A Situational Analysis of Ear and Hearing Care in South Korea Using WHO Ear and Hearing Care Situation Analysis Tool

doi:10.21203/rs.3.rs-3148219/v1

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A Situational Analysis of Ear and Hearing Care in South Korea Using WHO Ear and Hearing Care Situation Analysis Tool

https://doi.org/10.21203/rs.3.rs-3148219/v1

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Objectives: The World Health Organization emphasizes lifelong management of hearing diseases and suggests a state-led management program. In addition, the 'Ear and Hearing Care Situation Analysis Tool ' was produced and distributed so that the state-led management program could be implemented well. Therefore, the purpose of this study is to fill 'Ear and Hearing Care Situation Analysis Tool ', understand the current situation of ear and hearing management in Korea, establish a basis for establishing and improving policies related to hearing diseases, and produce data to report to World Health Organization.

Methods: The 'Ear and Hearing Care Situation Analysis Tool 'consists of a total of two sections, 41 questions in Section 1 and 203 questions in Section 2. Section 1 consists of questions that can evaluate health policies and support services. Section 2 consists of questions to evaluate the services and human resources of the ear and hearing management sector.

Results: Policies such as hearing aid support are in place, and outreach services such as free hearing tests are also being actively conducted. In all medical institutions, ear and hearing management treatment could be received, and medication prescriptions could be received without distinction. Workers such as audiologists, language therapists, special education teachers, and sign language interpreters, were specialized because they had well-established guidelines for training.

Conclusion: Overall, the domestic ear and hearing management sector has confirmed that policies and services are well prepared close to advanced countries compared to the current status of countries. It can be reported to World Health Organization to help improve domestic ear and hearing management policies and expand medical services.

World Health Organization

Ear and hearing care

Korean

Situation

Annual report

Hearing is one of the five senses and refers to a mechanical sense that detects the frequency and intensity of sound waves transmitted through a medium, such as air or water. The ear is a sensory organ that causes brain activity, which leads to thoughts and emotions, and it has a proportion equivalent to vision in perceiving the surrounding environment [1]. By 2050, approximately 2.5 billion people are expected to experience hearing loss, a known representative of hearing disorders, and at least 700 million people will need hearing rehabilitation. According to the WHO, as of 2021, more than 1.5 billion people worldwide have experienced hearing loss. Of these, 430 million suffer from severe hearing loss [2]. Failure to treat this condition can affect language development, education, employment, mental health, and depression through human relationships. Globally, the failure to properly address hearing loss costs more than $1 trillion each year. This includes the costs associated with healthcare, education, productivity losses, and social interactions. The causes of hearing loss include aging, noise damage, drug side effects, infections, head trauma, and allergies. It is important to mention that most of these causes can be addressed by health care-related services [3]. The WHO presented a state-led management program called the Prevention of Deficiency and Hearing Loss to emphasize the importance of lifelong management due to the following reasons: it can occur due to various causes at any time, hearing loss is very common, its prevalence rate is increasing rapidly, and lack of social interest on this matter [4].

Accordingly, since 2005, China has been implementing a national project called the Hearing the Future-China National Hearing Care Program, which includes the early diagnosis, prevention, treatment, and rehabilitation of hearing loss. India has also continued to implement a state-led policy called National Programme for the Prevention & Control of Deafness since 2008, and Australia is operating a government-led program to manage and supervise hearing screening, diagnosis, hearing loss prevention, and rehabilitation services from newborns to the elderly. The United States is striving to reduce the occurrence of social problems caused by hearing loss through the national “Healthy People 2020” [5].

In Korea, the number of people diagnosed with hearing loss increased from 280,000 in 2012 to 340,000 in 2016, and the treatment of hearing loss affects the increase in medical costs and hospitalization in the future [6]. For 2 years from 2007, a pilot project for the early diagnosis of neonatal hearing loss by region has been implemented, and newborn hearing selection and confirmation tests for hearing loss are being conducted mainly for low-income families. In addition, as of 2013, an early diagnosis of hearing loss for low-income newborns nationwide is being implemented, with all newborns being tested for congenital metabolic abnormalities and hearing loss screening. However, these projects are often implemented by municipal governments. As emphasized by the WHO, the government should strategically establish policies considering the adverse consequences associated with the disease. Other countries use the "Ear and Hearing Care Situation Analysis Tool" (EHCSA) distributed by the WHO to identify their Ear and Hearing Care (EHC) Situations, report them annually, and prepare strategic health policies accordingly. However, Korea is not reporting to the WHO. EHCSA is significant in evaluating the available direct and indirect policies, services, and human resources associated with ear and hearing therapy, and the health care systems of the country and helping to promote and maintain ear and hearing management at all levels of the healthcare system [7]. The WHO Collaboration Center (WHOCC) is an organization designated by the WHO Secretary-General to form part of an international cooperation network established by the WHO to support programs at national, international, regional, and global levels. According to the WHO Policy and Technology Cooperation Strategy, the WHOCC also participates in strengthening national resources in terms of information, services, research, and training to support national health development. The WHOCC serves as a support for WHO’s mission and program goals, development and strengthening of institutional capabilities in countries and regions, and there are six institutions in the EHC field. These include the University of Pretoria, University of Indonesia, Ear Science Institute Australia, Iran University of Medical Sciences, China Rehabilitation Research Center for Hearing and Speech Impairment, and National Research Center for Audiology and Hearing Rehabilitation. To prevent deafness and hearing loss, these institutions provide WHO support through the establishment of information on ear and hearing management, support the implementation of EHCSA manuals, and participate in cooperative projects among WHOCC networks related to EHC issues. As such, it is necessary to submit objective data on EHC in Korea, but currently, the Research Institute of Hearing Enhancement is replacing its function in Korea. Through this study, the goal is to fill EHCSA and identify the current situation of EHC in Korea to establish and improve policies related to medical services and hearing diseases.

Data analysis

EHCSA is a method for situation analysis developed by the WHO and includes the conditions of situation analysis [7]. Situation analysis refers to several methods that managers use to analyze an organization’s internal and external environments to understand its capabilities and environments. Representative examples include 5C analysis, SWOT analysis, and Porter’s Five Forces analysis, which use the "WHO EHCSA" developed by the WHO to understand the capabilities and environment of the country. Through this, the WHO emphasizes the current status of Ear & Hearing care in each country and the development of sustainable support measures. Data directly reported to the WHO are not accessible, but there are countries that have prepared outputs or conducted projects based on the EHCSA. The Islamic Republic of Iran produced their output by implementing a situational analysis of the EHC program using EHCSA; in Bangladesh, a paper using situational analysis through EHCSA was published to aid in the understanding of the status of rehabilitation services for the disabled [8]. In Germany, the Rehabilitation Service Assessment Tool was developed based on EHCSA to understand the status of rehabilitation services. The European Union recognized the importance of hearing management at the national level through the EHCSA and planned to prepare for future hearing health management policies [9]. In addition, to generate awareness, the project collected data related to the use of various hearing aids, their effects, and the correlation between factors affecting hearing damage and accompanying diseases through a big data platform called EVOTION. However, no research has been conducted on the EHCSA in Korea.

The "WHO EHCSA” was distributed to collect, evaluate, and report on ear and hearing management policies, services, and human resources and for the assessment of national health systems in the context of ear and hearing management. This can help to understand the dynamics of hearing loss and the systems and policies that support ear and hearing management, including available personnel, infrastructure, and services, and to establish an improved healthcare system that can help with hearing management. The tool has a total of two sections: Section 1 and Section 2 with a total of 41 and 203 questions, respectively. Section 1 supports overall health policies and services, such as total population, age distribution, gender distribution, illiteracy rate, internet penetration rate, life expectancy, fertility rate, vaccination status, deaf patient distribution, infant health policy, youth health policy, and disease management protocol.

Section 2 provides detailed information on human resources, such as departments and representatives dealing with EHC issues in the Ministry of Health and Welfare, EHC related institutions, policies, and programs. Questionnaires for assessment are also available.

Data collection process

The emphasis was on collecting indicators in line with the context of the questions in the WHO EHCSA. Information, such as country profile and vacation sites, was collected using documents from national institutions, such as WHO statistics, the Ministry of Health and Welfare, and the National Statistical Office. First, the indicators of the Korean Statistical Information Service (KOSIS) serviced by the National Statistical Office were confirmed. In addition, to confirm the specific information, documents, such as project reports and academic publications of national institutions that calculated the indicators, were checked. Finally, if the index was not secured through the search, consultations were conducted with experts.

National distribution data

To answer the questions, open materials distributed by the state and materials from the conference were used. Data from the National Statistical Office, 2021 population and housing census, 2021 future population estimation, 2020 death cause statistics, 2017 and 2021 birth statistics press releases were used. In the data from the Korea Centers for Disease Control and Prevention, the 2021 tuberculosis patient report status, 2020 Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) report status year, and tuberculosis treatment guidelines were used. In the data from the Ministry of Health and Welfare, clinical guidelines for screening genetic testing for newborns, criteria for determining the grade of the disabled, disaster crisis management measures for infectious diseases, and the classification of medical institutions were used. In addition, the World Population Review’s literacy rate by country 2022, Ministry of Science and Information and Communications Technology (ICT) 2021 wireless communication service subscriber statistics, 2021 Internet usage survey, Ministry of Education’s school health inspection guidelines and integrated education guidebook, National Health Insurance Service (NHIS) and Health Insurance Review and Assessment Service (HIRA)’s health insurance statistics year, and hospital inquiry services were included. KOSIS provided by the National Statistical Office, Population and Housing Survey, and Disability Statistical Yearbook published by the Korea Disabled Development Institute were mainly used.

KOSIS is a statistical service provided by the National Statistical Office for users to find the statistics they want at once by collecting major domestic and international statistics. Currently, it contains more than 1,000 types of state-approved statistics on the economy, society, and environment prepared by more than 300 institutions and provides the latest statistics on international finance, the International Monetary Fund, the World Bank, and the Organisation for Economic Co-operation and Development. Most national distribution data, such as the population and housing census and disability statistical yearbook, are uploaded on the portal [10].

The population and housing general survey is a basic national statistical survey conducted by the National Statistical Office to understand the size and characteristics of all people and houses in Korea and is released annually. It is a national basic statistical survey conducted on people and residences in the national territory at a certain time and period and is used as basic data in various fields, including policymaking, planning, research, and evaluation by national institutions, private companies, academic organizations, and the public. It is used to prepare secondary processing statistics, such as the Ministry of Employment and Labor’s labor supply plan, the Ministry of Health and Welfare’s premium rate and national pension fiscal estimate, the low birth rate and aging index, and the Ministry of Land, Infrastructure, and Transport’s housing supply rate [11]. The disability statistical yearbook is a statistical record that shows the situation of the disabled and has been distributed by the Korea Disabled Development Institute since 2015 [12]. It is based on the Convention on the Rights of the Disabled and the satisfaction of the needs of the disabled in different stages of their life cycle. Administrative data of major ministries related to the disabled are recorded and reprocessed to get linked with the performance of the policies for the disabled currently in effect in Korea, indirectly assessed by the government to actively implement policies and services for the disabled and used as basic data to institutionalize welfare policies for the disabled. The disability statistics yearbook consists of 11 social indicators, 9 health and welfare yearbooks, 7 disability statistics, and 13 social security categories. It collects indicators that represent the lives of the disabled, including a survey on household finance and welfare, annual reports on special education, housing, convenience for transportation, and access to information.

The main priority was whether the criteria for determining the data were calculated by national ministries. As most of the data produced by national ministries are targeted at the entire nation and collected at the national level, it can be inferred that these data have been verified in terms of representation and reliability. If there were no data, the data of the academic society or association in the field were used; if there were no data in the institution, the engineer or expert was consulted. The year of the data to be used was set as 2021, as the data from the major national ministries for the year 2022 would be distributed the following year, and the most recent data were used if there were no data for the year 2021.

1. Section 1

1.1. Population profile

Table 1 presents the questions about the population profile. The total population is approximately 51 million, and age distribution accounts for 3.3% of the total population of “0–5 years,” 8.7% of “6–15 years,” 64.4% of “16–60 years,” and 23.5% of “>60 years.” The sex distribution of both men and women was 50%. The data sources for the answers to these questions were the 2021 population and housing census data from the National Statistical Office [11]. In Korea, 8.6%, 91.4%, and 12% are the distributions of rural, urban, and slum dwellers, respectively. The data sources for the answers to this question were the 2021 Population and Housing Survey by the Ministry of Land, Infrastructure and Transport and the 2021 housing survey [11, 13]. The literacy rate is 97.9%, and the data source was the 2022 literacy rate by country of World Population Review [14].

1.2. Sociopolitical profile

Table 1 presents the questions about the sociopolitical profile. The language is Korean, and the percentage of the population using mobile phone services is 95% for smartphones and 5% for mobile phones. The data source was the 2021 wireless communication service subscriber statistics of the Ministry of Science and ICT [15]. The percentage of the population reached by Internet services is 99.9%, and the data source was the 2021 internet usage survey from the Ministry of Science and ICT [16].

1.3. Health status indicators

Table 1 presents questions about health status indicators. Life expectancy at birth is 83.9 years old, and the data source was Statistics Korea’s 2021 future population estimate [17]. The annual birthday rate is 5.2 per 1,000 people, and the data source was 2021 birth statistics from the National Statistical Office [18]. The under-five mortality rate is 3.2 per 1,000 live births, and the data source was statistics from the National Statistical Office’s 2020 cause of death [19]. Approximately 99.6% of births take place in health facilities, and the percentage of births taking place at home that are attached by lives. The data source was the National Statistical Office’s 2017 birth statistics press release [20]. Regarding birthplace, the National Statistical Office has not collected data since 2017; therefore, the presented data are the latest recorded data. Regarding vaccines, measles, mumps, and rubella are covered by one Measles, Mumps, and Rubella vaccine in Korea, and the vaccination rate is 97.7% at the age of 2, 97.3% at the age of 3, and 95.0% at the age of 6. In the case of meningitis, inoculation with both types of Haemophilus influenzae type b and pneumococcal conjugate vaccines must be applied to prevent it. The vaccination rate of the Haemophilus influenzae type b vaccine is 98.1% for the age of 1, 96.2% for the age of 2, 96.1% for the age of 3, and 95.9% for the age of 6. The vaccination rate for the PCV vaccine is 98.1% at the age of 1, 97.0% at the age of 2, 96.8% at the age of 3, and 97.1% at the age of 6. In Korea, the data on rubella vaccination rate for adolescents were not separately collected, so the answer could not be confirmed. The data source was the National Child Vaccination Status of the Korea Centers for Disease Control and Prevention in 2021 [21]. The number of cases of multidrug-resistance tuberculosis annually is 371, and the data source was the Korea Centers for Disease Control and Prevention’s 2021 tuberculosis patient report status [22]. The number of HIV/AIDS cases annually is 818, and the source was the Korea Centers for Disease Control and Prevention’s 2020 Annual Report on HIV/AIDS [23].

1.4. Hearing loss

Table 1 presents questions on hearing loss. Approximately 800,000 people in the country suffer from hearing loss, which is 1.6% of the total population. Mostly elderly people experience hearing loss, with 3.9% in their teenage, 8.1% in their 20s, 8.6% in their 30s, 10.6% in their 40s, 15% in their 50s, and 52% in their 60s or older. The data source was the 2021 disease statistics from the HIRA [24]. Early onset of child hearing loss occurs in 6 people per 1,000 live births, and the data sources were the guidelines of the Ministry of Health and Welfare for neonatal hearing screening. When disease statistics were checked for each major cause of hearing loss, chronic otitis media accounted for 0.72%, impacted ear wax for 2.4% as of 2021, low birth weight for 6.7%, meningitis for 0.02%, mumps for 0.02%, noise-induced hearing loss for 0.17%, ear-toxic hearing loss for 0.0003%, hearing loss in the elderly for 0.56%, and rubella for 0.000004%. Trauma and periodic factors could not be confirmed owing to personal information protection of national data. The low proportion of people suffering from mumps, meningitis, and rubella was possibly due to vaccination, and the data sources for the answers to this question were the 2021 disease statistics by the HIRA, 2020 underweight childbirth rate by the Korea Women’s Policy Institute, and 2020 total surveillance infectious disease statistics by the Korea Centers for Disease Control and Prevention [24, 25, 26].

1.5. Health care strategy

Table 1 presents the questions on health care strategies. The first question asks whether there is a national strategy related to the field in parentheses, and all of the answers are “Yes”. Maternal health has guidelines for obstetrics and gynecology in the internship training and treatment guidelines of the Korean Medical Association [27]. Child health has clinical guidelines for the genetic screening of newborns distributed by the Ministry of Health and Welfare in 2011 [28]. Since 2017, the Ministry of Health and Welfare has implemented an eye care project to prevent blindness in the elderly population. The aim of this project, along with the Korea Blindness Prevention Foundation, was to prevent blindness in the elderly and included eye examination, eye opening surgery, and rehabilitation projects for the elderly with low vision. Disability and rebalancing have a standard for determining the grade of disability, which has been announced by the Ministry of Health and Welfare by law since 2015. Occupational health includes medical management guidelines for workers diagnosed with noise-induced hearing loss in 2021, distributed by the Korea Occupational Safety and Health Agency in 2021 and treatment guidelines for epilepsy and lung disease, distributed in 2018 by the Korean Tuberculosis and Respiratory Society [29]. School health has been a sample survey project for school health tests since 1971. Currently, the Ministry of Education oversees it and distributes sample survey operation manuals [30]. Representatively, care of the elderly includes dementia-screening projects and dementia treatment management support projects implemented by the Ministry of Health and Welfare. Communicable diseases have a standard manual for disaster crisis management for infectious diseases announced as the Framework Act on Disaster and Safety Management and clinical care guidelines for the treatment of patients with COVID-19 newly distributed by the Korea Institute of Health and Medical Research and the Korean Medical Association [31]. Multidrug-resistant tuberculosis has a tuberculosis treatment guideline that has been continuously revised by the Korea Centers for Disease Control and Prevention since 2005, and a new section related to multidrug-resistant tuberculosis was added in 2020 [32]. HIV/AIDS has 2020 HIV/AIDS management guidelines distributed by the Korea Centers for Disease Control and Prevention, and the Korea AIDS Prevention Association conducts projects, such as nursing support projects, home welfare projects, AIDS counseling centers, and AIDS prevention education and training [33]. Non-communicable diseases have cancer treatment guidelines, such as the 2022 hepatocellular carcinoma treatment guidelines, distributed by the Korean Liver Cancer Society and the National Cancer Center, and the Ministry of Health and Welfare supports projects, such as medical expenses for patients with pediatric, adult, and lung cancers. The Ministry of Education distributed a guidebook for the implementation of integrated elementary and secondary school education in 2017 [34]. Korea is a member of the United Nations Convention on the Rights of People with Disabilities but not an optional protocol. The answer to the question “Has the country implemented policies on employment of persons with disabilities?” is “Yes” [35]. The Ministry of Employment and Labor implements employment policies for the disabled, including employment incentives, establishment of standard workplaces, assistance with engineering equipment, employment management cost support, employment of severely disabled people, and transition support for the disabled. The answer to the question “Are there any other policies that are relevant to ear and hearing care?” is “Yes”. The Korea Occupational Safety and Health Corporation has established a hearing preservation program and implemented policies for workers vulnerable to noise-induced hearing loss, and the Korean Academy of Sciences has distributed guidelines for the treatment of middle ear infections in children in 2014 and guidelines for the development of hearing aids and inspection confirmation in 2016. In the last question of Section 1 as a whole, the following “There is awareness among policy-makers about the need for ear and hearing care services. The country is ready to develop and implement a national strategic plan, and resources are available for this purpose.” can be selected as an answer.

Table 1

Questionnaires of Section 1
Subject	No.	Questionnaires
Population profile	1	Total population (in millions)
	2	Age distribution of population (%)
	3	Sex distribution (%)
	4	Rural-urban distribution (%)
	5	Literacy rate (as a % of total population)
Sociopolitical profile	1	Languages
	2	% of population using mobile phone services
	3	% of population reached by internet services
Health status indicators	1	Life expectancy at birth
	2	Annual birth rate
	3	Under-five mortality rate
	4	% of births taking place in health facilities
	5	% of births taking place at home that are attended by skilled birth attendants
	6	Are the following vaccines included in the immunization program of the country? (Measles, Meningitis, Mumps, Rubella, Rubella in adolescents)
	7	Number of cases of multidrug-resistant tuberculosis per year
	8	Number of cases of HIV/AIDS per year
Hearing Loss	1	Prevalence of disabling hearing loss
	2	Age distribution of hearing loss
	3	Incidence of congenital or early-onset childhood hearing loss (ECHL)
	4	What are the main causes of disabling hearing loss
Health care strategy	1	Does the country have a national strategy for (Maternal health, child health, eye care, disability and rehabilitation, occupational health, school health, care of elderly, communicable diseases, multidrug-resistant tuberculosis, HIV/AIDS, noncommunicable diseases, inclusive education)
	2	Has the country ratified the United Nations Convention on the Rights of Persons with Disabilities
	3	Are there existing policies on employment of persons with disabilities?
	4	Are there any other policies that are relevant to ear and hearing care?
	5	How would you summarize the overall situation regarding the preparedness of your country for development and implementation of ear and hearing care strategies?

2. Section2

2.1. Existing strategic plan or policies for EHC

Table 2 presents the question whether there are EHC policies implemented by the Ministry of Health and Welfare and other institutions. The answer to the first question corresponds to “Yes,” and the department dealing with it is the Disabled Policy Bureau of the Ministry of Health and Welfare. The representative is the Director of the Disabled Policy Bureau. The answer to the second question is also “Yes”. Representative programs include the school health examination sample survey project conducted by the Ministry of Education and the hearing preservation program conducted by the Occupational Safety and Health Corporation. Since the Ministry of Health and Welfare is not in charge of the above program, the answer to the third question is “No”. The last question was asked as summarized in 2.1, and I choose “There is a government-led committee or appointed coordinator for EHC. There is also a national strategic plan for EHC. Activities and programs are being implemented throughout the country” as an answer. The Ministry of Health and Welfare is not entirely in charge of the EHC program but other institutions are implementing the program.

2.2. Service delivery

Table 2 presents a question about the existence of primary medical care and the presence or absence of EHC. As primary care also includes otolaryngology, the answer to both the questions is “Yes,” and the data source was the paper defined for primary care [36].

2.2.1. Primary level

Table 2 presents a question about the overall matters of the primary medical institutions. The answer to the first question is “multiple facilities.” There are a total of five primary medical institutions according to the classification of medical institutions by the Ministry of Health and Welfare, and the items are clinics, health centers, health branches, health clinics, and health care centers [37]. Healthcare providers at primary level facilities include general physicians, ENT specialists, audiologists, speech therapists, hearing aid technicians, teachers of the deaf, sign-language interpreters, pediatricians, and obstetricians. As of 2020, the number of facilities was 2,665, with 2,569 clinics, 3 health centers, 88 health centers, and 4 health care centers nationwide, accounting for a ratio of 0.05 per 1,000 people. The data sources were the NHIS’s 2020 regional statistical year of medical use and the current status of lawmakers by city, county, district, and marked subjects [37, 38]. At this level, health awareness, tympanoplasty, information, education and communication, mastoid surgery, ear examination through otoscopy, hearing aid fitting, hearing assessment, cochlear implantation, treatment of acute otitis media, hearing and speech therapy, removal of foreign bodies from the ear, educational support for children with hearing loss, removal of earwax, and grommet insertion services are all provided. The data source was the hospital inquiry service of the HIRA. The answer to whether primary medical institutions provide outreach services is “Yes.” Many hearing aid companies provide free hearing tests, hearing aid checks, and hearing counseling for the elderly at welfare centers. At the primary level, on learning about the hearing problem, patients can visit private facilities, secondary, and tertiary hospitals.

2.2.2. Secondary level

Table 2 presents questions about the overall matters of secondary medical institutions. The answers to the first and second questions are “Yes” and “Multiple facilities,” respectively. Secondary medical institutions include hospitals and nursing hospitals according to the classification of medical institutions by the Ministry of Health and Welfare and Articles 1, 2, and 3 of the Medical Act. In secondary medical institutions, only ENT specialists provide EHC services. As of 2020, there were 241 hospitals and 157 nursing hospitals, with a total of 398 facilities per 1,000 people with a ratio of 0.008. The data sources were the NHIS’s 2020 regional statistical year of medical use and the current status of lawmakers by city, county, district, and marked subjects [37, 38]. The EHC services included items other than grommet insertion and educational support for children with hearing loss. Outreach services provide free hearing tests for welfare centers at hearing aid companies, and others. At the secondary level, on learning about hearing problems, patients can visit a tertiary hospital.

2.2.3. Tertiary level

Table 2 presents a question about the overall matters of tertiary medical institutions. The answer to the first question is “Yes.” Tertiary medical institutions include general hospitals and advanced general hospitals according to the classification of medical institutions by the Ministry of Health and Welfare and Articles 1, 2, and 3 of the Medical Act. Only ENT specialists provide EHC services in tertiary medical institutions. As of 2020, there were 187 general hospitals and 42 advanced general hospitals, for a total of 361, and the number of facilities was in the ratio of 0.007 per 1,000 people. The data source was the NHIS’s 2020 Annual Report on Medical Use by Region [38]. Medical institutions provide health awareness, tympanoplasty, information, education and communication, mastoid surgery, ear examination through otoscopy, hearing aid fitting, hearing assessment, cochlear implantation, treatment of acute otitis media, hearing and speech therapy, removal of foreign bodies from the ear, and removal of earwax. Municipal governments support outreach services when conducting medical support projects, and the data source was a medical support project for the homeless in Seoul. At the tertiary level, on learning about hearing problems, patients can visit a tertiary hospital. Advanced general hospitals were divided into national and private hospitals, with 12 out of 42 national and public hospitals accounting for 29% and 30 private hospitals accounting for 71%. For the last question, “EHC services are available at all tertiary, secondary, and primary level health facilities” can be selected as a summary answer for 2.2.

Table 2

Questionnaires of EHC & Service delivery
Subject	No.	Questionnaires
Existing strategic plan or policies for EHC	1	Is there a designated focal point or coordinator for ear and hearing care in the Ministry of Health?
	2	Is there an EHC national or sub national strategy, plan or program?
	3	Is the plan led by the Ministry of Health?
	4	How would you summarize the overall situation regarding the existence and implementation of strategic plans, programs and policies in the country?
Service delivery	1	Does the country have a national strategy for (Maternal health, child health, eye care, disability and rehabilitation, occupational health, school health, care of elderly, communicable diseases, multidrug-resistant tuberculosis, HIV/AIDS, noncommunicable diseases, inclusive education)
	2	Has the country ratified the United Nations Convention on the Rights of Persons with Disabilities
	3	Are there existing policies on employment of persons with disabilities?
	4	Are there any other policies that are relevant to ear and hearing care?
	5	How would you summarize the overall situation regarding the preparedness of your country for development and implementation of ear and hearing care strategies?
Primary level	1	Is there a health facility at primary level providing health care services and child care services and raising health awareness?
	2	Who are the health care providers at the primary level facilities?
	3	What is the population (in 1000s) for which the facility caters?
	4	Which of the following EHC services are provided at this level?
	5	Are outreach services for EHC available at the primary level?
	6	If a person reports with an ear or hearing problem that requires attention, to where is he or she referred from the primary level of care?
Secondary level	1	Is there a health facility at primary level providing health care services and child care services and raising health awareness?
	2	Who are the health care providers at the primary level facilities?
	3	What is the population (in 1000s) for which the facility caters?
	4	Which of the following EHC services are provided at this level?
	5	Are outreach services for EHC available at the primary level?
	6	If a person reports with an ear or hearing problem that requires attention, to where is he or she referred from the secondary level of care?
Tertiary level	1	Are EHC services available at tertiary level?
	2	What is the health facility at tertiary level providing EHC services?
	3	What is the population (in 1000s) for which the facility caters?
	4	Who are the health care providers at the tertiary level facilities?
	5	Which of the following EHC services are provided at this level?
	6	Are outreach services for EHC available at the tertiary level?
	7	If a person reports with an ear or hearing problem that requires attention, to where is he or she referred from the tertiary level of care?
	8	What percentage of EHC services and health care services are provided by the public health system/ the private sector
	9	How would you summarize the overall situation regarding services for provision of EHC in the country?

2.3. Health Workforce

2.3.1. ENT specialists

The question 2.3 is about the overall matters of workers in the EHC field. Table 3 presents a question about ENT specialists. As of the fourth quarter of 2020, the number of ENT specialists in Korea was 3,977, with a ratio of 0.8 per 100,000 people. The data source was the current status of specialist workforce by type of nursing institution 2020 in the National Statistical Portal [39]. The minimum education period is 2 years for preparatory courses, 4 years for the main course, 1 year for training, and 4 years for specialists; the source was the Korea Medical University Association. There are institutions that educate ENT specialists in Korea, with a total of 40 universities and medical graduate schools. The number of graduates produced annually is 116, based on those who passed the 2020 professional qualification exam. The skills of the ENT specialist include medical management of common ear conditions, surgical management of common ear conditions, myringotomy, grommet insertion, tympanoplasty, mastoid surgery, stapedectomy, cochlear implantation, audiometry, tympanometry, otoacoustic emissions/auditory brainstem response/auditory steady-state response, hearing aid fitting, ear mold preparation, audio-verbal therapy, and speech therapy.

2.3.2. Audiologists

Table 3 presents questions regarding audiologists. As of 2022, the number of audiologists in Korea is 475, with a ratio of 0.5 per 100,000 people. The data source was the audiologist’s qualification examination center. The minimum training period is 4 years. There are educational instruments and six universities in Korea based on the Department of Language and Hearing. The number of audiologists produced annually is 210, and the data source was the audiologist qualification examination center. Audiologists’ skills include audiometry, tympanometry, otoacoustic emissions/auditory brainstem response/auditory state response, hearing aid fitting, audio-verbal therapy, speech therapy, family counseling, counseling on the use of hearing aids, ear mold preparation, use of environmental aids, otoscopy, and diagnosis of common ear conditions.

2.3.3. Speech and audio-verbal therapists

Table 3 presents questions about speech and audio-verbal therapists. As of 2022, there are 2,800 language rehabilitation workers in Korea, and the data source was the Korean Language Rehabilitation Association. The minimum education period for speech and audio-verbal therapists is 4 years. There are educational instruments and 29 universities in Korea with language therapy-related departments. The number of speech and audio-verbal therapists produced annually is approximately 900, and the source was the current status of applicants for the language rehabilitation certificate of the National Institute of Health [40]. Skills of speech and audio-verbal therapists include audio-verbal therapy, speech therapy, audiometry, and counseling on the use of environmental aids.

2.3.4. Hearing aid and earmold technicians

Table 3 presents questions about hearing aid and earmold technicians. As of 2022, there are 288 hearing managers in Korea, the data source of which was the Korean Hearing Society. Hearing aid technicians and earmold technicians have a minimum educational period of 2 years, and there are educational instruments and six universities related to audiology in Korea. The number of hearing aid and earmold technicians produced annually is approximately 260, and the data source was the status of those who had passed the hearing management certificate of the Korean Acoustics Association [41]. The skills of hearing aid and earmold technicians include audiometry, tympanometry, family counseling, speech therapy, audio-verbal therapy, and counseling on the use of environmental aids.

2.3.5. Teachers of the deaf

Table 3 presents a question about teachers of the deaf. As of 2020, the number of teachers in this department in Korea was 650, with a ratio of 1.2 per 100,000 people. The data source was the 2020 Special Education Statistics of the Ministry of Education. The minimum training period is 4 years. There are educational institutions and 36 universities based in the Department of General Education and Special Education. The annual number of teachers in the department was about 180 in 2020, and the data source was the Ministry of Education’s 2020 special education statistics. The skills of teachers of the deaf include educational support for preschool children with hearing loss, educational support for school children with hearing loss, sign language practice, family counseling, counseling on the use of hearing aids and environmental aids, and the data source was the Korean Occupational Dictionary of the Ministry of Employment and Labor [42].

2.3.6. Sign language interpreters

Table 3 presents a question about sign language interpreters. As of 2018, the number of sign language interpreters in Korea was 2,968, with a ratio of 5.7 per 100,000 people. The source was research data on how to revitalize sign language interpreters provided by the Korea Disabled Development Institute [43]. The minimum training period is 1 year, and an additional 50 h of maintenance training must be completed after obtaining a sign language interpreter certificate. There are educational instruments and a total of four departments, including the Korean Deaf Association and Sign Language Interpretation-related departments. According to the Ministry of Education’s 2020 Special Education Statistics, the number of sign language interpreters produced annually is approximately 100. Skills of sign language interpreters include sign language interpretation, family and individual counseling, counseling on the use of hearing aids and environmental aids.

2.3.7. General physicians

Table 3 presents the questions about general physicians. As of the fourth quarter of 2020, the number of general physicians in Korea was 6,030, with a ratio of 11.6 per 100,000 people. The data source was the current state of the national statistical portal. The minimum training period is 6 years [39]. General physicians can provide diagnosis and medical management of acute ear infections, diagnosis and medical management of chronic ear infections, hearing tests, and removal of ear wax and foreign bodies.

2.3.8. Health workers

Health workers are personnel excluding medical personnel (doctors, dentists, oriental doctors, nurses, midwives, pharmacists, and herbalists) specified in the Medical Act and include emergency medical technicians, caregivers, health education specialists, and practical nurses.

1) Emergency medical technician

As of 2020, approximately 11,000 emergency medical technicians had been employed in Korea, with a ratio of 22 per 100,000 people. The source was statistics on the emergency medical status of the National Medical Center [44]. The minimum training period is 6 months, according to the emergency rescue test information of the National Testing Service, a Korean health care institution. Educational institutions have firefighting schools and emergency rescue education centers according to the Emergency Medical Act [45]. Emergency responders can provide services, such as raising health awareness in the community, medical management of ear infections, reference services, and removal of foreign bodies. The data source was the Korean vocational dictionary of the Ministry of Employment and Labor.

2) Health education specialist

Health education specialists are those who provide education related to health and health promotion and specialize in conducting health promotion projects. As of 2021, about 14,000 people were employed in Korea, with a ratio of 28 per 100,000 people. The data source was a survey on the current status of health education personnel activities at the Korea Institute of Health Promotion and Development [46]. The minimum education period is 4 years, depending on the matter in the survey on the status of health education history activities of the Korea Health Promotion and Development Institute. According to the Ministry of Health and Welfare’s notice on the national qualification management of health educators, there is the Korea Health Association, the Korea Nursing Association, the International Association for Moderation, and the Korea Health Promotion and Development Institute. Health educators can provide services, such as raising health awareness in the community, medical management of early influences, and reference services according to the notification of national qualification management for health educators.

3) Caregiver

As of 2020, approximately 13,000 caregivers had been employed in Korea, with a ratio of 26 per 100,000 people. The data source was the NHISs Statistical Yearbook of Long-Term Care Insurance for the Elderly [47]. The minimum education period is 6 months in accordance with the Ministry of Health and Welfare’s 2021 guidelines for training caregivers, and the educational institution is the caregiver center. Caregivers can provide services for raising health awareness in the community, medical management of early influences, referenced services, wax, and foreign body removal, according to the guidelines of the Ministry of Health and Welfare [48].

4) Practical nurse

As of 2020, approximately 400,000 practical nurses were employed in Korea, with a ratio of 800 per 100,000 people. The data source was the 2020 Health and Medical Personnel Survey of the Ministry of Health and Welfare [49]. The minimum training period is 1 year, depending on the qualification for applying for the practical nurse examination at the National Examination Institute, a Korean health care institution. Educational institutions include practical nurse training centers and practical nurse academies, according to the rules of nursing assistants and medical-related businesses of the Ministry of Health and Welfare [50]. Practical nurses can provide services by raising health awareness in the community, medical management of early influences, referenced services, wax. and foreign body removal, according to the 2021 guidelines of the Ministry of Health and Welfare for nursing care education.

2.3.9. Summarize

Table 3 comprehensively summarizes questions asked about domestic medical workers, and the summarized answer to the first question can be selected as “There are an adequate number of human resources for EHC available in all urban and rural areas of the country”. The summarized answer to the second question can be selected as “Training facilities for health workers are available as well as educational facilities for professional training, and these are adequate to provide EHC for the entire country”.

Table 3

Questionnaires of Health Workforce
Subject	No.	Questionnaires
ENT specialists	1	Total number in the country
	2	Minimum educational qualification required
	3	Are there educational institutions offering degree or diploma courses for training of ENT specialists?
	4	Total number of educational facilities offering degree or diploma in ENT specialists
	5	Number of persons graduating each year
	6	Skills of the ENT specialists
Audiologists	1	Total number in the country
	2	Minimum educational qualification required
	3	Are there educational institutions offering degree or diploma courses for training of audiologists?
	4	Total number of educational facilities offering degree or diploma in audiology
	5	Number of persons graduating each year
	6	Skills of the audiologists
Speech therapists and Audio-verbal therapists	1	Total number in the country
	2	Minimum educational qualification required
	3	Are there educational institutions offering degree or diploma courses for training of speech therapists or audio-verbal/auditory-oral therapists?
	4	Total number of educational facilities offering degree or diploma course
	5	Number of persons graduating each year
Hearing aid and earmold technicians	1	Total number in the country
	2	Minimum educational qualification required
	3	Are there educational institutions offering degree or diploma courses for training of Hearing aid or earmold technicians?
	4	Total number of educational facilities offering degree or diploma
	5	Number of persons graduating each year
	6	Skills of the hearing aid or earmold technicians
Teachers of the deaf	1	Total number in the country
	2	Minimum educational qualification required
	3	Are there educational institutions offering degree or diploma courses for training of teachers of the deaf?
	4	Total number of educational facilities offering degree or diploma
	5	Number of persons graduating each year
	6	Skills of teachers of the deaf
Sign language interpreters	1	Total number in the country
	2	Minimum educational qualification required
	3	Are there educational institutions offering degree or diploma courses for training of sign language interpreters?
	4	Total number of educational facilities offering degree or diploma
	5	Number of persons graduating each year
	6	Skills of sign language interpreters
General physicians	1	Total number in the country
	2	Minimum educational qualification required
	3	Which of the following ear and hearing care services do general physicians provide?
Emergency medical technician	1	Total number in the country
	2	Minimum educational qualification required
	3	Which of agency provides training for emergency medical technician?
	4	Which of the following ear and hearing care services do emergency medical technician provide?
Health education specialist	1	Total number in the country
	2	Minimum educational qualification required
	3	Which of agency provides training for health education specialist?
	4	Which of the following ear and hearing care services do emergency health education specialist?
Caregivers	1	Total number in the country
	2	Minimum educational qualification required
	3	Which of agency provides training for caregiver?
	4	Which of the following ear and hearing care services do caregiver?
Practical nurse	1	Total number in the country
	2	Minimum educational qualification required
	3	Which of agency provides training for practical nurse?
	4	Which of the following ear and hearing care services do practical nurse?
Summarize	1	How would you summarize the overall situation regarding availability of human resources for ear and hearing care within the country?
Summarize	2	How would you summarize the overall situation regarding availability of educational facilities for training of human resources for EHC within the country?

2.4. Medical products and health technology

2.4.1. Hearing devices

1) Hearing aids

Table 4 presents a list of questions asked regarding the scope and regulations for prescribing hearing aids in Korea. The answer to the first question is “Yes,” and digital technology, analog technology, body-worn, behind-the-ear, in the ear, open fit, and custom-made earmolds are all possible. For the third and fourth questions, there is a hearing aid fitting guidance for each hearing aid company, but it is not divided into grades and children ages. Hearing aid is covered under insurance, so the answer to the fifth question is “at full cost.” Regarding the maintenance of hearing aids, there are guidelines for each company, so the answer is “Yes,” and the fitting program manual of Resound, one of the hearing aid companies, was checked [51]. The portion of battery provision is not specified separately in the hearing-aid fitting program, and hearing-aid services can be received in the private sector. Representative institutions among non-governmental organizations include Snail of Love and Dasan.

2) Cochlear implants

Cochlear implants are available in both public health systems and the private sector, similar to hearing aids. This was confirmed in the hospital inquiry service of the HIRA, and the guidelines are publicly distributed by Snail of Love, a non-profit organization [52].

2.4.2. Other assistive devices

Table 4 presents the question of whether loop systems and capturing services are provided. All the answers of questions about loop systems are "Yes," and Wave Hearing carried out installments at Incheon International Airport, a church in Gangnam, Seoul, Hyundae Motor Studio in Goyang, Daejeon’s Cathedral, and Cheonan’s Independence Hall. In addition, installments were carried out in several elementary and middle schools by applying the hearing-loop system to the Goyang Special Education Support Office. Captioning services are also available on major Television channels. The guidelines for the provision of broadcasting programs for the disabled announced by the Korea Communications Commission stipulate that "closed caption broadcasting, screen commentary broadcasting, and Korean sign language broadcasting should be produced and organized in terrestrial broadcasting," and there were 41 terrestrial broadcasters in 2021 [53].

2.4.3. Medicines

Table 4 presents the question of whether there is a classification of drugs that can be prescribed by the type of medical institution. According to the Prescription Act, Article 17 of the Medical Act, broad-spectrum antibiotics, antibiotic ear drops, antifungal ear drops, and nasal decongestants can be prescribed at all medical institutions because there is no classification of drugs that can be selectively prescribed according to the medical institution. The answer to the last question is a summary of 2.4, and since measures and guidelines are in place for all questions, “Hearing aid services are available and accessible to most people in urban and rural areas of the country. CI are available and accessible to those in need of them” [54].

Table 4

Questionnaires of Medical products & health technology
Subject	No.	Questionnaires
Hearing aids	1	Are hearing aid services available through the public health system?
	2	What types of hearing aid are available through the public health system?
	3	Is there standardized guidance or recommendations for hearing aid fitting in adults?
	4	Is there standardized guidance or recommendations for hearing aid fitting in children?
	5	Are hearing aids fitted:
	6	Are repair and maintenance issues included in the hearing aid fitting program?
	7	Is battery provision part of the hearing aid fitting program?
	8	Are hearing aid services available in the private sector?
	9	Are any nongovernmental organizations providing hearing aid services?
Cochlear implants	1	Are cochlear implants services available through the public health system?
	2	Are cochlear implants services available in the private sector?
	3	Is there standardized guidance or recommendations on cochlear implantation?
Other assistive devices	1	Are loop systems available in public places?
	2	Are loop systems available in schools or special schools?
	3	Are captioning services available on majority of television channels?
Medicines	1	Which of the following broad spectrum antibiotics are available through the public health system and at which care level?
	2	Which of the following antibiotic ear drops are available through the public health system and at which care level?
	3	Which of the following antifungal ear drops are available through the public health system and at which care level?
	4	Which of the following nasal decongestant are available through the public health system and at which care level?
	5	How would you summarize the overall situation regarding the availability and accessibility hearing devices in the country?

2.5. Health financing

2.5.1. Financing of ear and hearing care services

Table 5 presents questions related to the enactment of the hearing care service. The answer to the first question is “Yes.” The Ministry of Health and Welfare had set up a budget for 2021 in the name of training public medical personnel, strengthening the publicity of local hospitals, and training professionals in vulnerable areas [55]. The government is conducting projects, such as newborn hearing loss test support project and hearing aid support project, but the support rate differs depending on income, so the appropriate answer selection would be “Some services are available free of charge, but others have to be paid for, fully or partially” [56]. In Korea, some of the medical expenses are covered by health insurance, so I choose “Costs are partially covered by health insurance” as the answer. For the last question, “EHC services are completely free” would be the reasonable choice.

2.5.2. Health insurance

Table 5 presents questions about the scope of health insurance. The answer to the first question is “Yes”. On November 1, 2020, out of the total population of about 51.829 million living in Korea, 51.345 million people subscribed to the National Health Insurance, accounting for 99% of the population. The data source was the 2020 health insurance statistical yearbook published by the NHIS and the HIRA [57]. Compared to the 78% private health insurance subscription rate in Korea as of 2020, the key provider of health insurance in the country was the government. The data source was the 2020 private medical insurance subscription rate distributed by the KOSIS [58]. The answer to the last question is about the summary of 2.5, and “Most of the cost of EHC is covered through government-led health financing schemes, and it is affordable for all.” is the appropriate answer.

2.6. Health information and research

2.6.1. Health information system

Table 5 presents questions about health-related data. The answers to the first and second questions are "Yes" because the NHIS, the HIRA, the National Cancer Center, and the Korea Centers for Disease Control and Prevention exist. In the case of the NHIS and the HIRA, the answer to the third question is “Program reports” because it is reported based on the information of the subjects subscribed to the national health insurance. The answers for the fourth and fifth questions are "Yes" because there is an infant screening cohort database among the databases of the NHIS and early or hearing information is included in the database. Although there are no data that the government reports only EHC distribution, the answer to the last question is "Yes" because there are data, such as the annual disability statistics, released by the Korea Disabled Development Institute [12].

2.6.2. Research

Table 5 presents the questions about domestic EHC research. The first question is whether there is a government-led institution that conducts EHC research in Korea. The answer is “Yes” because the Korea Vocational Ability Research Institute is conducting research in the field of hearing management as a learning module development and utilization project. The second question asked about the focus of domestic EHC research, and referring to a paper listed in the Korean academic journal Index in otolaryngology in 2022, I answered with "Clinical" because there were maximum numbers of clinical papers. The third question is whether there are any institutions that support EHC research; this is the case with the Korea Research Foundation and the Korea Academic Promotion Foundation. The last answer for the summary question of 2.6. is, “There is a government-led health information system in the country. It includes some information or indicators on EHC.” since EHC research is being actively conducted in Korea and the government is also supporting it.

Table 5

Questionnaires of Health financing, Health information and research
Subject	No.	Questionnaires
Financing of ear and hearing care services	1	Is there a budget allocation for EHC in the Ministry of Health?
	2	Does the government provide EHC services?
	3	Are EHC services provided by privately practicing specialists?
	4	Are EHC services provided by any nongovernmental agency?
Health insurance	1	Is health insurance available in the country?
	2	If yes, what percentage of the population is covered by it?
	3	Are EHC services provided by privately practicing specialists?
	4	Who are the key providers of health insurance in the country?
Health information system	1	Does the country have a national health information system?
	2	Are health related data and information collected and centrally administered in the country?
	3	What are the sources of health information reported by the country?
	4	Is there a system of personal child health records (through health or other departments)?
	5	Is information on ear or hearing included as part of this record?
	6	Is any information or indicator related to EHC reported at government level?
Research	1	Are there any government-led agencies or institutes conducting research in the field of EHC?
	2	What are the key areas of focus of the research in the field of EHC?
	3	Which are the key funding agencies supporting research in the field of EHC?
	4	How would you summarize the overall situation regarding the health information system in the country?

This study aimed to identify the current status of EHC in Korea using EHCSA distributed by the WHO in 2015, compare it with other countries, and establish and improve policies related to medical services and hearing diseases. To this end, we would like to examine various areas, such as domestic health policies, the status of patients with hearing-impairment, and the status of medical personnel, and report on Korea’s EHC field to the WHO.

In Iran, a situation analysis was conducted on the domestic ear and hearing care program based on the EHCSA. Through this, inadequate health literacy, weak intra sectoral and intersectoral cooperation, inadequacy of policy responses, non-integration of the EHC in the primary health care system, poor standard processes and resources of EHC, and lack of an EHC surveillance system were identified as major problems. [8]. In Bangladesh, approximately 1,200 experts were interviewed using the EHCSA, with insufficient rehabilitation staff training, lack of qualified medical personnel, insufficient primary and secondary medical facilities, and high rates of care service charges [60]. Twenty-two countries in sub-Saharan Africa had less than one ENT specialist, audiologist, and speech therapist per 100,000 people in all countries except South America [61]. In some countries, such as Burundi and Malawi, there are no cultivated speech therapists [62]. In Guatemala, ENT specialists were present in a ratio of 2.8 per 1 million people and 61 per 1 million people in Argentina, while in Southeast Asia, ENT specialists were in a ratio of 2.68 per 100,000 people in all countries except Thailand, and audiologists, speech experts, and sign language interpreters were all in low numbers [63]. The WHO used the WHO Workforce Indicator for Staffing Needs tool to assess the human resource gap in EHC. The gap in education for the development of related service experts was most prominent in low- and middle-income countries. In the case of arrogance, all those affected by earwax need 137 ENT specialists to be treated, with only 40 being able to treat, showing a 70% availability rate. In India, 1,075 ENT specialists are required to identify and diagnose common ear diseases in all patients up to the age of 15 [64]. At a tertiary medical institution in Santiago, Chile, patients need 78 experts to fit hearing aids, with approximately 0.01% of them in charge of the work [65].

In contrast, Russia supplemented its nationwide implant and hearing aid programs by introducing an artificial wow in 1991. Therefore, infants born with hearing impairments could receive hearing aids or artificial wows and rehabilitation services as needed, and up to 1,100 infants receive artificial wows each year. In addition, people of all ages can receive hearing tests and hearing aid fitting services at audiological centers, which are paid through the national budget [66]. In the UK, the National Health Service (NHS) supports people in need of hearing aids and artificial wows. Approximately 750,000 hearing aids and artificial wows are provided through the NHS each year, and a national supply chain of hearing aids has been established to provide them at low prices [67]. In China, various measures are being implemented to bridge the gap in human resources, such as auditory and verbal therapy. Since 1995, the Specialized Educational Program has been launched in collaboration with hearing and language rehabilitation experts, and more than 1,000 experts have been trained to date, providing hearing and language rehabilitation and aiming to establish a Chinese rehabilitation university. In addition, vocational training courses have been conducted since 2008 for high-quality hearing aid fitting [68].

Comparing policies and workforce status in other countries, data, such as Korea’s EHC program and workforce status, are at the level of advanced countries. The Ministry of Health and Welfare publishes a health and welfare white paper every year to understand major policies and achievements in the health and welfare sector and to help the government achieve new national goals and tasks. The policies implemented by the Ministry of Health and Welfare, current status of projects, and plans for implementing new policies are specified. There are child welfare policies, elderly welfare policies, low birth rate measures, disability welfare policies, oral health policies, mental health policies, and herbal medicine policies; however, EHC policies are not implemented or planned, except for innate hearing tests and hearing aid support policies [69].

The Korea Health Industry Promotion Agency’s "Hearing Aid Market Analysis" published in 2015 reported that the average growth rate of hearing aids worldwide is 6.9%. Looking at the ranking, Korea showed the fourth-highest growth rate of 8.5% after 18.3% in China, 10.3% in Germany, and 9.1% in France [70]. There are approximately 12,250 audiologists, 5,570 hearing aid sellers working as hearing experts, and approximately 13,000 hearing aid centers in the United States. Japan has 3,750 hearing aid centers, and Korea has 1,582 hearing aid centers that have been reported and are operating [71].

A survey was conducted to investigate the current status of the domestic hearing aid market, and 61.6% and 71.7% of the respondents said they needed a certificate to sell hearing aids in the category of factors that hinder the development of the domestic hearing aid market and need education as a hearing expert, respectively. In addition, it is difficult to determine the exact status of the supply of hearing aids because anyone can sell them by reporting to the medical device sales business [72, 73].

The above data are not updated continuously, so it is difficult to state that it represents the current situation because it is not the latest data and because the survey was conducted with a limited number of people. Therefore, this study is meaningful in that information on the latest status of the EHC programs was collected. Overall, both the health workforce and EHC programs are well-prepared, but incidences of hearing diseases, such as hearing loss, are continuously increasing, so various support measures need to be prepared to convert hearing aid-related certificates to national certificates or rehabilitation and support. In addition, domestic health policy improvements and medical service expansion should be achieved through the continuous collection of data on EHC.

We conducted a study to collect information at a level that could be reported in South Korea, which did not report the latest status of the EHC program to WHO. In the case of South Korea, overall, both health personnel and EHC programs are well prepared, but some parts do not reach the level of developed countries. In addition, since all the processes in this study must be carried out on an annual basis, continuous cooperation and expansion of related institutions is required. It is hoped that by confirming the case of South Korea, reports from countries that are not reporting to WHO will increase.

WHO: World Health Organization

WHOCC: World Health Organization Collaboration Center

EHC: Ear and Hearing Care

EHCSA: Ear and Hearing Care Situation Analysis Tool

KOSIS: Korean Statistical Information Service

NHIS: National Health Insurance Service

HIRA: Health Insurance Review and Assessment Service

Ethics approval and consent to participate

This research includes parts of human subjects research. However, our study is a retrospective study using previously collected data. This data is not personally identifiable from the time it is provided as Korean health insurance data. Therefore, written informed consent was waived from the participants. Our study confirms that all methods were performed in accordance with relevant guidelines and regulations. This study was approved by the Institutional Review Board of Yonsei University Wonju Severance Christian Hospital (Wonju, South Korea) (CR321338).

Consent for publication

Not applicable.

Availability of data and material

The datasets generated or analyzed during the current study are not publicly available due is controlled by South Korea's National Health Insurance Act but are available from the corresponding author on reasonable request.

Competing interests

All authors have no conflicts of interest.

Funding

not applicable.

Authors' contributions

Conceptualization: YJS.

Data curation: Juhyeong Lee, Junhun Lee.

Formal analysis: CYY, Juhyeong Lee.

Methodology: CYY, Juhyeong Lee.

Project administration: CYY, YJS, THK.

Visualization: CYY, Juhyeong Lee.

Writing – original draft: CYY, Juhyeong Lee.

Writing – review & editing: CYY, THK, YJS.

Acknowledgements

not applicable.

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No competing interests reported.

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A Situational Analysis of Ear and Hearing Care in South Korea Using WHO Ear and Hearing Care Situation Analysis Tool

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INTRODUCTION

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Data analysis

RESULTS

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