population is more than 52 million and the country’s territory measures 100,210 km². The political system is a representative Presidential democracy. Besides the federal level, there are regional and local governments headed by elected representatives ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... .

The health system consists of two subsystems: (a) one based on health insurance with public administration, financed by private resources, under the responsibility of a single insurance company, the National Health Insurance Corporation, with coverage of 96% of the population; and (b) a public health program called Medical Aid, with public financing through taxes, targeted to the poor and covering 4% of the population ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... ^,1919. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53.^,2020. Jeong H-S. Korea's National Health Insurance: lessons from the past three decades. Health Aff (Millwood) 2011; 30:136-44.. The health insurance adopts purchase of services from private providers, including a users’ copayment component ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... ^,1919. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53.^,2020. Jeong H-S. Korea's National Health Insurance: lessons from the past three decades. Health Aff (Millwood) 2011; 30:136-44.. The infrastructure features high availability of ICU beds (6.8/1,000 inhabitants, above the global average), concentrated in the private sector ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... .

According to reports, these healthcare establishments are distributed across different levels of care and operate in a fragmented and unlinked mode, without a network having case-resolution capacity through coordination by primary healthcare. There are multiple portals of entry into the health system through services with different technological densities ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... ^,2020. Jeong H-S. Korea's National Health Insurance: lessons from the past three decades. Health Aff (Millwood) 2011; 30:136-44.^,2121. Walker ME, Anonson J, Klotz K, Gallant S, McDougall A, Yarie D, et al. Primary health care in South Korea: does it exist? How can health educators and health practitioners improve it? Int J Health Promot Educ 2009; 47:128-35..

For the control of diseases, the country had a structure linked to the Ministry of Health and Welfare (MoHW), namely the KCDC, which dealt with epidemiological information and investigation of outbreaks. Public health is managed in centralized format by the agency that coordinates the country’s surveillance activities ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... ^,2020. Jeong H-S. Korea's National Health Insurance: lessons from the past three decades. Health Aff (Millwood) 2011; 30:136-44., using a decentralized structure located in the 16 provinces and 253 local public health centers, but with limited autonomy ¹⁸18. WHO Regional Office for the Western Pacific. Republic of Korea health system review. https://apps.who.int/iris/handle/10665/208215 (acessado em 03/Fev/2021).
https://apps.who.int/iris/handle/10665/2... .

In 2015, the South Korean National System for Prevention and Control of Infectious Diseases was restructured, based on an unsatisfactory rating of the country’s response to the MERS-CoV epidemic. The reform was designed according to a proposal debated in numerous seminars by epidemiologists and other experts, in addition to public hearings.

This reorganization resulted in building an early response system to contain outbreaks of infectious diseases in timely fashion, with the creation in the KCDC of an Emergency Operations System to monitor information on infectious diseases in real time and to respond immediately to detected outbreaks. The reform also established a specialized system for diagnosis and treatment within the existing quarantine installations for the detection and prevention of emerging infectious disease outbreaks, besides the creation of a screening system in the emergency units. The infrastructure for infection control in hospitals was also expanded, along with a revision of the management/governance models for emerging infectious diseases.

In September 2020, the KCDC was transformed into an independent government agency called the Korea Disease Control and Prevention Agency (KDCA), with the incorporation of the National Institute of Health (NIH), National Institute of Infectious Diseases (NIID), Regional Centers for Disease Control and Prevention (RCDCs), National Tuberculosis Hospitals, and National Quarantine Stations. The expansion of its autonomy and team gave this agency more authority and responsibility in the coordination of the national response to infectious diseases ²²22. Korea Disease Control and Prevention Agency. Opening of Korea Disease Control and Prevention Agency. Press release. September 14, 2020. https://www.kdca.go.kr/board/board.es?mid=a30402000000&bid=0030 (acessado em 03/Ago/2020).
https://www.kdca.go.kr/board/board.es?mi... .

Response to the COVID-19 epidemic

The South Korean government encouraged the MoHW to adopt a national response based on data and science ²³23. Jeong GH, Lee HJ, Lee J, Lee JY, Lee KH, Han YJ, et al. Effective control of COVID-19 in South Korea: cross-sectional study of epidemiological data. J Med Internet Res 2020; 22:e22103.. At the beginning of the pandemic, in March 2020, Ha ²⁴24. Ha KM. Emergency response to the outbreak of COVID-19: the Korean case. Microbes Infect 2020; 22:159-61. defended the position that the response should be risk oriented. The Chief Presidential Secretary, responsible for governance of all sectors, was a health systems researcher, which favored coordination between the Office of the Prime Minister, the Ministry of Social Assistance, and the KCDC, allowing a rapid response based on epidemiological information and resource reallocation. The MoHW worked in coordination with the provincial and metropolitan governments.

The response protocol activated by the government aimed to ensure coordinated and inter-sector action ²⁵25. Lee D, Heo K, Seo Y, Ahn H, Jung K, Lee S, et al. Flattening the curve on COVID-19: South Korea's measures in tackling initial outbreak of coronavirus. Am J Epidemiol 2020; 190:496-505., with participation by society and under strong national leadership ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.. Importantly, since 2016 the KCDC had established a risk assessment system ²⁶26. Kim H. The sociopolitical context of the COVID-19 response in South Korea. BMJ Glob Health 2020; 5:e002714.^,2727. Kim I, Lee J, Lee J, Shin E, Chu C, Lee SK. KCDC risk assessments on the initial phase of the COVID-19 outbreak in Korea. Osong Public Health Res Perspect 2020; 11:67-73..

The country’s response to the pandemic was triggered through the National Plan for Management of Infectious Diseases, based on which the local governments produced their implementation plans in coordination with the national level ¹⁶16. You J. Lessons from South Korea's COVID-19 policy response. Am Rev Public Adm 2020; 50: 801-8..

The first-level alert was issued on January 3, 2020, after notification of the first COVID-19 cases in China. The second-level alert was issued on January 20, 2020, following identification of the first case in South Korea ²⁸28. COVID-19 National Emergency Response Center, Epidemiology & Case Management Team, Korea Centers for Disease Control & Prevention. Contact transmission of COVID-19 in South Korea: novel investigation techniques for tracing contacts. Osong Public Health Res Perspect 2020; 11:60-3.^,2929. Shaw R, Kim Y, Hua J. Governance, technology and citizen behavior in pandemic: lessons from COVID-19 in East Asia. Prog Disaster Sci 2020; 6:100090.. This first case was a woman coming from Wuhan, China ³⁰30. Ki M; Task Force for 2019-nCoV. Epidemiologic characteristics of early cases with 2019 novel coronavirus (2019-nCoV) disease in Korea. Epidemiol Health 2020; 42:e2020007., identified at the airport. On January 27, 2020, the third-level alert was issued due to the increase in cases. Cases analyzed from January 20 to February 10, 2020, show that infection occurred mainly in Wuhan, but also in Guangdong (China), Singapore, Japan, and Thailand ³⁰30. Ki M; Task Force for 2019-nCoV. Epidemiologic characteristics of early cases with 2019 novel coronavirus (2019-nCoV) disease in Korea. Epidemiol Health 2020; 42:e2020007.. On February 20, South Korea reached the hundredth positive case of the disease and reported the first COVID-19 death ³¹31. World Health Organization. WHO coronavirus (COVID-19) dashboard. https://COVID19.who.int/ (acessado em 20/Fev/2021).
https://COVID19.who.int/... (Box 2). There was a sharp rise in incidence until late February ³²32. Kim S, Castro MC. Spatiotemporal pattern of COVID-19 and government response in South Korea (as of May 31, 2020). Int J Infect Dis 2020; 98:328-33. (Table 1; Figure 2; Box 2).

The country’s alert reached the highest level (level 4), mainly due to the massive outbreak in Daegu, on February 23, 2020 (Figures 2 and 3). The government mobilized national response protocols aimed at coordination between society and various levels of government to contain the pandemic ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464. and installed the National Disaster Prevention and Countermeasures Headquarters, headed by the Prime Minister. On March 21, 56.8% of the cases, that is, 5,051 of the 8,897 confirmed cases in the entire country, were linked to the 31st patient associated with the Sincheonji Church of Jesus ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.. This was the largest cluster associated with spread of the disease, with the epicenter in the city of Daegu ³²32. Kim S, Castro MC. Spatiotemporal pattern of COVID-19 and government response in South Korea (as of May 31, 2020). Int J Infect Dis 2020; 98:328-33., followed by the Daenam Hospital in the same city ³³33. Shim E, Tariq A, Choi W, Lee Y, Chowell G. Transmission potential and severity of COVID-19 in South Korea. Int J Infect Dis 2020; 93:339-44.. The mass contamination in the church, responsible for wide dissemination of the virus, was called “black swan” ³⁴34. Hwang J, Park H, Kim S-H, Jung J, Kim N. Basic and effective reproduction numbers of COVID-19 cases in South Korea excluding Sincheonji cases. medRxiv 2020; 31 mar. https://www.medrxiv.org/content/10.1101/2020.03.19.20039347v2.
https://www.medrxiv.org/content/10.1101/... . The increase in Rt in the month of April was related to the growth in local transmission in Greater Metropolitan Seoul (Seoul, city of Incheon, and province of Gyeonggi) ³⁵35. Dighe A, Cattarino L, Cuomo-Dannenburg G, Skarp J, Imai N, Bhatia S, et al. Response to COVID-19 in South Korea and implications for lifting stringent interventions. BMC Med 2020; 18:321.. The proportion of recovered cases was higher in women ³⁶36. Al-Rousan N, Al-Najjar H. Data analysis of coronavirus COVID-19 epidemic in South Korea based on recovered and death cases. J Med Virol 2020; [Epub ahead of print]..

South Korea developed an approach along two lines, namely the clinical case management response and the public health response, to prevent and detect new infections ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.. As for case management, actions in the health system were divided into two subsystems, “COVID-19” and “non-COVID-19”, aimed at guaranteeing continuity of care for the population’s other health needs. Governance and national coordination were relevant for the flow and delivery of supplies and organization of the referral system, with referral of patients between levels of care and on the city limits and provincial borders, even in the absence of a clear legal structure.

In care for COVID-19 cases, South Korea’s low case-fatality rate has been attributed to the capacity to reduce the infection rate in high-risk populations through detection and early isolation of cases ³⁷37. Ryu S, Ali ST, Lim J-S, Chun BC. Estimation of the excess COVID-19 cases in Seoul, South Korea by the students arriving from China. Int J Environ Res Public Health 2020; 17:3113., which prevented an overload on hospitals, leaving them available to care for the more severe cases ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464..

The country’s infrastructure for tacking COVID-19 was also expanded with: (i) implementation of Screening Centers at the district level to asses individuals with fever or respiratory symptoms; (ii) organization of negative-pressure intensive care units in university hospitals and those accredited through them; (iii) definition of hospitals and allocation of respiratory disease specialists for treatment of noncritical patients; (iv) implementation of clinical beds in “nonhospital” spaces (field hospitals) for treating mild cases, alongside health workforce training; (v) definition of governance and national coordination; and (vi) deployment of actions and inputs for health workforce protection.

Social communication technologies were used to encourage the population to maintain distancing and home work ³⁸38. Organisation for Economic Co-operation and Development. OECD country tracker policy - COVID-19. https://www.oecd.org/coronavirus/country-policy-tracker/ (acessado em 20/Fev/2021).
https://www.oecd.org/coronavirus/country... , and the country adopted various such measures, varying according to the epidemiological situation ¹⁹19. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53. and including cancellation of public events, travel bans/restrictions, and closing of schools and universities, all implemented progressively (Figures 2 and 3).

The country drew on standard procedures for risk communication in public health emergencies that had been implemented in 2017 ¹⁶16. You J. Lessons from South Korea's COVID-19 policy response. Am Rev Public Adm 2020; 50: 801-8.. When COVID-19 struck, the KCDC published daily information on its website on the evolution of the pandemic, updates to the strategies, and revision of regulations and measures in keeping with the epidemic’s evolution in the country ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.. Preventive practices were published continuously by the government ²⁹29. Shaw R, Kim Y, Hua J. Governance, technology and citizen behavior in pandemic: lessons from COVID-19 in East Asia. Prog Disaster Sci 2020; 6:100090. such as physical distancing and other preventive measures ⁴⁰40. Lee M, You M. Psychological and behavioral responses in South Korea during the early stages of coronavirus disease 2019 (COVID-19). Int J Environ Res Public Health 2020; 17:2977.. Studies have reported extensively on policies for the use of face masks ⁴¹41. Yu S, Kim S, Kang J. Face mask policies in South Korea in response to COVID-19. Asia Pac J Public Health 2020; 32:497-9.. Medical associations came out publicly in support of the KCDC ⁴²42. Joint statement of the Korean Society for Preventive Medicine and the Korean Society of Epidemiology on the response to the COVID-19 outbreak. Epidemiol Health 2020; 42:e2020019.. Alerts were sent to citizens’ cellphones by local authorities, with the new confirmed cases and their recent trajectories whenever available. The system had already been adopted by the Ministry of the Interior and Safety to inform on disasters ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111..

The isolation protocols that were adopted followed the recommendations of the International Health Regulations, not involving the closing of national borders ¹⁹19. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53.. A program was implemented for self-quarantine and contact tracing for all travellers ⁴³43. Petersen E, Wasserman S, Lee SS, Go U, Holmes AH, Al-Abri S, et al. COVID-19 - We urgently need to start developing an exit strategy. Int J Infect Dis 2020; 96:233-9., with mandatory use of a cellphone app ²³23. Jeong GH, Lee HJ, Lee J, Lee JY, Lee KH, Han YJ, et al. Effective control of COVID-19 in South Korea: cross-sectional study of epidemiological data. J Med Internet Res 2020; 22:e22103.. Individuals identified as contacts of confirmed or suspected cases were placed under home quarantine, or when this was not possible in public support centers at no charge ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.. In specific situations, there were also partnerships with the private sector, aimed at expansion of the healthcare infrastructure.

In Daegu, a network was operated that consisted of the Emergency Response Advisory Group, the Daegu Medical Association, and three support groups that acted in coordination in the control of the COVID-19 epidemic ¹⁶16. You J. Lessons from South Korea's COVID-19 policy response. Am Rev Public Adm 2020; 50: 801-8.. In the case of Hanam, the medical association, the Public Health Center, and the central and provincial governments joined forces to screen, test, and monitor the population by sharing public and private infrastructure as well as the workforce ⁴⁴44. Ku SS, Choe YJ. A public-private partnership model to build a triage system in response to a COVID-19 outbreak in Hanam City, South Korea. Osong Public Health Res Perspect 2020; 11:339-42..

As for case surveillance, widespread testing was adopted as a fundamental strategy for identifying cases and tracing contacts ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.^,4545. Choi JY. COVID-19 in South Korea. Postgrad Med J 2020; 96:399-402.^,4646. Han E, Tan MMJ, Turk E, Sridhar D, Leung GM, Shibuya K, et al. Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe. Lancet 2020; 396:1525-34.^,4747. Kang J, Jang YY, Kim J, Han SH, Lee KR, Kim M, et al. South Korea's responses to stop the COVID-19 pandemic. Am J Infect Control 2020; 48:1080-6.. South Korea established its testing capacity with three interventions: public-private partnerships for the development of testing technologies that included RT-PCR, the gold standard for COVID-19; approval of testing for suspected cases; and rapid development of these tests by the country through partnership with local governments ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,4444. Ku SS, Choe YJ. A public-private partnership model to build a triage system in response to a COVID-19 outbreak in Hanam City, South Korea. Osong Public Health Res Perspect 2020; 11:339-42.^,4646. Han E, Tan MMJ, Turk E, Sridhar D, Leung GM, Shibuya K, et al. Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe. Lancet 2020; 396:1525-34..

In a pioneering approach, the country implemented drive-thru screening centers to expand diagnosis with the reduction of health workers’ exposure ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.^,4545. Choi JY. COVID-19 in South Korea. Postgrad Med J 2020; 96:399-402.^,4848. Kim S, Lee JY. Walk-through screening center for COVID-19: an accessible and efficient screening system in a pandemic situation. J Korean Med Sci 2020; 35:e154.. Tests took an average of 10 minutes to perform, and the results were sent directly to patients through text messages within three days. In regions with difficulties for vehicle circulation, mobile compact booths were developed to perform walk-thru tests ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.^,4848. Kim S, Lee JY. Walk-through screening center for COVID-19: an accessible and efficient screening system in a pandemic situation. J Korean Med Sci 2020; 35:e154.. Public health doctors, or health professionals that worked during their period of military service, were deployed in the process ¹⁵15. Choi S. A hidden key to COVID-19 management in Korea: public health doctors. J Prev Med Public Health 2020; 53:175-7.. They were sent quickly to the COVID-19 epicenters and performed tests in Screening Centers, airports, and hospitals.

A 24-hour telephone hotline was set up for screening by primary care physicians to orient and manage cases ⁴⁴44. Ku SS, Choe YJ. A public-private partnership model to build a triage system in response to a COVID-19 outbreak in Hanam City, South Korea. Osong Public Health Res Perspect 2020; 11:339-42.. Free tests were offered in case of symptoms ⁴⁸48. Kim S, Lee JY. Walk-through screening center for COVID-19: an accessible and efficient screening system in a pandemic situation. J Korean Med Sci 2020; 35:e154.. This policy of care for cases that aimed at early detection, decreasing the pace of new infections, allowed more effective containment of the disease than in other countries ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,3939. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.. Extensive epidemiological investigations were conducted in the field, using information and communication technologies (ICTs), with intergovernmental cooperation ¹⁵15. Choi S. A hidden key to COVID-19 management in Korea: public health doctors. J Prev Med Public Health 2020; 53:175-7., using not only patient interviews and medical records but also credit card transactions, GPS, and television circuits to identify cases and contacts movements ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,2828. COVID-19 National Emergency Response Center, Epidemiology & Case Management Team, Korea Centers for Disease Control & Prevention. Contact transmission of COVID-19 in South Korea: novel investigation techniques for tracing contacts. Osong Public Health Res Perspect 2020; 11:60-3.^,4949. Korea Centers for Disease Control and Prevention. Coronavirus disease-19, Republic of Korea. http://ncov.mohw.go.kr/en/ (acessado em 20/Fev/2021).
http://ncov.mohw.go.kr/en/... . After the MERS outbreak in 2015, a national regulation facilitated sharing of these investigations with the general public ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,3939. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.^,5050. Lee D, Heo K, Seo Y. COVID-19 in South Korea: lessons for developing countries. World Dev 2020; 135:105057.^,5151. Lu N, Cheng KW, Qamar N, Huang KC, Johnson JA. Weathering COVID-19 storm: successful control measures of five Asian countries. Am J Infect Control 2020; 48:851-2..

Large-scale epidemiological investigation was possible due to the presence of 30 rapid response teams from the KCDC and expansion of the number of workers in local services ⁴⁹49. Korea Centers for Disease Control and Prevention. Coronavirus disease-19, Republic of Korea. http://ncov.mohw.go.kr/en/ (acessado em 20/Fev/2021).
http://ncov.mohw.go.kr/en/... . In approximately 250 districts, a temporary taskforce of officers from the epidemiological intelligence service was established with elementary and middle-level employees from government health centers. Although these workers were not regular qualified civil servants, they were trained in standard protocols for contact tracing. Importantly, since 1999, through the Field Epidemiology Training Program, the country had already adopted epidemiological intelligence service officers at the central and provincial levels in conducting epidemiological investigations ⁵²52. Kwon G-Y, Moon S, Kwak W, Gwack J, Chu C, Youn S-K. Epidemic intelligence service officers and field epidemiology training program in Korea. Osong Public Health Res Perspect 2013; 4:215-21..

The combination of surveillance measures, contact tracing, and workforce expansion and qualification aimed to inform the population and produce information to support decisions by the country’s authorities. Data and artificial intelligence (AI) streamlined the response and expanded the effectiveness in the activities’ coordination ¹⁶16. You J. Lessons from South Korea's COVID-19 policy response. Am Rev Public Adm 2020; 50: 801-8.. The fact that South Korea has the world’s fastest Internet favored the process ¹⁹19. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53.. Cellphone apps and online maps developed by private initiative and government agencies played an essential role in monitoring the epidemic’s evolution, to alert the public to the risk of exposure, and in the rapid adaptation of testing centers according to needs ⁴⁸48. Kim S, Lee JY. Walk-through screening center for COVID-19: an accessible and efficient screening system in a pandemic situation. J Korean Med Sci 2020; 35:e154..

With the increase in cases and the difficulty tracing contacts manually, the Ministry of Land, Infrastructure, and Transport deployed an integrated surveillance system to perform this activity automatically in collaboration with the KCDC and the Ministry of Science and Technology ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.^,5353. Arora AS, Rajput H, Changotra R. Current perspective of COVID-19 spread across South Korea: exploratory data analysis and containment of the pandemic. Environ Dev Sustain 2020; [Epub ahead of print].. A preexisting data platform for intelligent cities was adapted, combining data from the National Police Agency, three telecom companies ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464., and 22 credit card companies, culminating in the COVID-19 Intelligent Management System ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111., a support system for epidemiological investigation, which reduced the tracing time to less than 10 minutes.

The MoHW also developed a cellphone app to monitor potential patients, with threats of legal penalties (fines and imprisonment) to reinforce the limitations on movement. The Ministry of the Interior and Safety provided an app to monitor self-quarantine and assess contacts’ health conditions. With the expanded use of digital technologies, the question of right to privacy and use of data in the response to public health problems was problematized ⁵⁴54. Kim SW, Lee KS, Kim K, Lee JJ, Kim JY; Daegu Medical Association. A brief telephone severity scoring system and therapeutic living centers solved acute hospital-bed shortage during the COVID-19 outbreak in Daegu, Korea. J Korean Med Sci 2020; 35:e152.. Critics pointed to the excessive use of the State apparatus to control individuals through digital techniques ⁵⁵55. Baca G. Eastern surveillance, Western malaise, and South Korea's COVID-19 response: oligarchic power in Hell Joseon. Dialect Anthropol 2020; 44:301-7., with violation of infected patients’ civil liberties and allowing stigma by society ⁵⁶56. Yi J, Lee W. Pandemic nationalism in South Korea. Society 2020; 57:446-51.^,5757. Park S, Choi GJ, Ko H. Information technology-based tracing strategy in response to COVID-19 in South Korea: privacy controversies. JAMA 2020; 323:2129-30.. Despite psychological and mental health interventions, the need was identified for a better public approach to avoid collapse of the social support systems and stigmatization of patients ⁵⁸.

Even without closing borders or imposing a national lockdown ⁵⁰50. Lee D, Heo K, Seo Y. COVID-19 in South Korea: lessons for developing countries. World Dev 2020; 135:105057., there was a decrease in mobility in public transportation centers. The number of passengers in all stations decreased by 40.6% from January to March. A change was seen in the number of passengers in the Seoul subway at different moments in the COVID-19 epidemic ⁵⁹59. Park J. Changes in subway ridership in response ta COVID-19 in Seoul, South Korea: implications for social distancing. Cureus 2020; 12:e7668.. The authors pointed to a larger reduction in the flow of users in stations serving workplaces compared to stations devoted mainly to leisure-time activities ⁵⁹59. Park J. Changes in subway ridership in response ta COVID-19 in Seoul, South Korea: implications for social distancing. Cureus 2020; 12:e7668.. A study on use of the public bicycle-sharing system showed greater use of this type of personal transportation and voluntary waiving of conventional public transportation ⁶⁰60. Park S, Kim B, Lee J. Social distancing and outdoor physical activity during the COVID-19 outbreak in South Korea: implications for physical distancing strategies. Asia Pac J Public Health 2020; 32:360-2..

Starting in July 2020, new cases began to increase again, and different levels of physical distancing measures were announced and activated. Many confirmed cases had a history of travel to various countries, with the Unites States and Europe accounting for 65.2% ⁵³53. Arora AS, Rajput H, Changotra R. Current perspective of COVID-19 spread across South Korea: exploratory data analysis and containment of the pandemic. Environ Dev Sustain 2020; [Epub ahead of print].. On July 31 ⁶¹61. Korea Centers for Disease Control and Prevention. Press release. July 31, 2020. https://www.kdca.go.kr/board/board.es?mid=a30402000000&bid=0030 (acessado em 03/Ago/2020).
https://www.kdca.go.kr/board/board.es?mi... , among other measures, a maximum of 10% occupation was enforced in football and baseball stadiums, with online ticket purchases, mandatory mask-wearing to and from and during sports events (Box 2).

According to one study, a large antigovernment demonstration and loosening of social distancing policies led to an increase in the incidence in August 2020 ²³23. Jeong GH, Lee HJ, Lee J, Lee JY, Lee KH, Han YJ, et al. Effective control of COVID-19 in South Korea: cross-sectional study of epidemiological data. J Med Internet Res 2020; 22:e22103.. Level 2 alert was issued on August 15, 2020 ⁶²62. Korea Centers for Disease Control and Prevention. Press release. August 15, 2020. https://www.kdca.go.kr/board/board.es?mid=a30402000000&bid=0030 (acessado em 15/Mar/2021).
https://www.kdca.go.kr/board/board.es?mi... ^,6363. Korea Centers for Disease Control and Prevention. Press release. August 30, 2020. https://www.kdca.go.kr/board/board.es?mid=a30402000000&bid=0030 (acessado em 15/Mar/2021).
https://www.kdca.go.kr/board/board.es?mi... , due to local clusters and community transmission in Greater Metropolitan Seoul and other provinces. On September 30, 2020, the number of new cases dropped again and there was a decrease in social distancing to level 1 in October 2020, with an increase from 1.5 to 2.5 in November and subsequent months due to the rise in local transmission ⁶⁴64. Korea Centers for Disease Control and Prevention. Press release. October 12, 2020. https://www.kdca.go.kr/board/board.es?mid=a30402000000&bid=0030 (acessado em 03/Mar/2021).
https://www.kdca.go.kr/board/board.es?mi... (Table 1; Box 2; Figure 2). February 2021 witnessed a drop in cases, with mortality of 29.78 deaths/million inhabitants (February 15, 2021). Much higher rates were occurring in the United Kingdom (1,732.64 COVID-19 deaths/million), Italy (1,551.97 COVID-19 deaths/million), Portugal (1,511.37 COVID-19 deaths/million), United States (1,439.01 COVID-19 deaths/million), and Brazil (1,128.03 COVID-19 deaths/million) ⁶⁵65. Our World in Data. Coronavirus pandemic (COVID-19). https://ourworldindata.org/ (acessado em 01/Mar/2021).
https://ourworldindata.org/... .

In February 2021, the KDCA announced the start of COVID-19 immunization in the country ⁶⁶66. Korea Disease Control and Prevention Agency. COVID-19 vaccination to begin this week. Press release. February 22, 2021. https://www.kdca.go.kr/board/board.es?mid=a30402000000&bid=0030 (acessado em 03/Mar/2021).
https://www.kdca.go.kr/board/board.es?mi... . The first doses of the Pfizer-BioNTech vaccine, acquired through the COVAX Facility, were reserved for employees of COVID-19 referral hospitals. The country diversified the purchase of vaccines for immunization of persons working in health centers and recovery hospitals. An online registry was deployed to identify eligible individuals according to the established criteria. No publications were identified that analyzed the reason why the country only began vaccination in early 2021.

South Korea adopted a set of compensatory and social protection measures aimed at decreasing the economic impact of COVID-19 and guaranteeing maintenance of citizens’ livelihood ⁶⁵65. Our World in Data. Coronavirus pandemic (COVID-19). https://ourworldindata.org/ (acessado em 01/Mar/2021).
https://ourworldindata.org/... . The government announced the budget for measures to mitigate the pandemic and its economic effects, with the approval of a set of fiscal measures that included credit guarantees and emergency support for families and tourism, export industry, and strategic companies.

There were emergency subsidies in the form of coupons and cash to stimulate private consumption. There was also a budget outlay focused on job creation; emergency loans to companies in financial difficulties; the Korean New Deal Project, in which the country planned to create 1.9 million new jobs and invest USD 133 billion by 2025, with a focus on digital and “ecofriendly” projects. The country adopted measures to reduce workplace exposure to COVID-19 with the publication of a protocol and stimulus for flexible arrangements (home office and flexible hours, among other measures). Income support was established for sick workers and their families, for persons that had lost their jobs or income from self-employed work, stimulus for companies to adjust the work schedules and protect jobs and financial support for those suffering a reduction in consumer demand, as well as suspension of tariff payments, including electricity bills.

Discussion

The study found evidence that allows relating South Korea’s success in the control of the COVID-19 pandemic to a combination of strategies that include surveillance, timely case investigation, and use of digital technologies and AI, besides other inter-sector measures. National coordination by a collegiate body, technically qualified and centralized in an agency affiliated with the MoHW, was identified as one of the positive factors in the response to COVID-19 ⁷7. Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. COVID-19: how doctors and healthcare systems are tackling coronavirus worldwide. BMJ 2020; 368:m1090.^,1919. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53..

Thus, the response backed by epidemiological data oriented the adoption of measures and the quick mobilization of the protocol for the response to infectious diseases. The implementation of adequate surveillance allowed more flexible social distancing according to the local epidemiological situation.

Another outstanding feature was the assessment of suspected cases at Local Screening Centers with referral to healthcare units based on the degree of severity. These findings are reinforced by studies ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,88. Yoon YK, Lee J, Kim SI, Peck KR. A systematic narrative review of comprehensive preparedness strategies of healthcare resources for a large resurgence of COVID-19 nationally, with local or regional epidemics: present era and beyond. J Korean Med Sci 2020; 35:e387. reporting that the main lessons learned in the South Korean experience were early threat detection, rapid activation of the national emergency protocol by the national leadership, as well as triggering of the process for prompt establishment of the country’s diagnostic capacity.

According to the literature, the negative response to MERS in 2015 motivated the South Korean government to elaborate a protocol, including the establishment of public-private partnerships under State regulation for the development of high-sensitivity tests ¹⁶16. You J. Lessons from South Korea's COVID-19 policy response. Am Rev Public Adm 2020; 50: 801-8.^,4444. Ku SS, Choe YJ. A public-private partnership model to build a triage system in response to a COVID-19 outbreak in Hanam City, South Korea. Osong Public Health Res Perspect 2020; 11:339-42.^,4747. Kang J, Jang YY, Kim J, Han SH, Lee KR, Kim M, et al. South Korea's responses to stop the COVID-19 pandemic. Am J Infect Control 2020; 48:1080-6.^,5151. Lu N, Cheng KW, Qamar N, Huang KC, Johnson JA. Weathering COVID-19 storm: successful control measures of five Asian countries. Am J Infect Control 2020; 48:851-2.^,6767. Park J, Chung E. Learning from past pandemic governance: early response and public-private partnerships in testing of COVID-19 in South Korea. World Dev 2021; 137:105198.. The previous negative experience reportedly induced the production of such technologies as the implementation of drive-thru clinics and a culture of the use of surgical masks in the country ¹⁹19. Palaniappan A, Dave U, Gosine B. Comparing South Korea and Italy's healthcare systems and initiatives to combat COVID-19. Rev Panam Salud Pública 2020; 44:e53..

Meanwhile, the SARS epidemic in 2004 led the KCDC to reformulate the system of preparedness and response to imported infectious diseases through the implementation of an Emergency Operations Center, strengthening risk communication and the risk assessment strategy with the creation of new divisions and expansion of the number of professionals for epidemiological investigation ⁶⁸68. Cho H-W. Effectiveness for the response ta COVID-19: the MERS outbreak containment procedures. Osong Public Health Res Perspect 2020; 11:1-2..

Other studies point to a concern over substantial economic losses and the population’s fear of a possible new epidemic experience as factors favoring adherence to government’s instructions ⁵5. Oh J, Lee JK, Schwartz D, Ratcliffe HL, Markuns JF, Hirschhorn LR. National response to COVID-19 in the Republic of Korea and lessons learned for other countries. Health Syst Reform 2020; 6:e1753464.^,3434. Hwang J, Park H, Kim S-H, Jung J, Kim N. Basic and effective reproduction numbers of COVID-19 cases in South Korea excluding Sincheonji cases. medRxiv 2020; 31 mar. https://www.medrxiv.org/content/10.1101/2020.03.19.20039347v2.
https://www.medrxiv.org/content/10.1101/... .

The containment measures after the first cases, with a rigorous testing policy for early identification of cases, contact tracing, and recommendation of timely quarantine or isolation were essential. These findings have been ratified by comparative studies ⁹9. Chen H, Shi L, Zhang Y, Wang X, Sun G. A cross-country core strategy comparison in China, Japan, Singapore and South Korea during the early COVID-19 pandemic. Global Health 2021; 17:22.^,1010. Wang Z, Duan Y, Jin Y, Zheng Z. Coronavirus disease 2019 (COVID-19) pandemic: how countries should build more resilient health systems for preparedness and response. Glob Health J 2020; 4:139-45.^,1111. Lee SM, Lee D. Lessons learned from battling COVID-19: the Korean experience. Int J Environ Res Public Health 2020; 17:7548..

ICTs were listed as an important element in the response to the pandemic, as well as the availability of test results and up-to-date information on COVID-19 on the government and local websites; the governments’ integrated communication strategies, including municipalities; and the walk-thru testing stations. Intragovernmental interaction and the inter-sector response also appear to have been relevant elements. One study found that countries that were better equipped and prepared with testing, hospital infrastructure, and contact tracing, among other measures, responded better to the epidemic ³⁹39. Lee D, Lee J. Testing on the move: South Korea's rapid response to the COVID-19 pandemic. Transp Res Interdiscip Perspect 2020; 5:100111.. These results are corroborated by other authors ¹⁴14. Nageshwaran G, Harris RC, Guerche-Seblain CE. Review of the role of big data and digital technologies in controlling COVID-19 in Asia: public health interest vs. privacy. Digit Health 2021; 7:20552076211002953. who point to real-time epidemiological digital dashboards, interactive maps for locating cases, use of mobile apps, and georeferencing to monitor compliance with quarantine as factors that contributed to dealing with the pandemic.

Although the results of this review characterize primary care in South Korea as far from having a network structure with case resolution and coordinating care (approaching selective primary care ⁶⁹69. Aquino R, Medina MG, Nunes CA, Sousa MF. A Estratégia Saúde da Família e o reordenamento do sistema de serviços de saúde. In: Paim JS, Almeida Filho N, organizadores. Saúde coletiva: teoria e prática. Rio de Janeiro: Medbooks; 2014. p. 353-71.), the organization of the response to the pandemic used both the physical and human infrastructure and the establishment of local partnerships between various services as facilitating element in receiving users with respiratory symptoms for referral and case management.

The importance of primary care in responding to the pandemic has been well documented ⁷⁰70. Barbosa SP, Silva AVFG. A prática da atenção primária à saúde no combate da COVID-19. APS em Revista 2020; 2:17-9.^,7171. Nedel F. Enfrentando a COVID-19: APS forte agora mais que nunca! APS em Revista 2020; 2:11-6.^,7272. Facchini L. COVID-19: nocaute do neoliberalismo? Será possível fortalecer os princípios históricos do SUS e da APS em meio à pandemia? APS em Revista 2020; 2:3-10., showing that it is particularly effective in mild and moderate cases, in the coordination of users in the network, and in clinical management and monitoring of isolation, besides post-COVID-19 patient follow-up ⁷⁰70. Barbosa SP, Silva AVFG. A prática da atenção primária à saúde no combate da COVID-19. APS em Revista 2020; 2:17-9.^,7373. Sarti TD, Lazarini WS, Fontenelle LF, Almeida APSC. Qual o papel da atenção primária à saúde diante da pandemia provocada pela COVID-19? Epidemiol Serv Saúde 2020; 29:e2020166.^,7474. Daumas RP, Azevedo e Silva G, Tasca R, Leite IC, Brasil P, Greco DB, et al. O papel da atenção primária na rede de atenção à saúde no Brasil: limites e possibilidades no enfrentamento da COVID-19. Cad Saúde Pública 2020; 36:e00104120.. The expansion of existing structures and their linkage to primary care allowed control of the disease and avoided its spread.

In terms of the provision of services and coverage of care for most of the population, the South Korean health system is substantially private. However, the mobilization of available public structures at the provincial and local levels was essential for the response to COVID-19. When it proved necessary to mobilize nonpublic structures, the government was decisive in regulating the services, as in the control of the Daegu crisis, allowing legal backing for necessary interventions ³¹31. World Health Organization. WHO coronavirus (COVID-19) dashboard. https://COVID19.who.int/ (acessado em 20/Fev/2021).
https://COVID19.who.int/... .

Considering the health surveillance diagram adopted by studies in Brasil ⁷⁵75. Paim JS. A reforma sanitária e os modelos assistenciais. In: Rouquayrol MZ, organizador. Epidemiologia & saúde. São Paulo: Medsi; 1994. p. 455-66., this review’s results show that South Korea developed interventions to control risks and harms, besides adopting measures to prevent the pandemic’s economic and social effects, with risk communication strategies capable of promoting engagement by the population, professionals, policymakers, and technicians.

Final remarks

The evidence produced by the integrative review show that South Korea succeeded in controlling transmission and mitigating the pandemic’s harms, flattening the epidemic curve and without collapse of health services, suggesting that the country represents a successful case in the response to COVID-19.

There was linkage in the South Korean response between surveillance, risk and harm control, and action on certain social determinants to mitigate the pandemic’s socioeconomic effects. The country presents specificities, such as having experienced the MERS epidemic, which resulted in the institutional reform of the system for handling infectious diseases, creation of a protocol with various levels of intervention in epidemics, and legislation on the use of private data in health emergencies, allowing greater adherence by the population to the various tools, besides a normative legal framework to back the government’s measures in dealing with the epidemic.

The review’s results allow identifying a set of lessons from the South Korean experience, aimed at control and management of the disease. These feature the importance of major national coordination, linking actions by the various government ministries and agencies with orientation for inter-sector work. The coordinated government decision was based on epidemiological information with the adoption of measures to support and allocate resources for confronting the epidemic and its effects on the country’s economy. Protocols were available at each location containing appropriate level alerts for activating measures, depending on the epidemiological situation, as well as adequate risk communication using various tools and technologies, with daily updates on the situation and wide dissemination of information to society, besides daily messages on areas at increased risk. Border surveillance was performed even before confirmation of the first case.

Digital technologies (apps for mobile devices) were used as tools for case surveillance, monitoring of the self-quarantine and health situation of cases and contacts, or to follow mobility in the country. Laboratory capacity was expanded and testing centers were deployed, favoring a strategy that allowed large-scale contact tracing with early case detection and timely adoption of isolation or quarantine, leading to identification of clusters and adoption of measures to control transmission.

Temporary structures with the expansion of patient beds were created to treat less serious cases and linked to primary care for diagnosis, referrals, and local partnerships to receive individuals with respiratory symptoms. The policy highlights the importance of integration of primary care in responding to the pandemic and guaranteeing availability of personal protective equipment for health workers at various levels of care. Many workers were also recruited for epidemiological investigation and contact tracing activities in local services, which allowed expanding the epidemiological surveillance activities.

The current study displays certain limitations, as in any review, including the fact that one of the data sources was published articles with a diversity of research questions, methodological designs, and analytical techniques. We thus suggest deepening the research through comparative studies, drawing on greater methodological rigor in the data production and analysis, with a view towards allowing better comparison between countries.

The development of an effective response by South Korea has centered on epidemiological information oriented the adoption of measures for the expansion of physical infrastructure and staffing, laboratory response capacity, healthcare, and surveillance and monitoring of cases and contacts. The country’s success should thus be attributed to the combination of various types of strategies, featuring actions by the national coordination linked to local levels, surveillance, and case investigation.

Acknowledgments

To the Brazilian National Research Council and Brazilian Ministry of Health (Call for Projects MCTIC/CNPQ/FNDCT/MS/SCTIE/DECIT - 07/2020).

References

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