Determinants of Legislation on Social Health Insurance in Transition Countries

Abstract

This study aims to address the question: Why did transition countries enact laws related to social health insurance (SHI) at different times, even though they experienced dissolution of the Soviet Union at the same time in the early 1990s? We used Ragin’s fuzzy-set qualitative comparative analysis to investigate the configurations of causal conditions that affected the speed of developing SHI-related legislation in 24 post-socialist countries. The potential causal conditions were health status, economic status, level of governance, level of democracy, issue salience, and number of medical professionals. We found 3 pathways that led to the enactment of SHI-related laws and 1 pathway that inhibits enactment. The key factors impacting enactment of SHI-related laws were non-corrupt governments and realization of democracy. In addition, medical professionals’ involvement in policymaking could be the factor to enact SHI-related laws. Further research is needed for more in-depth analysis regarding what the laws specifically include, type of health insurance systems that were adopted based on the laws, and if the legislation contributed toward achieving universal health coverage.

Keywords

legislation health care reform insurance health universal health insurance USSR

This study aims to address the question: Why did transition countries enact laws related to social health insurance (SHI) at different times, even though they experienced dissolution of the Soviet Union at the same time in the early 1990s? Prior to this transition, countries operated a free medical care system for citizens based on the Semashko model of the Soviet Union, a powerful, centralized system¹ that can be considered the first version of the current universal health care coverage (UHC).² However, the inefficient centralized system and the national fiscal crisis rendered the Semashko system inoperable.³ This was exacerbated by the collapse of the socialist system in the early 1990s; gross domestic product fell, unemployment soared, and primary education, health care coverage, and health status deteriorated.^4–7 To solve this problem, these countries implemented health care reform with political and economic transitions after the collapse of the Soviet Union in the 1990s. Romaniuk and Szromek found that the public financial burden on medical expenses was one of the main drivers of health care system reform in transition countries.⁸ Therefore, in many countries, the key goal of the reform was the shift to SHI, which was based on the Bismarck model.^9,10 At that time, there were many goals to achieve through SHI, including decentralization, giving individuals the responsibility to manage their own health, assigning resource management responsibilities to health care service providers,¹⁰ and, most importantly, securing financial resources.^11,12 International communities, including the World Health Organization and International Labour Organization, also recommended the introduction of SHI as a means to achieve UHC, a key agenda in the health sector,^13,14 especially in low-income and developing countries.^15,16

The introduction of SHI, one of the social security systems, was influenced by various factors in addition to the health status and financial burden discussed earlier. According to the modernization theory of welfare state development theories, to resolve the social problems brought about by industrialization, the state tries to establish various welfare systems by using the national economic power secured by industrialization.¹⁷ On the contrary, power resource theory emphasizes the influence of the working class on the establishment of welfare systems; it refers to a society in which individuals can legitimately demand rights and obligations. In other words, a society with a high level of democratization leads to a welfare state.¹⁸ From the perspective of the state-centered theory, state governance is important.¹⁹ Indeed, according to Organisation for Economic Co-operation and Development and Transparency International reports, the higher the level of corruption in a country, the lower its public expenditure on health. In addition, when the salience of social issues is high, the government’s willingness to resolve issues increases, and thus the likelihood of creating new policies also increases.²⁰ The collapse of the Soviet Union and the introduction of capitalism were a significant external shock to the transition countries, and this was a crucial moment to seek a new health care system.

The World Health Organization recommended a proposal to not only introduce SHI, but also to guarantee it legally.^3,21 To achieve UHC goals through smooth operation of SHI, a mandatory health insurance system based on laws or regulations is required, as opposed to a voluntary system.^22–24 Laws play a key role in the realization of UHC,²⁵ with legislation being the most powerful means to enforce a country’s policies and reflect citizens’ opinions.²⁶ This health care transition began around the same time in various post-socialist countries in the early 1990s, but the timing of enacting laws on SHI differed across countries.¹² Some countries succeeded in fully legislating laws and some continued the process of creating bills, but some did not even attempt to draft bills.²⁷

The purpose of this study is to investigate the factors that affected the speed of developing SHI-related legislation in post-socialist countries. Social phenomena such as the creation of legislation do not occur as a result of a simple, single reason, but rather are the result of a combination of various factors.²⁸ Thus, we used Ragin’s fuzzy-set qualitative comparative analysis (fs/QCA) to find the compositive factors. The Fs/QCA using set theory is a program characterized by the interpretation of the relationship between outcome and combinations of causative conditions²⁹; therefore, this method is suitable for case-based studies on social phenomena involving qualitatively complex causal relationships. Additionally, Fs/QCA has the advantage of minimizing loss of information during analysis by expressing various levels between 0 and 1.³⁰

Materials and Methods

This study targeted 24 countries defined by the International Monetary Fund as transition countries, excluding Slovakia, Cambodia, China, Laos, Vietnam, Mongolia, and Bosnia-Herzegovina.³¹ Some data were missing for Mongolia and Slovakia, while Bosnia-Herzegovina had 2 systems with separate laws and institutions, thus making consistent analysis difficult. The 4 remaining Asian countries were excluded from the study because of different types of transitions – that is, they attempted moderate radical “reforms” and not a permanent and intrinsic radical “revolution.”³²

Outcome

To examine the time taken for SHI-related laws to be enacted in 24 countries, various literature reviews were conducted (see Supplementary Table 1). The year in which the transition began was different for each country³¹; therefore, point values were calculated as the difference between the year during which a country began its transition and the year in which it enacted SHI-related laws. For countries that have not yet enacted the relevant laws (Armenia, Belarus, Turkmenistan, and Uzbekistan), the year of enactment was considered as 2020.

Causal Condition

Health status

Data on health status included “mortality rate, under-5 (per 1,000 live births),” and “life expectancy at birth, total (years).” After standardizing these 2 indicators, the average of the standardized scores was considered as the value of the year. Subsequently, the average scores from 1991 to 1996, which can be considered as the first stage of the transitional phase of Brzezinski,³³ were used. The data were extracted from the World Bank’s World Development Indicators.

Economic status

When analyzing national economies, gross domestic product per capita is typically used; however, the early 1990s data of some countries included in this study were missing. Therefore, we used the average values from 1995 to 1996 because the data for all 24 countries began to be recorded only in 1995. Data were extracted from the World Bank’s World Development Indicators.

Governance

Among the governance factors, corruption index can be seen as a factor that affects the universal health care coverage of a country.^34–36 Therefore, we used values of “control of corruption” from the Worldwide Governance Indicators published by the World Bank. However, since the indicators were published at 2-year intervals beginning in 1996, data from the early 1990s were not available. The use of only 1 year of data could reduce data reliability; thus, we used the average values for 1996 and 1998.

Democracy

According to power resource theory, the more the political power of the working class expands, the more the state of welfare develops.³⁷ However, because it was impossible to obtain data for the early 1990s on “trade union density rate,” the average values of political rights and civil liberties data published by Freedom House were calculated and used. The data from 1992 to 1996 were used.

Issue salience

High issue salience can lead to the exploration of new systems and reforms related to social issues.^38,39 This study used data regarding the first free election turnout announced by the International Institute for Democracy and Electoral Assistance as an indicator of issue salience. Because the first free election was an important way of expressing public interest in government policies for the first time in a democracy,⁴⁰ the turnout can be interpreted as a measure of the public’s interest in the transition process.

Medical professionals

Medical professionals who are strongly influenced by health policies^41,42 have great influence on the health care policymaking process.⁴³ This study used “physicians (per 1,000 people).” The data extracted from the World Bank’s World Development Indicators and average values from 1991 to 1996 were used.

Fuzzy-set analysis

Calibration

Three qualitative anchors were required to calibrate the values of all the conditions and to produce fuzzy-set scores between 0 and 1.³⁰ The anchors signified the threshold for full membership (fuzzy-set score = 0.95), crossover point (fuzzy-set score = 0.5), and full non-membership (fuzzy-set score = 0.05). In this study, the maximum, median, and minimum values of each indicator were used as each of the points mentioned above, respectively (Table 1). Calibration to fuzzy-set scores was done automatically using fs/QCA 3.0 software.

Table 1.

Three Qualitative Anchors.

Outcome and Causal Conditions	Threshold for Full Membership (0.95)	Crossover Point (0.5)	Threshold for Full Non-Membership (0.05)
Outcome^a	−1	5	28
Causal conditions
Health status	1	0.71	0.01
Economic status	10746.05	1396.51	196.04
Governance	1.16	−0.57	−1.37
Democracy^a	1.6	3.5	6.9
Issue salience	98.92	79.5	53.91
Medical professionals	4.8	3.32	1.44

^aThe larger the value, the closer is the negative result; therefore, maximum value was used as the threshold for full non-membership and minimum value was used as the threshold for full membership.

Testing for necessity

According to the set relationship, “necessary condition” indicates that the fuzzy-set scores of conditions are consistently equal to or higher than the fuzzy-set scores of the outcomes; at this time, consistency should be near perfect with 0.9 or more.^44,45 In other words, it indicates that a causal condition is a superset of an outcome condition. In this study, as proposed by Ragin, necessity tests were conducted prior to the sufficiency test, and the consistency threshold necessary for the condition was set as 0.9.²⁹

Testing for sufficiency

Contrary to the necessity test, if the fuzzy-set score of a condition or configuration of conditions is consistently equal to or less than the fuzzy-set score of an outcome,⁴⁴ it can be regarded as a “sufficiency condition,” and the consistency should generally be greater than 0.85.³⁰ In other words, it means that the causal condition or configuration of conditions is a subset of the outcome condition. A truth table is used to systematically analyze the complexity of the causal relationship and find configurations of causal conditions sufficient for the outcome.³⁰ Because there were 6 causal conditions in this study, the truth table produced a total of 64 possible configurations of conditions²⁶ and indicated how many cases (countries) corresponded to each configuration. In fact, if there was no case corresponding to a configuration, then it is unlikely to exist. Therefore, this study set the minimum number of cases of meaningful configuration of conditions to 1. Then, among the configurations of conditions with more than 1 case, the minimum consistency threshold of an adequate condition was set to 0.9. That is, the configuration of a condition with at least 1 case and consistency of at least 0.9 was considered as a subset of a country set with the speed of enactment for SHI-related laws that was fast or slow. Once the truth table was constructed, the solutions were automatically produced with the Standard Analysis function in the Fs/QCA software.³⁰ The sufficiency tests were conducted as required to explore pathways that promoted or inhibited enactment of SHI-related laws.

Results

Testing for Necessity

The necessity analysis included 6 conditions and positive and negative forms of outcome indicators. The consistency between “economic status” and “slow enactment” was 0.87, which was the closest to the threshold, but no indicator exceeded 0.9, the minimum threshold of consistency (Table 2). In other words, no individual condition was found to promote or inhibit enactment of SHI-related laws in post-socialist countries.

Table 2.

Result of Testing for Necessity.

Causal Conditions^a	Fast Enactment		Slow Enactment
Causal Conditions^a	Consistency	Coverage	Consistency	Coverage
HEL	0.752322	0.787045	0.597473	0.536032
hel	0.556502	0.617167	0.762635	0.725322
ECO	0.673375	0.863952	0.471119	0.518371
eco	0.624613	0.579325	0.876354	0.697057
GOV	0.663313	0.779800	0.519856	0.524113
gov	0.595201	0.591084	0.781589	0.665642
DEM	0.746130	0.773676	0.533394	0.474318
dem	0.493034	0.551993	0.745487	0.715771
ISS	0.664861	0.696110	0.735560	0.660454
iss	0.675697	0.748713	0.661552	0.628645
MED	0.570433	0.630453	0.684116	0.648418
med	0.681888	0.715678	0.610108	0.549147

Abbreviations: DEM, democracy; ECO, economic status; GOV, governance; HEL, health status; ISS, issue salience; MED, medical professionals.

^aCausal conditions in capital letters denote presence of the condition, and lower-case letters (small letters) indicate absence of the condition.

Testing for Sufficiency

Configurations of causal conditions for promoting the enactment of SHI-related laws

Of the 64 configurations of causal conditions, 10 with corresponding cases were included in the analysis (Table 3). Configurations of causal conditions with consistency above 0.9 were considered to have an outcome. In other words, the 4 configurations with a consistency of 0.9 or higher were a subset of the post-socialist country set in which the enactment of SHI-related laws was relatively swift after the transition.

Table 3.

Truth Table for Promoting the Enactment of SHI-Related Laws.

HEL	ECO	GOV	DEM	ISS	MED	No. of Cases	Fast Enactment	Raw Consistency
1	1	1	1	1	0	2	1	0.953043
1	0	1	1	1	0	1	1	0.940397
1	1	1	1	0	1	2	1	0.932243
0	1	1	1	1	1	1	1	0.921512
1	1	1	1	0	0	2	1	0.904762
0	0	0	0	0	0	1	0	0.838926
0	0	1	0	0	1	1	0	0.762048
0	0	0	0	0	1	3	0	0.757741
0	0	0	0	1	0	2	0	0.674952
0	0	0	0	1	1	2	0	0.667917

Abbreviations: DEM, democracy; ECO, economic status; GOV, governance; HEL, health status; ISS, issue salience; MED, medical professionals.

‘1’ means the presence of that condition, and ‘0’ means the absence of that condition.

Based on the truth table, 3 pathways for promoting the enactment of SHI-related laws in post-socialist countries were identified (Table 4). The overall consistency of the 3 pathways was 0.91 and coverage was 0.56. The first was the configuration of a high health status, high governance status, high democratic status, high issue salience, and low number of medical professionals. The cases corresponding to this pathway were Slovenia and the Czech Republic; the consistency of this configuration was 0.95 and coverage was 0.44. The second was the configuration of high health status, high economic status, high governance status, high democratic status, and low issue salience. The cases corresponding to this pathway were Hungary, Lithuania, Poland, and Estonia; the consistency of this configuration was 0.9 and coverage was 0.42. Finally, there was the configuration of low health status, high economic status, high governance status, high democratic status, high issue salience, and large number of medical professionals. Latvia corresponded to this pathway, where consistency was 0.92 and coverage was 0.24.

Table 4.

Sufficient Configurations of Conditions to Promote the Enactment of SHI-Related Laws.

Configuration^a	Raw coverage	Unique coverage	Consistency	Cases^b
HELGOVDEMISSmed	0.445046	0.131579	0.951987	Slovenia (0.73, 0.82), Czech Republic (0.67, 0.92)
HELECOGOVDEMiss	0.426471	0.0936533	0.907743	Hungary (0.7, 0.95), Poland (0.69, 0.44), Lithuania (0.57, 0.62), Estonia (0.53, 0.95)
helECOGOVDEMISS*MED	0.245356	0.005418	0.921512	Latvia (0.54, 0.5)
Solution coverage: 0.564242
Solution consistency: 0.91468

Abbreviations: DEM, democracy; ECO, economic status; GOV, governance; HEL, health status; ISS, issue salience; MED, medical professionals; SHI, social health insurance.

^aCausal conditions in capital letters denote presence of the condition, and lower-case letters (small letters) indicate absence of the condition.

^bNumbers in brackets indicate membership score for the configuration and fuzzy-set score for the outcome (promoting the enactment) in each country.

Configurations of causal conditions inhibiting the enactment of SHI-related laws

Of the 64 configurations of causal conditions, 10 with corresponding cases were included in the analysis (Table 5). Configurations of causal conditions with consistency above 0.9 were considered to have an outcome. In other words, a configuration with a consistency of 0.9 or higher was considered as a subset of the post-socialist country set in which enactment of SHI-related laws was relatively slow after the transition.

Table 5.

Truth Table for Inhibiting the Enactment of SHI-Related Laws.

HEL	ECO	GOV	DEM	ISS	MED	No. of Cases	Slow Enactment	Raw Consistency
0	0	0	0	1	0	2	1	0.919694
0	0	1	0	0	1	1	0	0.888554
0	0	0	0	1	1	2	0	0.870544
0	0	0	0	0	0	1	0	0.809843
0	1	1	1	1	1	1	0	0.790698
1	0	1	1	1	0	1	0	0.788079
0	0	0	0	0	1	3	0	0.783242
1	1	1	1	0	1	2	0	0.71028
1	1	1	1	0	0	2	0	0.695238
1	1	1	1	1	0	2	0	0.605217

Abbreviations: DEM, democracy; ECO, economic status; GOV, governance; HEL, health status; ISS, issue salience; MED, medical professionals.

‘1’ means the presence of that condition, and ‘0’ means the absence of that condition.

Based on the truth table, a pathway for inhibiting the enactment of SHI-related laws in post-socialist countries was identified (Table 6). The consistency of the pathway was 0.91 and the coverage was 0.43. The configuration consisted of low health status, low economic status, low governance status, low democracy status, high issue salience, and a low number of medical professionals. Turkmenistan, Uzbekistan, Tajikistan, and Azerbaijan corresponded to this pathway.

Table 6.

Sufficient Configuration of Conditions to Inhibit the Enactment of SHI-Related Laws.

Configuration^a	Raw Coverage	Unique Coverage	Consistency	Cases^b
helecogovdemISS*med	0.434115	0.434115	0.919694	Turkmenistan (0.86, 0.95), Uzbekistan (0.81, 0.95), Tajikistan (0.8, 0.81), Azerbaijan (0.73, 0.56)
Solution coverage: 0.434115
Solution consistency: 0.919694

Abbreviations: DEM, democracy; ECO, economic status; GOV, governance; HEL, health status; ISS, issue salience; MED, medical professionals; SHI, social health insurance.

^aCausal conditions in capital letters denote presence of the condition, and lower-case letters (small letters) indicate absence of the condition.

^bNumbers in brackets indicate membership score for the configuration and fuzzy-set score for the outcome (inhibiting the enactment).

Sensitivity Analysis

We performed sensitivity analysis to confirm that the study results were robust (see Supplementary Table 5). The consistency threshold was set to 0.8 and the minimum frequency threshold was set to 2. As a result, different configurations were created, but all the core conditions (i.e., governance, democracy) were included and coverage was more than 0.5; hence, the fundamental interpretation of the results did not change. In addition, although the crossover point for each condition was changed to +/– 10%, the consistency did not change significantly.

Discussion

The purpose of this study was to explore the compositional relationship among various conditions to identify which factors influenced the 24 post-socialist countries to enact the SHI legislation after their transition. First, as a result of the necessity test, no condition exceeded a consistency of 0.9. This indicates that there was no single condition necessary for post-socialist countries to promote or inhibit the enactment of SHI-related laws after their transition. In other words, the socialist state did not determine whether to enact SHI-related laws based on only 1 variable after the transition. To understand how and when laws are enacted, the interactions between multiple variables must be considered.

Next, we explored the configurations of causal conditions that had adequate conditions for the outcomes. Three pathways for promoting legislation were identified, and we included all the E.U. and Organisation for Economic Co-operation and Development member countries, or the so-called developed countries. According to the classification of transition speed, they were all grouped under the “sustained big-bang group” or “advanced start group.”⁴⁶ These groups, which consist mainly of the Baltic and Eastern European countries, had experience in Western Europe before socialism happened and were geographically close to Western Europe; thus, they could be more directly affected by advanced countries.⁴⁷ They also had the specific goal of “joining the EU” and received external assistance, in addition to domestic efforts, to meet the economic conditions that the European Union required.^48,49 As a result, stable economic growth was possible from the mid-1990s. In addition, from a political perspective, most of these countries achieved de-communization in a nonviolent and active way, such as the Velvet Revolution in the Czech Republic and the Singing Revolution in the Baltic countries. Countries that were transformed peacefully and steadily under the initiative of people had a better level of democracy from the beginning of the transition, and those that replaced their governments through free elections pursued efforts to establish clean governance.⁵⁰ The fuzzy-set scores for corruption control and for political rights and freedom of these countries were quite high.

To better understand the second pathway, the case of Hungary was examined. The 1956 Hungarian Revolution, a spontaneous uprising against the communist regime, implied the beginning of a political crisis for Hungarian communism.⁵¹ After the revolution, Hungary adopted a unique Hungarian Communism model that resulted in a partial market economy and political freedom,⁵² and this experience drove Hungary to emerge as a leading country in the democratization process of Eastern European countries. However, the country experienced the worst economic situation at the end of the 1980s because of the limitations of an ineffective communist system.⁵³ Under these political and economic circumstances, Hungary began to reform its health care system in preparation for the economic crisis in the mid-1980s and enacted its SHI-related laws in 1989 before the collapse of the Soviet Union.⁵⁴ Apparently, Hungary was able to quickly enact its SHI-related laws not only because of the economic crisis but also because of the participation of medical professionals in the spirit of high democracy. Medical professionals who were underpaid actively requested the introduction of SHI to improve income and working conditions and, in the case of Estonia, the medical association was politically active.^52,55

The third pathway included Latvia; unexpectedly, the fuzzy-set score of outcomes in Latvia was 0.5, which indicates it was neither fast nor slow in enacting SHI-related laws. Poland, which was included in the first pathway, was not fast in enacting SHI-related laws because its fuzzy-set score of outcomes was 0.44. This contradiction suggests that there are other causal pathways for enacting SHI-related laws in some of the post-socialist countries, but the indicators analyzed in this study are limited in explaining this result. Thus, further research is needed.

According to the pathway that inhibits legislation, even if public participation in social issues is high, SHI-related laws were difficult to enact even if all other conditions are absent. Among the countries in this pathway, Tajikistan – the only country in Central Asia in which Islamic political parties have been legalized and the presence of Islam has a great influence on politics⁵⁶ – was analyzed. During the transition, Tajikistan, which experienced the only civil war in Central Asia as a result of the confrontation between Islamic rebels and pro-Communist forces, remains the poorest country in the former Soviet Union area.⁵⁷ President Emomalii Rahmon was elected in 1994 and remains in power, and political rights and civil liberties have consistently declined; in 2019, Tajikistan’s Corruption Perceptions Index was ranked at the bottom, at 153 in the list of 180 countries.^58,59 In 2008, 14 years after the country enacted a constitution that states all people have a right to UHC, Tajikistan enacted a law to introduce a compulsory health insurance system, although it has yet to be implemented.⁶⁰ Tajikistan is strongly characterized by religious influence, unlike most other countries. Thus, more detailed research is needed on how political and economic factors influence social security policies, including health insurance, in a religious and cultural context.

Uncorrupted government and high democracy were key factors in enacting SHI-related laws. Our findings are consistent with previous studies, showing that an uncorrupted government and democracy are important in achieving UHC.^61–63 In addition, according to the first pathway involved in enacting SHI-related laws, it is possible to enact these laws regardless of the economic status of the country. This finding contrasts with previous studies on the relationship between economic status and attainment of UHC.^24,62,64 Furthermore, medical professionals can impact SHI enactment as health care experts and interest groups.⁶⁵

This study has some limitations. First, although all the causal conditions were selected on a theoretical basis, the possibility of other conditions influencing the enactment of SHI-related laws during the transition cannot be excluded. Second, due to the characteristics of transition countries, it was difficult to secure data from the early 1990s; all post-socialist countries could not be studied, and various indicators could not be used. Third, fs/QCA has the limitation that all individual conditions have the same, equal influence within the configurations of causal conditions. Fourth, because the study only focused on whether SHI-related laws were enacted or not, the individual characteristics of each country were not reflected; Azerbaijan, Tajikistan, and Ukraine have enacted these laws, but they have yet to be enforced. Kazakhstan enacted the law, but abolished it later. Nevertheless, most studies on post-socialist countries only included comparisons with minority countries; the present study’s expansion to include 24 countries could contribute to a better understanding of the transition countries. This study has also contributed toward understanding the causal relationship between the enactment of SHI-related laws and social factors by approaching the subject creatively with a comparative analysis by country using fs/QCA, which is not commonly used in health science research.

Conclusions

This study shows that the post-socialist countries cannot enact SHI-related laws based only on 1 variable, and there are many pathways for enacting SHI-related laws. It could provide implications for policymakers and countries that have not yet enacted SHI-related laws for UHC or that have the possibility of transition. Based on our findings, further research is needed for an in-depth analysis of what the laws specifically include – that is, the type of health insurance systems that were adopted based on the laws – and whether the legislation contributed toward achieving UHC.

Supplemental Material

sj-pdf-1-joh-10.1177_0020731420952013 - Supplemental material for Determinants of Legislation on Social Health Insurance in Transition Countries

Supplemental material, sj-pdf-1-joh-10.1177_0020731420952013 for Determinants of Legislation on Social Health Insurance in Transition Countries by Sungkyoung Choi, Myongsei Sohn, Hyoung-Sun Jeong and Soyoon Kim in International Journal of Health Services

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sungkyoung Choi

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Sungkyoung Choi, PhD, is a research assistant professor in the Medical Law and Ethics Division, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, South Korea. Her research interests are in the areas of health policy and legislation, health law and ethics, and the health workforce. She is currently conducting research on the development of curricula for patient safety and the 5-year plan for nursing policy in South Korea.

Myongsei Sohn, PhD, MD, is an emeritus professor at Yonsei University. He has spent more than 3 decades as a faculty of the Yonsei University College of Medicine, taking roles as a member and vice-chair of the executive board of the World Health Organization and as president of the Asia-Pacific Consortium for Public Health. He currently serves as a founding member and chairman of the Institute for Global Engagement and Empowerment, Yonsei University, South Korea.

Hyoung-Sun Jeong, PhD, is a professor in the Department of Health Administration, Yonsei University College of Health Science, South Korea. Previously, he was a project manager in the Health Policy Unit, Organisation for Economic Co-operation and Development, from 1997 to 2002. He has research expertise in health insurance, universal health coverage, national health accounts, and the health care industry. He has conducted many research projects for Korean national organizations, and he is a member of various government committees that determine health care policies for South Korea.

Soyoon Kim, PhD, MD, is a professor in the Medical Law and Ethics Division, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul, South Korea. In addition, she leads the Department of International Health Science, Graduate School of Public Health Yonsei University, and is the director of the Asian Institute for Bioethics and Health Law (a World Health Organization Collaborating Centre for Health Law and Bioethics). Her research areas include medical law, medical ethics, advanced biotechnology and clinical ethics, medical disputes, patient safety, and global health. Currently, she is conducting and participating in research in various fields related to her interests.

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