key: cord-0711906-mbn3m0k7
authors: Choi, Yon Jung
title: The Power of Collaborative Governance: The Case of South Korea Responding to COVID‐19 Pandemic
date: 2020-11-26
journal: World Med Health Policy
DOI: 10.1002/wmh3.376
sha: 12980e634cb3651f123438f0488bb32d1e6fb291
doc_id: 711906
cord_uid: mbn3m0k7

The COVID‐19 pandemic, the unprecedented global health crisis, has challenged the current systems of governance, both global governance and national governance. While the alleged “advanced” societies have shown their vulnerabilities and incompetence to deal with this crisis so far, a few countries have shown better ways of responding, in particular South Korea. In dealing with this kind of health crisis, criticism and praise can easily point to the national government and their policies, but rarely to the entire governance system and collaborative efforts of various actors. This article explores the synergy produced by the entire governance system participated in by various sectors, including both public and private ones, namely the collaborative governance, as an important factor of its more successful control of the epidemic compared with other countries.

The global pandemic of COVID-19 in 2020 generated over 15 million confirmed cases and half a million deaths globally, in addition to tremendous financial damages to families and businesses (as of July 23, 2020). 1 This unprecedented global health crisis has challenged the current systems of governance, both global governance (led by intergovernmental organizations, such as the World Health Organization (WHO) and other transnational health-related organizations) and national governance led by the governments of sovereign nations. The alleged "advanced" societies have shown their vulnerabilities and difficulties in dealing with this crisis so far, as evidenced by the lack of efficient policies and public information, poorly designed/functioning health-care systems, the shortage of essential facilities and medical equipment (e.g., face masks and ventilators), poor coordination and cooperation among related agencies, organizations and personnel, and sociocultural conflicts. 2 1 These numbers continue to grow. The World Health Organization (WHO) predicts that COVID-19 could last 4-5 years throughout the world (Kelland, 2020) . 2 As an example of sociocultural conflict, the wearing of face masks, considered to be the best measure to prevent the spread of the virus, has been culturally resisted in some societies.

Amid the global fight against this pandemic, however, a few countries have shown better ways of responding, in particular South Korea. Several factors (including some obvious ones) have assisted its mid-stage success in controlling the disease, such as the geographical size, the density of medical facilities, a well-established health-care system, relatively loose privacy laws, the availability of advanced technology, and certain cultural aspects (e.g., cultural acceptance of wearing masks). In dealing with this kind of health crisis, criticism and praise can easily point to national governments and their policies, but rarely to an entire system of governance and various actors' collaborative efforts. This article explores the synergy produced by an entire governance system comprising multiple sectors, including both public and private ones, namely collaborative governance, as an important factor in its greater success of controlling COVID-19 than that of other countries.

The Initial Stage: Rapid Spread

The first confirmed case in South Korea occurred on January 20, one day before the first case in the United States. The outbreak started from the Shincheonji Church of Jesus in Daegu and spread quickly, which resulted in South Korea having the second most confirmed cases (after China) within the first month. As a result, countries blocked South Korean entries across their borders and imposed travel restrictions from/to South Korea. 3 In fact, the rapid growth of confirmed cases in South Korea at this early stage reflects the massive, aggressive testing it performed, which the rest of the world failed to do.

The government responded to COVID-19 quickly from the early stage. It is certain that the experience of previous outbreaks, such as the Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS) helped prepare the country for this pandemic. With the lessons learned from these previous epidemics, the government and related sectors have worked to create better systems of governance, including developing a holistic disease control system that enables massive testing and effective contact tracing. By April, the daily new confirmed cases dropped to single digits. The speed of the flattening of the curve of new infection in South Korea was remarkable, whereas a number of countries have suffered from a rapid increase in confirmed cases. By May, South Korea had reduced new daily cases by over 90 percent from its peak (Thomson, 2020) . As of May 25, South Korea showed the lowest fatality rates (2 percent) in the world, with 3 At the peak, 187 countries have put travel restrictions from South Korea at peak . 11,206 cases and 267 deaths (Chung, 2020) . Even factoring the population into account, this number is significantly smaller than of other countries.

Unlike many countries that implemented full mandatory lockdowns, South Korea effectively managed to contain the virus without them. A great number of countries studied how South Korea served as the "Global Golden Standard" in responding to COVID-19 (Rubin, 2020) . Several national leaders, including President Emmanuel Macron of France and Prime Minister Stefan Löfven of Sweden, requested details from President Moon of South Korea. In addition, more than 100 countries requested help from South Korea with coronavirus testing (Shin & Kauranen, 2020) . Tedros Adhanom Ghebreyesus, the head of the WHO, also urged countries "to apply the lessons learned in Korea and elsewhere, and adapt them to the local context" (WHO, 2020).

It seemed the situation was under control: new cases had dropped to nearly zero but a second large outbreak occurred in May, with 102 new cases reported, which were linked to nightlife with younger individuals. Although there had been clusters of outbreaks, these were believed to be manageable-the number of deaths per capita and the economic contraction had been "among the world's lowest" (Landman, 2020) .

Authorities are still wary of the possibility of the second wave, especially if people grow tiresome of voluntary social distancing as the crisis continues. Because cold weather in later months weakens individuals' immune systems, the government and its partners from various sectors have prepared for this potential resurgence in the future.

The South Korean public health system's battle against COVID-19 is a great example of collaborative governance. Collaborative governance refers to a mode of governance that "brings multiple stakeholders together in common forums with public agencies to engage in consensus-oriented decision making" (Ansel & Gash, 2007, p. 543) . In other words, it is "a type of governance in which public and private actors work collectively in distinctive ways, using particular processes, to establish laws and rules for the provision of public goods" (Ansel & Gash, 2007, p. 545) . In this case, "public goods" is the successful control of COVID-19 from its disastrous spread.

A number of policy decisions made and conducted in South Korea have been identified by researchers and the media as critical factors in the country's successful management of the situation, including extensive testing, contact tracing, effective social distancing campaigns, mandatory quarantine through self-isolation, the designation of COVID-specialty hospitals and treatment centers, categorizing medical facilities based on the severity of symptoms, and the establishment of drive-through/walk-in test centers. However, the implementation of these policies requires more than simply establishing the policies. The entire governance system needs to be able to work smoothly and effectively, and in order to do so, a high level of coordination and cooperation among various actors in both public and private sectors is important, as demonstrated in this article. The actors who have participated in the public health emergency response system of South Korea are identified in Figure 1 below. The following sections explain the roles each actor played in the collective response to the crisis.

For collaborative governance to work effectively, government leadership is critical for bringing the participating actors together and facilitating collaboration and cooperation (Ansel & Gash, 2007; Vangen & Huxham, 2003) . With previous epidemics (e.g., MERS in 2015 , SARS in 2002 , and H1N1 in 2009 , the greatest blame was directed at the "uncoordinated" and inadequate response of the government. 4 Figure 1 Actors Participating in Collaborative Governance of South Korea in Response to Several other problems in governmental response were also revealed through these previous experiences, including lack of transparency and unavailability of testing kits (Landman, 2020; Thomson, 2020) .

These previous experiences helped the government better prepare, bringing significant changes to its public health emergency response system. Recognizing the necessity of a more holistic governance system in which various actors in related sectors participate, laws were changed in order to (i) clarify the roles of the national government, local governments, public health sector, and industry sector in responding to an emergency situation, 5 (ii) expedite the process for laboratories to develop and use unapproved diagnostic test kits, and (iii) allow the Korea Centers for Disease Control and Prevention (KCDC) to access extensive personal data from 28 companies, including cellular data, financial data, GPS information, and social network system (SNS) information in the case of a public health emergency (Landman, 2020) .

With these prior efforts for enhancing the disease control system, the KCDC (the designated leader by the national government) quickly developed and implemented several policies for controlling the rapid spread of COVID-19, including (i) establishing a number of easily accessible testing centers, (ii) implementing wellestablished contact tracing system, (iii) imposing mandatory 2-week quarantine, and (iv) providing detailed disclosure of information. Acknowledging the importance of massive testing after going through previous infections, the government quickly installed a number of local testing centers so that people who are suspicious of having the symptoms can quickly and safely be tested. These testing sites include not only major hospitals but also local clinics and public health-care facilities (Chung, 2020) .

The government also took proactive measures to enforce testing, including asymptomatic patients, through contact tracing as opposed to the reactive policy of the majority of other countries. Many countries have had difficulties in implementing effective contact tracing due to several issues involved, such as the issue of privacy, the unavailability of necessary technology, lack of staff and resources, and the issue of coordination among related organizations. Contact tracing in South Korea has become well-developed and organized over the years and is supported by the revised privacy laws, which are relatively looser than other countries such as the United States and the United Kingdom; well-established information technology; public awareness of the importance; and a well-managed collaborative governance system. Thus, once a patient's infection is confirmed, he/ she will share personal information (e.g., cell phone number and credit card number) with the authority. The whereabouts of that person's past are traced within minutes using big data analytics and AI (artificial intelligence) technology, including the cellular data, credit card transaction information, and surveillance camera footage (Chung, 2020) . Anyone who had direct contact with the infected individual who is traced by the system must undergo testing.

Under the mandatory quarantine policy, anyone who may have been in contact with infected individuals, or those entering South Korea from abroad, must be 5 For example, the new laws require local governments to send alerts (i.e., emergency text messages) to residents to inform of current situations (Thomson, 2020) . quarantined for two weeks while confirmed patients are either hospitalized or treated at special facilities. This 2-week mandatory quarantine is based on selfisolation, but tight monitoring/enforcement measures are in place, with consequences for breaking quarantine. Not only would the person be prosecuted 6 but his/her rule-breaking behavior would also be heavily publicized. Public shaming is by far the most effective measure to make this policy work.

One of the key factors of the national government's effective leadership has been its efforts to build public trust through the disclosure of transparent information and extensive medical/financial support associated with the epidemic. A revised privacy law allows the government to access personal information extensively in case of an emergency. The government decided to disclose information related to COVID-19 (excluding information related to personal identification) to the public that was as detailed as possible in order to enhance public trust and cooperation and encourage prompt responses. The Ministry of Health provides information in daily briefings led by scientists and experts to share information instead of politicians to enhance public trust (Landman, 2020) . In addition, the public receives detailed alerts via text messages about the whereabouts of confirmed cases, including the names of shops and stores the infected person visited and the travel routes he/she took (Toussaint, 2020) . The government also covers any medical costs associated with COVID-19 to reduce the financial burdens of medical facilities and the patients (Ahn, 2020) .

The success of these governmental policies relies on the coordination and cooperation with the quarantined, their workplaces, their neighbors, local governments, public and private medical facilities, businesses, civil society organizations, and the general public. Tracing, monitoring, and enforcement require great effort, staff, and resources, as well as a law-abiding attitude on the part of the quarantined and those with confirmed infections, and public support. The national government alone does not have the capacity to handle the large and growing number of the confirmed and the quarantined. One of the key factors for effective collaborative governance is the broad and active participation of various stakeholders (Reilly, 2001) . The sections below describe how other organizations and sectors have participated in the overall governance of the public health emergency response system in this crisis.

Local governments are one of the active actors in the collaborative governance system and implemented various local-level policies in response to the infection. The following statement of Kyung-Hwa Kang, foreign minister of South Korea, illustrates this approach nicely. 6 Fines for violation can go as high as $2,500.

We took an all-government approach. The Prime Minister created a task force of all government ministries and, crucially, all regional and city governments, too-we are a very devolved democracy. (Kang Kyung-Hwa, Foreign Minister of South Korea, emphasis added) 7

Local governments send alerts to residents via text messages when there are confirmed cases in their locality and publish relevant information (e.g., number of new confirmed cases, visited locations and travel routes of the confirmed, and whether they were wearing masks) on their websites (Ahn, 2020) . Health service officials in local public health facilities monitor the quarantined. They contact the quarantined on a daily basis (twice a day) and ask about symptoms and whether he/she is following the rules such as self-isolation home or in a designated facility, no contact with people from outside, taking sanitization measures, and so on.

A good example of a local government's participation in this collaborative governance is the city of Daegu. Daegu was hit severely as the epicenter of the first large outbreak, with a number of people from the Sincheonji Church headquartered in the city . With the first confirmed case on February 18, the situation escalated quickly, with over 5,000 cases in Daegu alone by March 7 . The local government officials (public health officials) and local health system leaders, supported by the national government, mobilized "a regional reorganization of the health system along with several hospital-level interventions" to ease the shortage of medical resources such as hospital beds, health-care workers, and supplies of equipment, and to protect both medical staff and patients . The Daegu Medical Association has implemented a four-category risk-stratification system called the "COVID-19 Brief Severity Scoring System" based on the severity of the symptoms and developed protocols to treat patients separately based on these categories. Patients with no or mild symptoms were monitored and treated at community treatment centers-a number of dormitories for corporate training institutions were transformed into these centers, 8 whereas severer patients were hospitalized at local or tertiary hospitals . The city also designated 10 hospitals to treat COVID-19 patients exclusively. These policies allowed the hospitals to reserve medical resources only for those who need them, while effectively isolating and treating as many cases as possible in community treatment centers . It also helped to protect the medical staff better and prevent the rapid spread of the disease in the community.

Similar policies and measures were conducted by local governments in other regions, and there are a number of COVID-specialty designated hospitals throughout the nation. There has also been close cooperation and collaboration among local governments themselves. In the case of the shortage of medical 7 It is quoted from her speech at a virtual World Economic Forum COVID Task Force meeting presented at https://www.weforum.org/agenda/2020/03/southkorea-covid-19-containment-testing/. Accessed July 24, 2020. 8 The dormitories of companies, such as Samsung and LG, have been transformed into a temporary community center to treat patients. resources in one region, other provinces have quickly provided support by opening up beds in their hospitals or sending medical professionals to the region in need (Fleming, 2020) .

Led by the National Medical Center, the governance of medical facilities and hospitals in South Korea is well established, which has enabled the development and implementation of various policies throughout the nation in a much more coordinated way than other countries with more decentralized systems. For example, the referral system created by the National Medical Center allows it to "coordinate referrals from lower-level facilities to higher-level facilities, even in the absence of a clear legal framework for accomplishing effective coordination" . Local hospitals and medical facilities have also conducted effective measures to stop the spread, including strict screening procedures at their entrances, the development of safer and easier testing and treatment methods, and separating areas to prevent cross-contamination among patients. They also adopted a policy of "aggressive" use of personal protection equipment (PPE) recommended by the KCDC, requesting the extensive use of protection with surgical masks, N95 respirators, eye protection, shoe covers, and coveralls in any possibly affected cases . Medical facilities in South Korea also pioneered drive-through testing centers to reduce person-to-person contact. Quickly adopted by the government, there are over 600 testing facilities, including 50 drive-through centers (as of May 6) nationally, all of which report testing results to the KCDC (Thomson, 2020; Watson, Jeong, Hollingsworth, & Booth, 2020) .

Building close partnerships with private companies are considered to be another critical factor in South Korea's successful response to COVID-19 . Companies and other private entities took prompt action against the disease and actively cooperated with the public sector. A few days after the first confirmed case, the government decided to bring over 20 biotech/medical companies together to come up with ideas to prevent a pandemic, including the development of diagnostic test kits for mass production (CNN, 2020). Several companies have managed to produce test kits quickly within a few weeks. It usually takes a year and a half for a diagnostic test to be approved by the authority, but this time the KCDC approved the test kits within a week, which was unprecedented. With the active participation of these biotech companies, South Korea was able to conduct over 145,000 tests by March 5, which is more than the combined number tested in countries of the United States, the United Kingdom, France, Italy, and Japan at that time, and it reached at over 300,000 tests, which is a per capita rate more than 40 times that of the United States (as of April 10; Fisher & Choe, 2020; Thomson, 2020) . Companies producing test kits are now making approximately 100,000 kits per day and exporting them to many countries (Fisher & Choe, 2020) .

For the contact tracing policy to be effective, well-organized collaboration and cooperation among various related sectors are essential. A system with extensive and accurate databases is needed to trace the whereabouts of the patients, and it requires close partnerships with the immigration department (for border entry information), telecommunication companies (for GPS information), the police department (for surveillance camera footage), public/private transport operators (for detailed information on travel routes), and credit card companies (for identifying visited locations through the use of using financial data) (Salmon, 2020) . Related companies have actively participated in building an effective contact tracing system.

Tech companies have collaborated with the public sector in response to the infection. In order to solve the problem of a shortage of face masks and to distribute them in an equitable manner, the government has implemented several policies, 9 and one of them was partnering with private companies to develop mobile applications (apps) to show the number of available face masks at nearby locations of the users (Ahn, 2020) . In addition, a few companies have developed mobile apps to detail and inform of "hour-by-hour, sometimes minute-by-minute, timelines of infected people's travel-which buses they took, when and where they got on and off, even whether they were wearing masks" to the public (Fisher & Choe, 2020) .

Besides the direct partnership with the government, there has been active corporate engagement in the collaborative response to the epidemic. Working closely with the KCDC, local governments, and medical facilities, many companies have made not only monetary donations but also provided necessary products and services to the people affected by COVID-19. South Korean conglomerates, including LG, Samsung, and Hyundai, have provided PPEs to medical facilities, other necessaries such as water, toiletries, and sanitizers to medical staff, and groceries and daily necessities to the quarantined and affected people (Lee, 2020). As mentioned above, companies such as Samsung, LG, and Hanhwa, have also offered their training centers for use as community treatment centers. A significant number of companies, including smalland-medium-sized enterprises, have also shown vibrant voluntary support for the vulnerable through activities of philanthropy and Corporate Social Responsibility.

The effectiveness of this collaborative governance largely depends on public participation. The government regards the public as co-partners, continually emphasizing that their participation is critical. As a result, almost everyone wears a face mask, avoids to go to crowded areas, and takes sanitization measures seriously (e.g., social distancing, carrying hand sanitizers, and washing hands frequently) (Thomson, 2020) . The quarantined have also been following requirements relatively well. Due to the public awareness of the seriousness of the pandemic, societal pressure maintained adherence to rules and norms. The active participation of the public reflects, perhaps 9 The national government took over the production and distribution of face masks by purchasing 80 percent of all KF-94 face masks and distributing them to medical facilities and pharmacies at a discounted price. It has also imposed restrictions on the number and day of purchase per person. not so much of the culture of collectivism or Confucianism, as many Westerners believe, 10 but the people's high level of health consciousness and their trust in the current policies and effectiveness of the overall governance system. In addition, transparent public information and well-planned public campaigns and education, along with their experiences with previous epidemics, have made the public well alert of the situation and better prepared for this type of health crisis.

Unlike other countries, no mandatory lockdown was required in South Korea to control the spread of COVID-19. Local businesses and organizations voluntarily took necessary actions, schools and workplaces made the swift transition to homeschooling and teleworking and arranged flexible schedules. Restaurants and shops have actively taken sanitary measures to ensure health security (e.g., temperature screening and requiring masks at the entrance of buildings, restrictions in the number of visitors, social distancing among customers). Many hotels, offices, and other large buildings have installed thermal imaging cameras to identify people with fevers (Fisher & Choe, 2020) . Social distancing and lockdown were recommended but not mandated, but, with the active civic engagement, the whole governance of disease control has been quick and efficient.

A number of local nongovernmental organizations (NGOs) have also played pivotal roles through vibrant campaigns, voluntary activities, and movements to support the national response to the epidemic. Working closely with local governments and service providers, NGOs have led various social distancing campaigns, have sent voluntary workers to disinfect needed areas, provided emergency kits to people in need, and so on. Civil society organizations (CSOs), including NGOs and trade unions, have also pushed the government to give proper attention to the vulnerable such as low-income families, the disabled, and migrants, as evidenced in the proposal statement collectively announced by a number of CSOs on March 19. 11 They have monitored and reported conditions of "assisted living facilities, homeless shelters, and vulnerable individuals at home" to the authority and stepped in to provide the needed products and services when there is a governmental gap (Kim, 2020) .

The successful control of the spread of COVID-19 in South Korea has become a noble case for other countries to follow. Besides the factors identified by researchers and media, the well-organized entire governance of the public health emergency response system involving various public and private actors should be added to the 10 In fact, the political views of the public are more polarized on a number of political issues, and creating good public support of a policy can be challenging for a number of matters in South Korea. It is not certain if Confucianism has helped the success of the response to the COVID-19 pandemic. 11 This Proposal may be read on the website of People's Health Institute. The Proposal from Trade Unions and Civil Society Organizations in response of COVID-19. http://health.re.kr/?p=6357. Accessed July 25, 2020.

list of important success factors. There are social and political differences that limit the extent to which the South Korean response can be replicated, including privacy regulation, cultural differences, and technological capabilities. Proactive testing and aggressive contact tracing are regarded as the most effective measures, but these may not be possible in other countries due to regulatory, cultural, or epidemiological restrictions.

Although the South Korean public health governance system cannot be duplicated, there are general guidelines that can be applied for countries to build more collaborative public health emergency response systems:

1. Build an effective leadership in the government to facilitate cooperation and collaboration. 2. Identify partners who can play important roles in the system, including national governmental organizations from different sectors, local governments, industries, civil society organizations, and the public. 3. Define their roles and designate duties to collaborate partners as clearly as possible. 4. Build democratic processes (not one-way command and control) to increase chances for cooperation and collaboration among various actors from different sectors. 5. Give participating actors enough flexibility and autonomy to develop and implement their own policies. 6. Develop channels and forums to communicate with and exchange feedback among participants. 7. Provide transparent information frequently and in detail to build mutual trust and respond promptly.

Although the development of vaccines and treatment for COVID-19 is an important and urgent step to reduce the spread, the current crisis should serve as a vaccine for future pandemics (Thomson, 2020) . As previous epidemics in South Korea helped the country build a more robust health governance system, this pandemic should help other countries to build stronger immune systems for future health crises. Collaborative governance can serve as one solution to build a better system, as demonstrated in the case of South Korea.

Yon Jung Choi, PhD, is a policy fellow at the Center for Science, Technology, and Innovation Policy at George Mason University, focusing on her research on global governance, private governance, social innovation, and corporate social responsibility (CSR).

Corresponding author: Yon Jung Choi, ychoij@gmu.edu

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